PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
SECTION 10: GASTROENTEROLOGY
This section has been reviewed and approved by the Chief, Division of Gastroenterology as
well as the Program Director, Internal Medicine Residency Program at Prince George’s
Hospital Center.
________________________
Chief, Division Of Gastroenterology
______________________________
Program Director, Residency Program
I. Overview
Gastroenterology encompasses the evaluation and treatment of patients with disorders
of the gastrointestinal tract, pancreas, biliary tract, and liver. It includes disorders of
organs within the abdominal cavity and requires knowledge of the manifestations of
gastrointestinal disorders in other organ systems.
The general internist should have a wide range of competency in gastroenterology and
should be able to provide primary and, in some cases, secondary preventive care,
evaluate a broad array of gastrointestinal symptoms, and manage many gastrointestinal
disorders. The general internist is not expected to perform most technical procedures
with the important exception of flexible sigmoidoscopy. However, he/she must be
familiar with the indications, contraindications, interpretations, and complications of
these procedures.
The goal of this rotation is to provide the internal medicine resident with the ability to
evaluate and manage an array of gastrointestinal and hepatologic symptoms and
disorders. Residents may be given an opportunity to assist faculty during select
endoscopic procedures. This rotation will help residents evaluate and develop a
diagnostic and therapeutic approach to patients with general gastroenterology and
hepatology disorders. The residents will learn screening guidelines for colon cancer
and other gastroenterologic disorders.
During the rotation the residents do inpatient consults with the staff attending, observe
and participate in certain procedures including endoscopies, PEG placements etc, give
at least one subspecialty noon conference as well as see patients in the outpatient
setting once a week with a GI attending. Resident responsibilities are detailed in Section
I of the Resident Handbook. The resident is supervised for all patients by a staff
Gastroenterologist for all patients.
II.
Principle Teaching Methods
It consists of frequent encounters with the attending physician regarding patient care.
The resident will discuss all patients with the attending physician and interpret clinical
data to formulate a differential. The attending will assign reading topics on a regular
basis and review the material with the residents. This will include accepted national
guidelines as well as upcoming treatment modalities in the management of various
gastroenterologic diseases. The faculty will also critique the residents consult notes,
examination and management plan. Rounds will include short 15-30 minute discussions
on current topics driven by patient encounters and initiated by resident and completed by
the attending physician on most days. Latest information dealing with the topic as
provided by literature search and pertinent articles should be discussed. Residents
should become familiar with the indications and screening for Colon Cancer and other
common GI diseases by the end of the rotation. The residents are also exposed to a
variety of cases of viral and chemical hepatitis as well as to procedures like ERCP and
MRCP.
Residents are required to review a minimum number of test results with the attending on
service to meet the requirements of the rotation. These requirements are listed in the
logsheet at the end of this section. Residents must print a double-sided copy of the
logsheet and complete the requirements and turn in the logsheet to the program
coordinator at the end of the month to get credit for the rotation. All topics listed in the
logsheet must be discussed in detail during the rotation.
The residents must also observe and assist where applicable the attending physician
during procedures like PEG placement, EGD, Colonoscopy. During the rotation the
resident must present a topic during GI Conference. The topic must be discussed with
the attending physician and chief residents beforehand to ensure the following spectrum
of diseases are covered in the entire academic year:
 GI bleed- upper and lower
 Pancreatitis
 Colitis- ischemic, inflammatory, radiation
 Motility disorders- esophagus, intestinal, gastroparesis
 Hepatits- viral, alcoholic, drug induced, ischemic
 Malignancies- pancreatic, colon, MALT, hepatoma, metastatic disease,
 Diarrhea- secretory, osmotic, infectiousEnd stage liver disease
 HIV associated upper and lower GI infections
 Gall bladder and biliary duct related- gallstones, cholecystitis and cholangitis
III. Strengths and Limitations
The gastroenterology faculty consists of a volunteer faculty that has a strong
commitment to patient care and resident education. The patient and disease exposure is
broad. The residents have close interaction with the faculty with daily rounds and
procedures (endoscopies, PEG placement etc.). The faculty is also easily accessable to
the residents for patient care related issues during the day via phone and comes in to
the hospital for any GI emergencies. The residents also gain exposure to outpatient
management of GI cases by attending the weekly GI clinic at Gleridge Medical Center.
The experience gained is typical of a community hospital.
IV. Goals and Objectives for Gastroenterology Rotation
Legend of Learning Activities
Learning Venues
1. Direct Patient Care/Consultation
2.
3.
4.
5.
6.
Attending Rounds
Gastroenterology Clinic
Self study
Gastroenterology conference
Core Lecture Series
Evaluation Methods
A. Attending Evaluations
B. Direct Observation
C. 360O evaluation
D. Intraining examination
Competency: Patient Care
Demonstrate the ability to use history, physical
exam, laboratory, and ancillary tests to assess
the status of a patient with acute gastrointestinal
hemorrhage
Interview patients more skillfully, gathers
accurate and essential information with
emphasis on gastrointestinal illness
Examine patients more skillfully with competent
and complete observation of normal and
abnormal signs
Define and prioritize patient’s medical problems
Generate and prioritize differential diagnoses
with appropriate testing and therapeusis
Develop rational, evidence-based management
strategies
Demonstrate ability to generate differential
diagnosis, diagnostic strategy, and define the
appropriate therapeutic plan and ongoing
modifications in a patient with GI diseases
Competency: Medical Knowledge
Articulate the pathophysiology, evaluation and
management of patients with GI diseases and
their complications
Expand clinically applicable knowledge base of
the basic and clinical sciences underlying the
care of medical service patients, both out and
inpatients.
Access and critically evaluate current medical
information and scientific evidence relevant to
patient care
Competency: Interpersonal and
Communication Skills
Interact in an effective way with physicians and
nurses participating in the care of patients
requiring gastroenterology consultation and care
Communicate effectively with patients and
families, with particular emphasis on explanation
of complex and multisystem illness and the
Learning Venues
ALL
Evaluation methods
A, B, D
1, 2, 3
A, B
1, 2, 3
A, B
1, 2, 3, 4
1, 2, 3, 4
A, B, D
A, B, D
1, 2, 3, 4
A, B, D
ALL
A, B, D
ALL
A, B, D
ALL
A, D
ALL
A, B, D
1, 2, 3
A, B, C
1, 2, 3
A, B, C
testing required to confirm diagnositic
possibilities
Present patient information concisely and
clearly, verbally and in writing. Adhere to
confidentiality
Teach colleagues effectively
Show understanding of differing patient
preferences in diagnostic evaluation and
management of gastrointestinal disorders
Competency: Professionalism
Treat team members, primary care givers, and
patients with respect
Actively participate in consultations and rounds
Attend and participate in all scheduled
conferences
Demonstrate respect, compassion, integrity and
altruism towards patients, families, colleagues,
and all members of the health care team
Demonstrate sensitivity to confidentiality,
gender, age, cultural differences and disabilities
Identify deficiencies in peer performance
Competency: Practice Based Learning
Identify limitations of medical knowledge in
evaluation and management of patients with
gastrointestinal disorders and use the medical
literature to address these gaps
Competency: Systems-Based Practice
Understand and utilize the multidisciplinary
resources necessary to care optimally for
hospitalized and out patients and the limitations
of various practice environments.
Collaborate with other members of the health
care team to assure comprehensive patient care
Use evidence-based, cost-conscious strategies
in the care of hospitalized and outpatients
1, 2, 3
A, B, C
ALL
1, 2, 3
A, B, C
A, B
1, 2, 3
A ,B, C
1,2
1, 2, 3
A,B
Singn in on
attendance sheet
A, B, C
1, 2, 3
A, B, C
ALL
C
ALL
A, D
ALL
A, B, C
1, 2, 3
A, B, C
ALL
A, D
V. Educational Content
A. Acute GI conditions
1) Understand the differential diagnosis, appropriate tests and management of:
 Acute abdomen
 Acute appendicitis
 Ascites
 GI bleed
 Bowel obstruction, ischemia
2) Develop procedural skills in and interpret results of:
 Paracentesis
 Placement of nasogastric tube
 Fecal leukocytes
 Test for occult blood
B. Esophagus
1) Understand the differential diagnosis, appropriate tests and management of:
 Barrett’s esophagus
 Squamous and adeno carcinoma,
 Esophagitis – acid and other (Monilia, CMV, etc.)
 Motility Disorders
 Varices
2) Interpret results of:
 24-hour esophageal pH monitoring
 Bernstein test
 Contrast studies (including upper gastrointestinal series, small-bowel follow
through, barium enema)
 Esophageal manometry
C. Stomach and Duodenum
1) Understand the differential diagnosis, appropriate tests and management of:
 Ulcer disease
 Hiatal hernia illness
 Foreign body and Bezoar
 Gastritis – drugs, H. pylori and stress
 Motility disorders and mitotic disease
 Malignancy
2) Interpret results of:
 Assays for Helicobacter pylori
 Biopsy of the gastrointestinal mucosa
 Upper endoscopy
 Scans of gastric emptying
 Gastric acid analysis, serum gastrin level, secretin stimulation test
D. Intestine
1) Understand the pathophysiology of:
 Motility
 Digestion and absorption
2) Understand the differential diagnosis, appropriate tests and management of:
 Infection,
 Malabsorption
 Short bowel syndrome, bacterial overgrowth
 HIV illness
 Obstruction and pseudo-obstruction
 Tumors
 Inflammatory Bowel disease
3) Interpret results of:
 Colonoscopy
 Computed tomography, magnetic, resonance imaging, ultrasound of the
abdomen
 Culture of stool for ova, parasites
 D-xylose absorption test and other small bowel absorption tests
 Endoscopic retrograde cholangiopancreatography
 Examination for stool for ova, parasites






Fecal electrolytes
Fecal osmolality
Mesenteric arteriography
Qualitative and quantitative stool fat
Serum B12 and Schilling tests
Tumor markers
E. Colon and Rectum
1) Understand the differential diagnosis, appropriate tests and management of:
 Inflammatory Bowel disease
 Angiodysplasia
 Irritable Bowel Syndrome
 Diverticulosis, diverticulitis,
 Colitis – (viral, bacterial, collagenous, lymphocytic, etc.)
 Cancer
 Polyposis syndromes
 Hemorrhoids
 Anusitis
 Appendiceal disease
2) Interpret results of:
 Lactose and hydrogen breath tests
 Colonoscopy
 Flexible sigmoidoscopy
 Laxative screen
F. Liver
1) Understand the differential diagnosis, appropriate tests and management of:
 Fatty liver, NASH, cirrhosis
 Cholestasis
 Viral hepatitis, use of Interferon
 Portal hypertension – TIPS, banding, surgery
 Ascites
 Hepatic encephalopathy
 Hepato-renal syndrome
 Autoimmune hepatitis
 Drug induced and alcoholic disease
 Hemochromatosis
 Polycystic disease
 Abscesses (bacterial an Amebic)
 Liver carcinoma, metastatic disease to the liver
 Transplantation
2) Interpret results of:
 Computed tomography, magnetic resonance imaging, ultrasound of the
abdomen
 Blood tests for autoimmune, cholestatic, genetic liver diseases
 Viral hepatitis serology, Liver function tests
 Discriminant function
 Liver biopsy
 Percutaneous transhepatic cholangiography, ERCP, MRCP
G. Biliary Tract Disease
1) Understand the differential diagnosis, appropriate tests and management of:
 Acute cholecystitis
 Biliary obstruction
 Cholangitis iincluding Sclerosing cholangitis
 Primary biliary cirrhosis
 Cholelithiasis
2) Interpret results of:
 Gall bladder radionuclide scan
 Percutaneous transhepatic cholangiography, ERCP, MRCP
 Autoimmune serologies
 Liver function tests
H. Pancreas
1) Understand the differential diagnosis, appropriate tests, and management of:
 Acute pancreatitis and its complications
 Chronic pancreatitis and its complications
 Pancreatic cancer
2) Understand and interpret results of:
 Amylase and lipase
 CT scans of the abdomen
 ERCP, MRCP
3) Understand indications for ERCP, stents and radiation therapy
I.
Miscellaneous
1) Peritonitis
2) HIV disease and its affect on various GI organs
3) Approach to patient with:
 Nausea and vomiting
 Abdominal pain
 Diarrhea
 Constipation
 GI bleeding, appropriate tests and management including bleeding scan
4) Endoscopy relating to GI illness and effects of therapeutic procedures
(polypectomy, sphincterotomy, etc.)
5) Pathology and its relation to GI disease – biopsy interpretation, stool for O & P,
duodenal drainage, liver biopsy, cytology, etc.
6) Gastrointestinal manifestation of diabetes, chronic renal disease
7) Gastrointestinal care in the surgical patients
VI. Recommended Readings
All senior residents are encouraged to read the MKSAP for Gastrenterology during their
one-month rotation. Questions will help develop analytical thinking. Residents should
also consult Harrison’s Principles of Internal Medicine. Residents are also encouraged to
read from MDConsult and Up To Date on a case by case basis. Other recommended
readings are as follows:
1) Bounds BC and Friedman LS. Lower gastroeintestinal bleeding. Gastroenterol Clin
North Am. 2003 Dec;32(4):1107-25.
2) Swaroop VS. Colonoscopy as a screening test for colorectal cancer in average-risk
individuals. Mayo Clin Proc. 2002; 77: 951-956
3) Tremaine WJ. Practice guidelines for inflammatory bowel disease: an instrument for
assessment. Mayo Clin Proc. 1999; 74: 495-501
4) Podolsky DK. Inflammatory bowel disease. NEJM, Aug 8, 2002; 347(6): 417-429
5) Farrell RJ and Kelly CP. Celiac sprue. N Engl J Med. 2002 Jan 17;346(3):180-8
6) Tamboli PC. Current medical therapy for chronic inflammatory bowel diseases. Surg
Clin N Am 87 (2007), 697-725
7) Szarka LA. Diagnosing gastroesophageal reflux disease. Mayo Clin Proc. 2001; 76:
97-101
8) Arora AS. Medical therapy for gastroesophageal reflux disease. Mayo Clin Proc.
2001; 76: 102-106
9) Huang CS and Lichtenstein DR. Nonvariceal upper gastrointestinal bleeding.
Gastroenterol Clin North Am. 2003 Dec;32(4):1053-78
10) Mertz HR. Irritable bowel syndrome. N Engl J Med. 2003 Nov 27;349(22):2136-46.
11) Shiotani A and Graham DY. Pathogenesis and therapy of gastric and duodenal ulcer
disease. Med Clin North Am. 2002 Nov;86(6):1447-66
12) Suerbaum S and Michetti P. Helicobacter pylori infection. N Engl J Med. 2002 Oct
10;347(15):1175-86
13) Ragni et al. Survival of Human Immunodeficiency virus-Infected liver transplant
recipients. JID 2003: 188 (15 Nov) 1412-1420
14) Torriani et al. Peginterferon Alfa-2a plus Ribavirin for Chronic Hepatitis C virus
infection in HIV-infected patients. NEJM 2004; 351: 438-450
15) Imperiale et al. Fecal DNA versus Fecal Occult Blood for Colorectal-Cancer
screening in an Average-risk Population. NEJM 351; 26: 2704-2714
16) Bjelakovic et al. Antioxidant supplements for prevention of gastrointestinal cancers: a
systematic review and meta-analysis. The Lancet vol 364: 1219-1228
17) Marik P and Zaloga G. Meta-analysis of parenteral nutrition versus enteral nutrition in
patients with acute pancreatitis. BMJ vol 328: 1407-1410
18) Moayyedi et al. An update of the Cochrane Systematic review of Helicobacter Pylori
eradication therapy in nonulcer dyspepsia: Resolving the discrepancy between
systematic reviews. AM J Gastroenterology. Vol 98 No. 12, 2003: 2621-2626
19) Wong B et al. Helicobacter Pylori eradication to prevent gastric cancer in a high-risk
region of China. JAMA Jan 14,2004. Vol 291, No 2: 187-194
20) Isenmann R et al. Prophylactic antibiotic treatment in patients with predicted severe
acute pancreatitis: A placebo-controlled, double-blind trial. Gastroenterology 2004;
126: 997-1004
21) Moayyedi et al. The efficacy of proton pump inhibitors in nonulcer dyspepsia: A
systematic review and economic analysis. Gastroenterology 2004; 127: 1329-1337
22) Whitcomb D. Acute Pancreatitis. NEJM 354; 20, May 18,2006: 2142-2150
23) Mannon P et al. Anti-interleukin-12 antibody for active Crohn’s disease. NEJM 351;
20, Nov 11, 2004: 2069-2079
24) Krawitt E. Autoimmune hepatitis. NEJM 354; 1, Jan 5, 2006: 54-66
25) Mukherjee S et al. Beta-Blockers to prevent Esophageal varices- An unfulfilled
promise. NEJM 353; 21, Nov 2005: 2288-2290
26) Gines P et al. Management of cirrhosis and ascites. NEJM, Apr 15 2004; 350(16):
1646-1654
27) Binder H. Causes of Chronic diarrhea. NEJM 355; 3, July 2006: 236-239
28) Schoenfeld P et al. Colonoscopic screening of average-risk women for colorectal
neoplasia. NEJM 352; 20, May 2005: 2061-2068
29) Musher D and Musher B. Contagious acute gastrointestinal infections. NEJM 351;
23, Dec 2004: 2417-2427
30) Navarro V, Senior J. Drug-related hepatotoxicity. NEJM 354; 7, Feb 2006: 731-739
31) Hoofnagle J. Hepatitis B – Preventable and now treatable. NEJM 354;10, March
2006: 1074-1076
32) Liaw Y et al. Lamivudine for patients with chronic hepatitis B and advanced liver
disease. NEJM 351; 15, Oct 2004: 1521-1531
33) Poland G, Jacobson R. Prevention of Hepatitis B with the Hepatitis B Vaccine. NEJM
351; 27, Dec 2004: 2832-2838
34) Hampel H et al. Screening for the Lynch syndrome (Hereditary nonpolyposis
colorectal cancer). NEJM 352; 18, May 2005: 1851-1860
35) Meyerhardt J, Mayer R. Systemic therapy for colorectal cancer. NEJM 352; 5, Feb
2005: 476-487
36) Suk-Fong A. The maze of treatments for Hepatitis B. NEJM 352; 26, Jun 2005: 27432746
PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
GASTROENTEROLOGY LOGSHEET
RESIDENT NAME______________________________________________
PGY LEVEL_______________
PANCREATITIS
MR#
Assessment and Plan
Discussed with
resident
Comment by
supervising attending
(Resident diagnosis
correct/not, missed
findings etc)
SIGNATURE of
Supervising
attending & DATE
MR#
Assessment and Plan
Discussed with
resident
Comment by
supervising attending
(Resident diagnosis
correct/not, missed
findings etc)
SIGNATURE of
Supervising
attending & DATE
MR#
Assessment and Plan
Discussed with
resident
ROTATION MONTH_____________
BILIARY
DISEASES
GI BLEED
DIARRHEA &
MOTILITY
DISORDERS
Comment by
supervising attending
(Resident diagnosis
correct/not, missed
findings etc)
SIGNATURE of
Supervising
attending & DATE
RESIDENT NAME:___________________________________________
TEST
MR#
Resident’s diagnosis and
plan
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supervising attending &
DATE
MR#
Resident’s diagnosis and
plan
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supervising attending &
DATE
MR#
Resident’s diagnosis and
plan
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supervising attending &
DATE
MR#
HEPATITIS
PROFILE
POLYP
BIOPSY
RESULT
ABDOMEN CT
SCAN
ASCITIC FLUID
/ IBD FINDINGS
Resident’s diagnosis and
plan
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supervising attending &
DATE