1. The document discusses various gastrointestinal disorders that can present with non-gastrointestinal symptoms, including GERD, asthma, chronic cough, chest pain, ENT symptoms, and others.
2. It provides an overview of approaches to evaluating these atypical presentations, including pH monitoring, impedance monitoring, treatment with PPIs, and considering other potential etiologies.
3. Surgical intervention may be considered for refractory cases, though response is variable depending on the specific disorder and symptoms. Overall, the document aims to help clinicians avoid pitfalls in diagnosing and managing GI disorders that present atypically.
Ulcerative Colitis: Applying Guidelines in PracticeDevi Seal
This presentation developed was by David Rubin, MD, Millie Long, MD, MPH, and Anita Afzali, MD, MPH, for a CME activity titled, Ulcerative Colitis: Applying Guidelines in Practice
Presented by Darren M. Brenner, MD at the Scleroderma Patient Education Conference hosted by the Scleroderma Foundation Greater Chicago Chapter on Saturday, October 12 in Chicago, IL.
A protocol presentation I created during my training at KEMH. Disease was ulcerative colitis. Suggestions made by expert evaluating this have not been incorporated.
GERD (gastroesophageal reflux disease, or chronic acid reflux) is a condition in which acid-containing contents in your stomach persistently leak back up into your esophagus, the tube from your throat to your stomach.
Although GERD itself isn't a life threatening condition, it can lead to more serious health issues and complications if it's left untreated.
La terapia medica e chirurgica della malattia perianale di Crohn - Gastrolear...Gastrolearning
Gastrolearning II modulo/21a lezione
La terapia medica e chirurgica della malattia perianale di Crohn
Relatore: Prof. Paolo Gionchetti (Università di Bologna)
Ulcerative Colitis: Applying Guidelines in PracticeDevi Seal
This presentation developed was by David Rubin, MD, Millie Long, MD, MPH, and Anita Afzali, MD, MPH, for a CME activity titled, Ulcerative Colitis: Applying Guidelines in Practice
Presented by Darren M. Brenner, MD at the Scleroderma Patient Education Conference hosted by the Scleroderma Foundation Greater Chicago Chapter on Saturday, October 12 in Chicago, IL.
A protocol presentation I created during my training at KEMH. Disease was ulcerative colitis. Suggestions made by expert evaluating this have not been incorporated.
GERD (gastroesophageal reflux disease, or chronic acid reflux) is a condition in which acid-containing contents in your stomach persistently leak back up into your esophagus, the tube from your throat to your stomach.
Although GERD itself isn't a life threatening condition, it can lead to more serious health issues and complications if it's left untreated.
La terapia medica e chirurgica della malattia perianale di Crohn - Gastrolear...Gastrolearning
Gastrolearning II modulo/21a lezione
La terapia medica e chirurgica della malattia perianale di Crohn
Relatore: Prof. Paolo Gionchetti (Università di Bologna)
Acid peptic disease /dental courses /certified fixed orthodontic courses by I...Indian dental academy
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Gastroesophageal Reflux Disease (GERD) is a common disorder that has undergone many paradigm changes in the last 15 years. We discuss the current paradigms in the pathophysiology, diagnosis and management of GERD.
Functional Digestive Disorders and the Role of Diet by Giovanni BarbaraKiwifruit Symposium
Prof. Giovanni Barbara, Professor of Medicine and Gastroenterology at the University of Bologna, Italy: http://www.kiwifruitsymposium.org/presentations/functional-gastrointestinal-disorders-and-the-role-of-diet/
Roughly 30% of the population is affected by at least one of the several functional gastrointestinal disorders (FGIDs) with functional dyspepsia, irritable bowel syndrome (IBS) and chronic constipation (CC) being the most common.
Gastroesophageal reflux disease in children.Indian Society of Pediatric Gast...Vijitha A S
Gastroesophageal reflux disease in children.Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition (ISPGHAN) 2022 update
DR VIJITHA A S
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
How to Give Better Lectures: Some Tips for Doctors
NON GI PRESENTATION OF GI DISORDER
1. Non GI presentation of GI
disorders
How to avoid pitfalls
Speaker: Dr Shim Hang Hock
Gastroenterologist
2. Aim
• Some GI diseases commonly have non-GI
presentations
• to provide overview and approach in avoiding pitfalls
2
3. GERD
3
• Common
• US population study
• 44% monthly
• 7% daily
• Diagnosis made based on:
• Typical symptoms
• Endoscopy findings
• Ambulatory reflux monitoring
• Response to anti secretory medications
Locke et al. Gastroenterology. 1997;112(5):1448-1456.
7. Asthma and GERD
• Postulated pathogenic mechanism:
• GERD
• Microaspirate bronchospasm
• Esophagus and bronchial tree shares the same neural innervation via
vagus nerve
• Low pH / distension of oesophagus vagal stimulation
bronchospasm
• Asthma
• Increased pressure gradient across diaphragm
• Effect of asthma medications (bronchodilators) on LES pressure/
gastric secretion
7
8. GERD related asthma
• Symptoms of regurgitation/heartburn before onset
of asthma
• Symptoms made worse
• after large meal
• Lying in supine position
• Nocturnal cough
8
9. Asthma
• 28 studies
• Prevalence of GERD:
• asthma 59.2% vs control 38.1%
• Prevalence of asthma:
• GERD 4.6% vs. control 3.9%
• Inconsistent findings on response-relationship
• Significant association but paucity of data on direction of causation
11. • Fewer patients had at least one asthma exacerbation
when treated with lansoprazole than when given
placebo (8 versus 22 patients, respectively; P<0.05)
11
RDB = randomized double-blind; RSB = randomized single-blind; PC = placebo controlled trial; CO = crossover trial; PG =
parallel-group trial.
16. 16
Chang AB , Lasserson TJ , Gaffney J et al. Gastro-oesophageal reflux treatment for
prolonged non-specifi c cough in children and adults. Cochrane Database Syst Rev 2011
17. • Underlying IHD should always be excluded first for all
patients, especially those with risk factors
• Mechanism connecting GERD and chest pain poorly
understood
• Esophageal factors for non cardiac chest pain
• GERD
• Dysmotility
• Visceral hypersensitivity
• Eosinophilic esophagitis
17
Non cardiac chest pain
Fass R et al. Gastroenterology. 1998;115(6):1363-1373
18. Non cardiac chest pain
18
• May sometime be the only presenting complaint for GERD
• 8 RCT
• Pooled risk ratio of continued chest pain post PPI 0.54 (95% CI 0.41-0.71)
• PPI vs 24hr pH monitoring/endoscopy
• Pooled sensitivity 80%
• Specificity 74%
• Odds ratio 13.83 ((95% CI 5.48-34.91)
19. GERD related ENT symptoms
• 10% Hoarseness
• Up to 60% of refractory sorethroat / reflux laryngitis
• 25-50% of globus sensation
• Symptoms in isolation not specific
19
Vaezi MF. J Clin Gastroenterol. 2003;36(3):198-203.
Hicks DM et al. J Voice. 2002;16(4):564-579
20. “Reflux” laryngitis
• Diagnosis should not be made based on
laryngoscopy alone
• May be present in up to 80% of normal population
20 Vaezi MF. Nat Clin Pract Gastroenterol Hepatol. 2005;2(12):595-603.
• Response to irritants:
• alcohol, smoking, postnasal
drip,
• viral illness, voice overuse,
• environmental allergens
21. • Poor concordance with extreme intrarater variability
• 40-50% “reflux laryngitis” do not respond to
antisecretary treatment
21
Branski RC , Bhattacharyya N , Shapiro J . Th e reliability of the assessment of endoscopic laryngeal
findings associated with laryngopharyngeal reflux disease . Laryngoscope 2002 ; 112 : 1019 – 24 .
22. 22
• 8 RCT (n =344, study duration 8-16 weeks)
• PPI therapy resulted in a nonsignificant symptom
reduction compared to placebo (relative risk 1.28,
95% CI 0.94-1.74)
23. 23 Katz et al. Am J Gastroenterol 2013; 108:308 – 328
27. 27
Symptom Indices
• The three main symptom indices include
1. Symptom index (SI)
• % of symptom episodes that are related to reflux.
• (Number of symptom episodes related to pH < 4)/(Total number
of symptom episodes) × 100.
• considered positive when ≥ 50%.
2. Symptom sensitivity index (SSI)
• (Number of symptom episodes related to pH < 4)/(Total number
of reflux episodes) × 100.
• considered positive when ≥ 10%.
3. Symptom association probability (SAP).
28. 28
Symptom Indices
• Symptom association probability (SAP)
– Divide total 24-hour pH recording data into 2-minute
segments.
– In each 2-minute segment, it is determined if there are
reflux events and if there are reported symptoms.
– The data are then summarized into a 2 × 2 table.
29. 29
Symptom Indices
• Symptom association probability (SAP)
• The association between reflux and symptoms is then
calculated using Fisher’s exact test.
• An SAP > 95% is considered positive and indicates that the
probability of the association of reflux and symptoms
occurring by chance is < 5%.
• A high SAP suggests that a patient’s symptoms are likely
secondary to reflux.
32. Multichannel
Intraluminal impedance (MII)
• Impedance
• a measure of total resistance to the alternating current
flow
• inversely proportional to
• Electrical conductivity of the luminal contents
• Cross-sectional area between the two electrodes.
• Air has a low conductivity impedance increase
• Swallowed or refluxed material has a high conductivity impedance
drop
60. Achalasia
• High resolution manometry (HRM) has allowed
subtyping of achalasia
• Type I (classic achalasia)
• minimal oesophageal pressurization
• Type II
• absent peristalsis with oesophageal pressurization
• Type III
• lumen obliterating spasm
67. Case 1
• 63 years old woman with
a 10-year history of
intermittent chest
discomfort with
occasional dysphagia to
solids and liquids.
• Physical exam of the
hands
• OGD and esophageal
biopsy normal
71. Systemic sclerosis
• Most patients. will have abnormal esophageal
manometry:
• Striated esophagus is normal
• Decreased amplitude in the
smooth muscle esophagus
• Aperistalsis may occur
• LES hypotonic
73. Functional chest pain
• Rome IV criteria
• Retrosternal chest pain
• Absence of esophageal symptoms
• Heartburn, dysphagia
• Exclusion of other etiologies
• Symptoms for last 3 months with symptoms onset at
least 6 months before diagnosis
73
74. Potential mechanism
• esophageal hypersensitivity
• altered cerebral processing of esophageal pain,
• autonomic dysregulation, or
• abnormal mechanophysical properties of the
esophagus
74 Maradey-Romero C et al. Curr Gastroenterol Rep 2014; 16:390.
75. Approach to noncardiac chest pain
• History
• Exclusion of ACS and other life threatening conditions
• PE, aortic dissection, esophageal rupture, tension
pneumothorax
• Associated esophageal symptoms
• Heartburn, regurgitation, dysphagia
• Relieve with PPI
• Alarm symptoms
• Dysphagia, odynophagia, bleeding, LOW, recurrent
vomiting
75
76. • Drug history
• PMHx: asthma, allergies
• Social history: smoking
76