GI Episode 011 Transcript
Dr. Hare: [00:00:00] Hello and welcome to the Be Excited Podcast. I’m assistant professor Dr. Jason Hare, and today on the podcast we have the GI or gastrointestinal service episode. Our guest today on the podcast is Lauren Campitelli, PA-C. Lauren. Welcome and thanks for being here today. Thanks for having me. Can you tell us a little bit about your experience as a PA since graduating?
And I know you graduated from the mothership here in 2019 as one of our students. Tell us about your service since then.
Lauren Campitelli: I started out in the emergency department actually for about two and a half years, and I switched over to GI about one year ago. The GI service that I work in, we work two weeks in the outpatient clinic and then one week inpatient in the hospital.
Dr. Hare: Okay. And I, you were prior to that in the emergency department for two and a half years? Yes. Same hospital or different hospital?
Lauren Campitelli: Different hospital.
Dr. Hare: Okay. [00:01:00] And was that intentional on your part then? Going to a general service like emergency service over to specialized service?
Lauren Campitelli: It was intentional.
When I first graduated, I had a few job offers that were in various specialties. I also had a job offer to work in the emergency department and I ended up choosing the emergency department just to get general experience and see what specialties I gravitated toward or away from. There were certainly some that I gravitated away from.
Mm-hmm. I found that I always gravitated towards the abdominal pain patients. If there was an abdominal pain that came into the ER that was mine, I would put my name on it asap. And those are the patients that I enjoyed the most. So that’s how I ended up working in gi.
Dr. Hare: Interesting. And. So how was your experience in the emergency department then during that time?
Did you, did you find that rewarding? What was the, the, the pluses and the minuses, I guess, of working as a PA in emergency medicine?
Lauren Campitelli: I did find it to be rewarding. It was [00:02:00] a little difficult because I graduated and started right when Covid started. So I started in March Uhhuh right when all the shutdowns were happening, moved away from Pittsburgh.
So it was definitely a learning experience. I think a lot of the typical emergency medicine things that you would expect to see in your first few years, I did not see, I saw a lot of covid. There were still obviously things thrown throughout the mix. Did a lot of stitches, a lot of procedures. But yeah, I think it was time to move on to a specialty.
I’m
Dr. Hare: sure that was a difficult and probably emotional time to be in an emergency room setting, especially straight out of school. We’ve all heard stories certainly of folks coming into the emergency room and, you know, dropping off their loved ones and not being able to come in and, and even be with their loved ones in those scenarios, and then folks going upstairs.
That must have been a little bit, at least traumatic to, to, to deal with during those early years.
Lauren Campitelli: It was, and it was such a stark contrast between when I was there as a student. [00:03:00] So I ended up working in an emergency department that I had a rotation at, and when I was a student there, it was great and free flowing.
But yeah, working there during Covid was a lot different. Great experience, but it was definitely hard.
Dr. Hare: I can only imagine how, how difficult that must have been. And so there’s a, another, I guess, teaching point, learning point for PA students. You did a rotation in the same emergency department at which you got a job.
So was that a connection that you made while you were there?
Lauren Campitelli: It was. I really liked the people there. I hit it off with the unit director and a lot of the people there, and that’s how I ended up there. They had a job opening and he texted me, and that’s all she wrote.
Dr. Hare: Oh, I love that. And that’s, that is something that I talked to my advisees about a lot, which is, you know, send a thank you note when you’re done.
Make sure they have your email address. Those connections that you make in those rotations, even in early in the year when you’re still, you know, [00:04:00] potentially close to a year from being a practicing pa. , you can still make a good impression on them and you can still maintain those connections over the course of the coming year and get that position.
Locked down, I guess, for lack of a better term, after graduation. As long as you maintain that connection just a little bit. So that’s, that’s interesting. I have those conversations a lot with advisees and it’s nice to hear that. It is something that still works out occasionally.
Lauren Campitelli: Absolutely. And you were my advisor, so it worked out for me.
Dr. Hare: There you go. Yeah, and I, sometimes I, if students can’t figure out the thank you you note thing, I hand them a stack of thank you notes out of the bottom of my desk here and say, Hey, here you go. You should you should be using these. GI was a service that you gravitated toward from the emergency room
We’re right now in the gi module in Clin Med and about, about to finish up. And so one of the things that discussing with our students is the, the vagueness and the difficulty sometimes because [00:05:00] there’s a relatively short list of symptoms and signs that you see in GI as, as a presenting symptom.
And you know, it’s nausea, vomiting, diarrhea, constipation pain, and then bleeding at either end. Either hematemesis or melena. What sort of presentations concern you when they walk in the door?
Lauren Campitelli: I tend to be in the camp of everything is concerning until proven not to be. Uhhuh. Obviously with GI we learn about the red flags and those are something that we take to heart clinically as well.
I think some of the things that we learn about whenever you get to practicing clinically kind of go by the wayside, but that’s certainly not one of them. Those red flags are something that we very much pay attention to, but in gi, that to me is what is the main diagnostic challenge is a lot of the things do present similarly.
So you will see someone in clinic whose complaint is, I’ve been bloated for a year, I’ve had nausea for two years, I’ve had diarrhea for six months, and [00:06:00] nobody can figure it out. I’ve had X, Y, and Z tests. So it’s our job to go through those red flags, take some things off the table, put some more things on the table even to figure out what is causing their symptoms.
And
Dr. Hare: there are a whole bunch of organs inside the inside the abdominal cavity, in the chest cavity that can potentially cause some similar differentials. Do you often have to parse out differentials that are, say pelvic or genital urinary or, you know, nephrolithiasis, things of that nature?
Lauren Campitelli: We do, and that is something that I’ve been able to draw from my er experience that I’m hoping I am able to maintain through time. Whenever you’re in the emergency department, your differential is very broad, but your differential is, is very broad in GI as well. You know, if you have a female with bloating and lower abdominal pain, is it gi, could it be a colorectal malignancy?
Could it be an ovarian process? So there are certainly a lot of differentials you have to parcel through, [00:07:00] and I think that keeping your questions very broad and narrowing from there is always something that you should be doing.
Dr. Hare: So in a recent episode we talked with Paige Thompson, who’s an endocrine pa and one of her appreciations for her service in endocrine and diabetes is that it really does cross over with primary care and internal medicine and general medicine a lot.
It sounds as if you have to keep a lot of the general medicine differentials in mind all the time.
Lauren Campitelli: You do even thyroid disease, is that the cause of someone’s diarrhea, someone’s constipation. So it very closely overlaps with primary care and I think GI knowledge and primary care is very useful.
Dr. Hare: Excellent. what is it then that, that you enjoy about your job on a day-to-day basis? I know not everybody enjoys their job on a day-to-day basis, but. What is it that gets you going back to work every day and not well, let’s say looking for that next job.
Lauren Campitelli: I like the challenge of [00:08:00] gi. I like when a patient comes in with a vague complaint, if they’ve seen someone else first.
If you’re the one that’s able to listen long enough and ask enough questions and get to the cause of their symptoms, it’s very gratifying to see these patients improve. When you see a patient in clinic, again, if you found that right combination of medication to stop chronic diarrhea, that has kept them from being able to go to the grocery store freely without having to map out the bathrooms.
That is something that’s really rewarding and. Immediately gratifying.
Dr. Hare: Yeah. I love that. That’s well, and of course being a PA in general is, is rewarding. And often because of the flexibility that you have moving between services, you can often find that thing that, that really strikes a balance for you, which glad to hear that.
That is certainly working out for you. One of the things on the list that I have here is procedures. And I know that this is a little bit different for you in GI service versus [00:09:00] the GI surgery service. You really don’t do a lot of the procedural things. That would be something you would send down the hall, for instance.
Lauren Campitelli: Exactly. So we have six physicians in our group and six PAs. So all of our doctors do the procedures. We do a lot of the ordering of the procedures whenever we see patients in the clinic. And then the doctors are the ones that do the endoscopies. Oh,
Dr. Hare: That’s always in my, my setting, which is family medicine in a psych hospital, we are consistently thinking to ourselves, okay, is this likely to be a diagnostic challenge or is this more likely to be a surgical issue to send to gi?
Is this a question that we need to ask of you all on the diagnostic side? Or is it, you know, an interventional kind of a moment for that patient? Next up, let’s dive into our list of must not miss diagnoses. And of course, must not miss diagnoses are high morbidity and mortality problems, which exist in pretty much every area of [00:10:00] medicine.
And for gi you certainly have a, a significant list of things that can cause. Issues for patients that can cause dysfunction and, and potentially death. The first one on your list is colon cancer. Tell us about why colon cancer is such a concerning must not miss diagnosis.
Lauren Campitelli: Colon cancer is the first one that jumps to mind because I think sometimes it can be easy to miss those early warning signs.
It has a high morbidity and mortality, and it’s something that we’re starting to see in younger folks. So recently they actually decreased the screening age for colonoscopies from age 50 to 45. Mm-hmm.
Dr. Hare: Interesting. And that’s that screening side of things I know that this is fraught with, with Individual patient considerations.
But are you recommending , flex sigmoidoscopy, or colonoscopy or fit testing as first line? Or is there anything that you push patients toward in that service?
Lauren Campitelli: We [00:11:00] typically recommend colonoscopy first and foremost. A lot of patients are resistant to colonoscopy at first because everyone has a story of, I know someone who had a complication, but I’ve come to find that oftentimes if you talk to patients about what their concern is, whether it’s the prep or the procedure itself, they’re usually more comfortable by the end of the conversation.
Sometimes it is a tough sell. We’re telling a patient, Hey, drink these jugs of liquid. You’re gonna go to the bathroom hundreds of times. And be put to sleep so we can look in your colon. It’s sometimes it is a tough sell. It’s not a very glamorous test, but if you explain the importance and explain to the patient, if you don’t have any polyps and your family history doesn’t change, we won’t need to do this for 10 years.
Or if you have polyps five years, I think most, most patients end up responding very well to that.
Dr. Hare: And the idea being there that you can not just do the diagnostic with the colonoscopy, [00:12:00] but you can also remove polyps while there. So this is diagnostic and treatment is an interesting one to me. I had one of my preceptors in PA school said that to us that as students that colon cancer was the only cancer that’s really, truly preventable, that could be stopped in its tracks.
In his opinion, at least, of course, he was, he was a little biased, but he felt that it was really, truly the only preventable cancer because of that ability. How do you feel about that statement nowadays? I think that’s probably changed a little bit.
Lauren Campitelli: Yeah. I would say that colon cancer, for the most part is preventable.
If we follow the screening guidelines, there’s nothing more heartbreaking than seeing a patient come in to the hospital or to the clinic with these smoldering warning signs for years. One that comes to mind that we see frequently is an iron deficiency anemia, regardless of age. There’s obviously, it’s heartbreaking at any age to see [00:13:00] anyone be diagnosed with a malignancy, but when you have someone young who say they had a CBC preoperative plea for whatever reason, and this anemia was never followed up on, they never had iron studies and they were never.
Referred to GI and then a year or two down the line, they’re diagnosed with a colon mass that few years ago might have been preventable or diagnosed at an earlier stage. That is a, that’s a tough one to swallow, and that’s a tough one to tell families. No, no doubt.
Dr. Hare: And then, what percentage would you say these days are colonoscopies versus flexi versus fit test?
And then I know we also have the, the CT scan as an option as well. How, how does that break down these days?
Lauren Campitelli: In our office, we mainly opt for colonoscopy. A lot of patients will come and make an appointment first to talk about the different procedural options. I would say colonoscopy is definitely first and foremost, FIT testing and Cologuard testing.
We will prescribe to patients if they’re unwilling to have a procedure, [00:14:00] we will follow up a colonoscopy on any of those tests that are abnormal. The thing to note with those is those just are not appropriate in some patients. So with a family history of colon cancer, colon polyps, or personal history of polyps, they should not be having those tests.
They should be having their routine screening recall colonoscopies. As far as the CT colonography goes, we typically will do that if a patient cannot have a completed colonoscopy for some reason, whether it’s that they have a stricture or they have a very torturous colon, that is difficult to. Get all the way to the cecum.
Those patients will typically do the CT colonography on, but I would say for the most part, we gravitate towards colonoscopy. Flex Sig is something that we will often do in I B D patients or rec rectal bleeding, if a patient has had a completed colonoscopy to ensure that there is no neoplasm. Sometimes we’ll start with a flex sig to see, is it hemorrhoidal bleeding?
Is it a [00:15:00] radiation proctitis, or things of other etiologies before making them do a full colon prep.
Dr. Hare: And so you can see the pathology and the descending colon through the rectum, et those scenarios if that pathology exists. Right. Okay. And then the abdominal CT I always found interesting because the idea that you would do that screen, I.
And then if there’s a problem though, you have to go back and do the scope in most cases.
Lauren Campitelli: right. Really with any of the screening tests. That’s why I think that if you talk to patients, if you hear their concerns, whether it be about the prep, the procedure itself, sometimes even the sedation, if you explain to them that if any of those screening tests are abnormal, then the colonoscopy is gonna be the next step.
A lot of patients will just choose to kind of cut out the middleman and just go for the full colonoscopy with polypectomy if necessary.
Dr. Hare: Let’s talk about next steps here. If you have a suspected malignancy, are [00:16:00] you, you’re grading that with the colonoscopy and biopsy in that moment, or is that an exploratory surgery?
Lauren Campitelli: It’s typically when a patient’s inpatient and say they come in for rectal bleeding through the emergency department, typically we will get colorectal surgery involved while they’re inpatient and whether they need to do a colon resection, they will make those decisions while the patient’s actually still in the hospital.
Dr. Hare: Okay. Yeah. And that, that certainly makes sense. And they’re, they’re doing resections and In the, for the most part, those are gonna be resections in the, in the gut at that point, and so iron deficiency anemia then is one of the major symptoms there that we get concerned about in these patients. And certainly we see that more frequently in females than we see it in males, primarily because of menstrual cycles. But certainly in males it, it, it is a, a big red flag.
And hopefully folks are recognizing that iron deficiency anemia is not just a natural consequence of menstrual cycles and that it’s actually a potential sign of something else going [00:17:00] on in the body,
Lauren Campitelli: right? We do have patients who come in and they say, I’ve had this history of anemia, I had abnormal menstrual cycles.
But from a GI standpoint, even if you get an occult test that does not show blood well, that’s sometimes just this very short snapshot in time. What were your bowels doing in that moment? If there wasn’t any blood in that split second that you had that bowel movement? So it’s something that we in the GI realm take very seriously.
Oftentimes, we will do an upper endoscopy, a colonoscopy, and sometimes even a capsule endoscopy where we have the patient swallow a pill camera.
Dr. Hare: So how that’s an interesting aside, so how, how common is the use of the the pill endoscopy? Method.
Lauren Campitelli: I would say it’s very common, especially in follow-up.
Unfortunately, we cannot get capsules inpatient. So oftentimes if we have someone in the hospital who comes in with, say, melena, we do an upper endoscopy, that looks fine. We do a colonoscopy, that [00:18:00] also looks fine. Sometimes we can do a push enteroscopy to go into the small bowel a little bit further. But ultimately, if we don’t see any sites of bleeding, we will send the patient home and follow up in the office to do a capsule endoscopy.
That is very common in our elderly, elderly patients that are on anticoagulation. Whenever they restart their anticoagulation, whether it be at home or in the hospital, they will often have even small bleeding AVMs that we just were not able to see on endoscopies.
Dr. Hare: And so what does the, what’s the result of a pill endoscopy?
The diagnostic test and the images that you get from that? What, what is that
Lauren Campitelli: like? So it takes a ton of pictures throughout your whole GI tract and our physicians snapshots. Yeah, snapshots in time. Okay. Essentially makes a video out of it and our physicians go through that and if they’re able to see any spots with active bleeding, they will have the patient go back to the hospital and do a push enteroscopy to intubate the bowel as far as they can to try to find that spot.
The reason that’s more helpful is because [00:19:00] instead of going in blind with an enteroscopy, they usually will have a general idea of where that spot is and how far they need to go into the small bowel. No,
Dr. Hare: that’s very interesting. Okay. And so, and is that being read by the GI Service or is that something that Radiology actually picks
Lauren Campitelli: up?
The read on our physicians read that actually the GI doctors do. That’s
Dr. Hare: interesting. Okay. So the next one on the list is pancreatic cancer. Pancreatic cancer is a condition that is certainly known to be potentially painful. And high morbidity mortality kind of condition tell how does that show up in your office?
Lauren Campitelli: It depends. There were actually, I can draw on my emergency department experience for this.
Whenever you saw a patient come in with a newer onset diabetes with painless jaundice, that is a scary, scary thing to see in the office setting. We have a lot of just vague abdominal pain complaints. Epigastric pain in particular is one that has a broad differential. [00:20:00] Epigastric pain can be from a lot of different things.
Could they have. An ulcer that’s presenting with epigastric pain. Could they have gallbladder disease that’s presenting with epigastric pain? Could it be a pancreatic malignancy? So those are things that we have to parcel through. And again, going back to those red flags, are they having weight loss? That is a huge sign that there’s something very serious going on.
Are they having anorexia? So those are all things that we need to take into consideration. I tend to have a lower threshold for at obtaining a contrasted image. If a patient’s complaining of epigastric pain, they’ve had an endoscopy, that looks fine, they’ve had an ultrasound, that looks fine. They don’t have cholelithiasis.
So you have to always keep the worst case scenario in mind when you’re seeing patients with a complaint really of any sort, but especially epigastric pain. Yeah, certainly
Dr. Hare: you wouldn’t want to send a patient home with a, that concern in the back of your mind. And then have that show up later on as being, as potential ca [00:21:00] cancer certainly understand that.
And then so how often does that, does pancreatic cancer actually demonstrate, I suppose it’s where in the, in the pancreas the the malignancy exist, but how often does that show up as a blood sugar change? Age,
Lauren Campitelli: I will say I’ve only had that textbook case one time where I had a patient who exercised a lot.
She really watched her diet. She was diagnosed with diabetes about a year prior to me seeing her in the emergency department. And she came in just with painless jaundice. And her CAT scan unfortunately showed a pancreatic malignancy
Dr. Hare: Those beta cells then the malignancy is in that case, doing damage to the beta cells.
Okay. And then the next one you have on your list is then any cancer.
And that’s, that is, I think, indicative of the possibilities here for these presentations, although many presentations showing up as potentially cancer. [00:22:00]
Lauren Campitelli: Right. And I think that’s something interesting to note in the age of telemedicine because you can’t feel a patient’s abdomen through video chat. And oftentimes if you’re hearing a patient’s story, even if they’re crossing off some of those red flags, when you put your hand on their abdomen, if you feel something abnormal, you need to dig into that further.
And that’s something that we do very frequently in the office. We feel abdomens all day. So whenever you feel something abnormal, it’s very, very important to follow up on. So, I put any malignancy on that must not misdiagnosis because there are some patients who opt for only telemedicine, and I just think in the GI realm, if you’re complaining of abdominal pain or really anything that, that’s a little bit of a slippery slope.
Dr. Hare: Yeah, I can imagine. This is one of the things that we talk about in our telemedicine discussion and other, other telemedicine discussions inside the program is that your history has to be really, if, if it’s only gonna be history and you’re [00:23:00] only gonna be able to see someone’s on video for a brief period of time.
You really have to have a pretty comprehensive review of systems and history question set to make sure that you’re not missing something. Because often patients just say, oh yeah, and I have this other thing, you know, and it’s, they don’t, they don’t necessarily associate it with the primary issue in the moment, but they, they’re probably missing something and in some cases, and that telemedicine can really miss that at times.
And so I don’t think we’re ever gonna get away from the need for hands-on medicine thankfully for our jobs, I suppose. So the the next thing on the list is inflammatory bowel disease and presumably that’s Crohn’s and ulcerative colitis as an umbrella term for those.
Tell us about the presentation for those.
Lauren Campitelli: So I have those on the must not miss diagnosis list because sometimes they are easy to miss. Typically with ulcerative colitis and Crohn’s, [00:24:00] the symptoms at first aren’t always very severe. They don’t always present with a classic pain or bleeding or weight loss.
We see so many patients in the office that do have ibs, irritable bowel syndrome. So how do you screen for patients that could have I B D that need a colonoscopy and a bit further of a workup? So again, going back to those red flags, are they having rectal bleeding? Are they having weight loss? Are they waking up in the middle of the night to move their bowels?
Patients with IBS should not be waking up in the middle of the night with the urge to move their bowels, that fecal urgency tenesmus or the constant feeling that they need to go to the bathroom and only passing very small amounts of stool, but always having that irritation. Those are all things that are important and we need to take into consideration when we’re seeing patients to make sure that they don’t have a Crohn’s or an ulcerative colitis, which are obviously managed a lot differently than ibs.
Dr. Hare: So what would your initial workup for a patient that you’re concerned about Crohn’s or ulcerative colitis be like, is that [00:25:00] a, an immediate colonoscopy? And lab, I presume?
Lauren Campitelli: So typically, whenever we are thinking either Crohn’s or uc in the office setting, we will check a battery of labs. The ones that most readily come to mind would be a cbc, a CMP, to check LFTs and electrolytes.
We will often check a fecal calprotectin as well. That is an inflammatory marker in the stool that is pretty strongly associated with I B D, so that’s often very helpful. And then a colonoscopy is certainly the next step. Oftentimes we will check inflammatory markers in the blood as well, a SED rate in A C R P.
And some people, depending on the provider, will actually get an I B D differentiation panel.
Dr. Hare: Okay. And then the so the gold standard here for either of those would presumably be the colonoscopy because we’re going directly to the
Lauren Campitelli: source, right.
Colonoscopy with some biopsies to see if there’s any chronic inflammation in the colon. Okay.
Dr. Hare: And then [00:26:00] next on our list you have celiac disease and as you note, they tend to look well but have some irritating and problematic GI symptoms, but they don’t always associate it with a significant problem or even their diet in some
Lauren Campitelli: cases. Right. We will see patients in the office who come in and they’ll tell us, I have BLO with everything I eat.
I have diarrhea with everything I eat. Gluten is in a lot of things, a lot of things that you might not even think of. And often these patients look, well. I think there’s this bias whenever we think of celiac disease, to think of a patient who looks malnourished or looks very acutely ill, but that’s not necessarily the case.
So we have to keep that in the back of our minds. We usually always gravitate as well to thinking of celiac and association with diarrhea. But we’ll see patients with severe constipation who you’ll diagnose with celiac. Right. Interesting. Sometimes it’s something as minimal as just a slight [00:27:00] elevation in LFTs that leads us to a diagnosis of celiac disease.
Dr. Hare: So we often talk about elimination diets in the nutrition side. But presumably an elimination diet might be something that you would think about in your service as
Lauren Campitelli: well. It is. And typically any patient with celiac disease, we will refer to nutrition. It’s hard for them. These are things they’ve been eating their whole life and it’s hard to go out to eat and to have that always in the back of your mind of, well, my friends are going out tonight, but they’re going somewhere that I can’t go.
I won’t be able to find anything on the menu. So that’s something that’s a big life change for our celiac patients.
Dr. Hare: Yeah, , and, every food store that you go into, it now becomes a search for the, the thing that will not cause a problem. Every time you’re hungry you have to go on the search for something that doesn’t cause a problem.
I can imagine that would be certainly difficult. Okay. And then choledocholithiasis number six on your list. So you [00:28:00] noted that labs tend to lag and it tends to be a tricky diagnosis. Tell us about choledocholithiasis and how it differentiates from some similar conditions in the gut, if you would.
Lauren Campitelli: So, gallbladder disease can be tricky in the inpatient setting or the outpatient setting. So we have to differentiate what a patient could be suffering from. Symptomatic cholelithiasis is that classic colicky right upper quadrant pain. Typically with a fatty meal, patients can live with stones in their gallbladder.
They often do. Sometimes when they present, they’ll say it happens every once in a while, but it’s not very severe. Those are the patients we diagnose with stones in their gallbladder. The patients that we see with choledocholithiasis are those patients who either pass a gallstone or sludge in into the common bile duct.
So we will often see an increase in their transaminases, and they’re more acutely ill with worse, more constant pain. And those patients we manage a lot differently than asymptomatic cholelithiasis. So those [00:29:00] patients, we typically will get an MRCP first to confirm that they have choledocholithiasis, and then we often move on to an E R C P to retrieve that stone.
And then they often have their gallbladder removed during that same admission.
Dr. Hare: Okay. That MRCP and ERCP question is certainly one of those things that our students, I think, struggle with a little bit in the diagnostic realm. And understanding who does those procedures, first of all?
And what does that look like functionally?
Lauren Campitelli: So the MRCPs are done in radiology and most of our physicians will actually do ERCPs the decision to do an MRCP first. I will say typically in the hospital setting, that’s just kind of an automatic next step is to obtain an MRCP and
Dr. Hare: that’s a magnetic resonance.
Lauren Campitelli: Cholangiopancreatography
Dr. Hare: Cholangiopancreatography, okay. And then the E R C P is.
Lauren Campitelli: [00:30:00] Endoscopic retrograde cholangiopancreatography. Excellent. You’ll have to double check me and make sure Right. I don’t ever say the full thing out loud. Right.
Dr. Hare: Well, that’s why we have acronyms and medicine, but just wanna to define those a little bit.
Lauren Campitelli: They will get the MRCP first. Okay. If the MRCP shows a definite choledocholithiasis, then they will absolutely move on to an E R C P. But oftentimes, even if it doesn’t, if the patient’s pain is not improving, if their labs are not improving, so if their bilirubin, ALT, AST, Alk Phos are still very high, then we will still sometimes move on even to an ERCP if the MRCP is negative.
Okay.
Dr. Hare: And the ERCP, we also have the potential to be Interventional with the ERCP as well at the same time. So what sorts of procedures are done with the ERCP?
Lauren Campitelli: So the procedural aspect of the E R C P, they will actually do different maneuvers to remove that [00:31:00] stone from the bile duct.
Sometimes they’ll perform a sphincterotomy at the same time. If there’s a stricture that’s not allowing the stone to pass or even some sludge, we will sometimes even see stenting through an ERCP say if a patient has a mass that’s causing them to have an obstruction.
Dr. Hare: And then so what kind of endpoints are possible with Choledocholithiasis? So you, you listed as a must not miss, so presumably there are some truly morbidity and mortality inducing possibilities there.
Lauren Campitelli: So one of the main reasons I wanted to have it on my must not miss is because I think it’s a little bit confusing.
I think gallbladder pathology can be confusing and sometimes difficult to diagnose. Choledocholithiasis is something that I always warn my cholelithiasis patients about in the office. Sometimes they will opt to not have their gallbladder removed and just maintain a low fat diet, but choledocholithiasis is something we have to keep in the back of our minds.
One of [00:32:00] my ER patients actually came in just with back pain. She said, I have back pain. I’ve had scoliosis my whole life. It feels like a spasm. But when you ask those questions, are you vomiting? Are you nauseous? Explain the pain. Is it radiating? She actually ended up having choledocholitaisis. She wasn’t presenting or even complaining of abdominal pain.
Another one that we had very recently had presented to the ER several times and it wasn’t until her labs jumped through the roof that they recognized that she could have Choledocholithiasis. Her CAT scans were negative. So that’s something we always have to keep in the back of our minds,
Dr. Hare: which labs gets out of range in that scenario.
Lauren Campitelli: So we would expect to see an elevation in bilirubin, ALT, AST, and Alk Phos and something that we need to kind of look forward to and try to prevent would be any sort of cholangitis.
Dr. Hare: So let’s move on to a discussion of, of a couple of cases if you don’t mind. [00:33:00] The, the first one, being the first must not miss on your list as well, the colon cancers.
So talk us through a a kind of a classic colon cancer case, if you would, with presentation.
Lauren Campitelli: So this isn’t really a patient specific example. I just think it’s general and applicable to a lot of patients that present with colon cancer. They will typically present to the office with abdominal pain, some rectal bleeding, sometimes some weight loss. But typically they’ve already had some sort of primary care workup.
A lot of people will see their PCP first with abdominal pain or with a little bit of rectal bleeding, and that’s when they come to see us. They don’t always have abnormal labs. If they do, it’s often in iron deficiency anemia. But PCPs will, they tend to refer patients to us once they’ve already started that abdominal pain workup and they’ll refer them to us to see does this patient need a colonoscopy, even if they’ve had one already.
Do they need another one [00:34:00] was their last colonoscopy five years ago, 10 years ago. So that’s when gi in the outpatient realm, we tend to take over.
Dr. Hare: Okay. Okay, so let’s move on to the next one. And this one, one is not one that we’ve broached just yet. And that is GI bleeds in general and obviously could potentially be colon cancer in those instances. And you know, I I, I feel like I’ve talked about this a lot lately with my colleagues and students, but the idea that.
GI bleeds can present in a variety of ways, and usually we get some clues as to where the bleed is, depending on how close it is to the exit to the rectum versus Hema emesis and GI side or on the gastric side. Tell us about GI bleeds and where you start with your diagnostic process on those
Lauren Campitelli: GI bleeds are very tricky.
It’s not something, it’s one of those things that I have found has [00:35:00] diverged a little bit from the way that you learn about them in textbooks. So even if you’re seeing a patient who’s having bright red rectal bleeding, sure it could be in the colon, but it also could be a very brisk upper GI bleed. So that’s something that comes with time and hearing a lot of different patient stories, seeing their hemodynamics and seeing their labs.
That kind of has to guide your decision making. Should we start with an endo? Should we start with a colon? Should we do both at the same time? You know, we often see patients in the outpatient setting or in the clinic who said, well, I was having diary. It was initially black and then it was red, or vice versa.
So you just have to use your judgment and look at their hemodynamics, and if you have a feeling that there still could be something going on, even if they’ve had an endoscopy that’s negative, then it’s time to move on to the colonoscopy. And sometimes, like we talked about even getting a capsule endoscopy.
And so
Dr. Hare: what are the most common places in the [00:36:00] GI tract to have a bleed?
Lauren Campitelli: So for the lower GI tract, we’ll often see diverticular bleeds, and those can be tricky to diagnose. Oftentimes when we do a colonoscopy, the bleeding has stopped. So there are some recommendations that if you see a patient, the first test with lower GI bleeding, if it’s hemodynamically significant, should actually be a CT angiogram.
Can we catch that bleeding in action and sometimes even send them to IR? For embolization and the upper GI tract, it’s very, very common for us to see ulcers, especially on our patients with NSAIDs. So I would say that’s the most common cause of upper GI bleeding that I see, and certainly with lower GI bleeding, it’s those diverticular pockets.
And
Dr. Hare: then do you do a lot of H Pylori testing?
Lauren Campitelli: We do a lot of h pylori testing. Certainly whenever a patient has an upper endoscopy, if they are able to have biopsies, if their coags would permit, then we will take biopsies for h pylori in the gastric antrum. If for some reason they did not have biopsies [00:37:00] during their procedure, we will do either breath testing in the office or stool testing.
The only. Thing that makes that a little bit difficult is they have to be off of proton pump inhibitors. So if a patient has an acute ulcer, we have to take into consideration when it’s appropriate to stop PPI therapy to test them for h pylori. Oftentimes when a patient has a gastric ulcer, we like to repeat an endoscopy within about three months to make sure it’s healing appropriately.
So at that time, if for some reason they did not have a biopsy during their first scope, they will have one during the second to rule out h pylori.
Dr. Hare: How is an embolization done and is that the standard, I suppose, for a GI bleed anywhere in the system?
Lauren Campitelli: So, I don’t know if I would say it’s necessarily the standard.
Some of the guidelines are suggesting that getting a CT angiogram and maybe IR embolization is an appropriate first line, but colonoscopy after an active bleed is also very appropriate first line as well. So the IR [00:38:00] embolization is done, they just insert cath mm-hmm. To the spot that’s bleeding. Okay. And usually put like a coil in it
Dr. Hare: And then you come across a bleed during a colonoscopy, what is the procedure for stopping the bleed in that moment? Is that a colonoscopy attachment?
Lauren Campitelli: So we see there are a few different ways to stop bleeding during a colonoscopy. Typically, it’s all done through the scope.
We can apply clips, hemo clips, some doctors will apply hemo spray typically for upper GI bleeds. And there’s a p c. Argon plasma coagulation therapy that they will use, depending on the type of bleed in the site, will typically dictate what type of therapy they choose. Okay.
Dr. Hare: the GI Bleed symptoms backing up just a little bit to the, to the earlier presentation of GI Bleeds, what are the most common ways in which those patients show to either primary care or the emergency room or to the GI service?
Lauren Campitelli: I would say if it’s in the outpatient setting, typically it’s bleeding [00:39:00] that has stopped or bleeding. That’s very minimal. If you’re seeing melena in the outpatient setting, it’s usually a patient who comes in and says, I was having some dark bowel movements a few weeks ago, but they’ve stopped. Typically if they persist longer than that, they would’ve reached out to their family doctor or to us and said, Hey, I have black bowel movements.
And we’ll say, go to the ER immediately. If it’s in the inpatient setting or gi I, it can really be a wide array, even if it just sounds like hemorrhoidal bleeding. We will see patients in the emergency department, they’ve had bright red blood one wiping, and we kind of have to risk stratify those patients, get a thorough history, look at their chart and see if they’ve had a colonoscopy to completion to determine next steps.
Dr. Hare: you had mentioned previously the iron deficiency anemia question, so presumably there are some folks who in the outpatient setting have iron deficiency as a result of the bleeds
Lauren Campitelli: or not. Oftentimes, or just occult bleeding that they can’t see. They will tell us they’re [00:40:00] having normal brown bowel movements every day.
Sometimes when we test their stool, we will see blood, sometimes not, but that still certainly warrants the thorough GI evaluation.
Dr. Hare: the next one on your list are cirrhosis cases. Tell us a little bit about the presentation of those folks.
Lauren Campitelli: So we see a lot of cirrhosis patients in the hospital.
Typically whenever we are seeing them in the hospital, it’s for decompensated cirrhosis. So for ascites, for hepatic encephalopathy. Even for variceal bleeding, which typically is brisk and very significant. So those are the patients that we typically see with cirrhosis in the inpatient setting. On the outpatient setting, we typically will see these patients for monitoring.
So these patients have a higher risk of hepatocellular carcinoma, so it’s very important to make sure they’re up to date on their imaging and their afp. So our practice, we get an abdominal ultrasound in an AFP every six months.
Dr. Hare: you, you mentioned ascites and hepatic encephalopathy. Are those some of [00:41:00] our more common, the more common issues that you see at presentation?
Hyperammonemia as a result of the encephalopathy or as a result of the the hepatic issues can cause some mental status changes in those moments. Is that often a presenting symptom for those folks?
Lauren Campitelli: It can be. We will see some patients who come in with confusion. Oftentimes, cirrhosis, I will say, presents in a more vague way, and those patients who don’t carry a diagnosis of cirrhosis and don’t know that they have it yet will often come either to the clinic or to the hospital saying, I just don’t feel right.
I’m losing weight. They have maybe some bloating that’s actually ascites, but they look down and they see that their abdomen is bigger, so they will describe it as bloating. It’s usually those patients that we see that we ultimately then diagnose with cirrhosis. Usually the patients that we see that are coming in for recurrent ascites or hepatic encephalopathy are already aware of the diagnosis of cirrhosis.
Dr. Hare: And so most of [00:42:00] those patients presumably have a significant alcohol history?
Lauren Campitelli: Typically? Yes. And I will say just anecdotally from working in this GI service, a lot of people that I work with will say that they’ve seen a lot more of that through covid, and especially in younger folks, unfortunately.
Dr. Hare: So people drinking alcohol younger in a more significant fashion? Yes. Yeah. Okay. Are there any diagnoses that can lead to cirrhosis that are not alcoholic?
Lauren Campitelli: Yeah, so something that we worry a lot about is the progression of fatty liver disease. So NASH causing fibrosis and ultimately cirrhosis. We worry about some autoimmune diseases.
I actually had an interesting case where a patient came in with elevated LFTs and when she went through her. Baby book that she had, she found that she always had elevated LFTs and we ended up diagnosing her with primary biliary cirrhosis and other autoimmune diseases. And certainly viral diseases like hepatitis we worry about as well.
Dr. Hare: Next on the list is acute pancreatitis. [00:43:00] And I’ll be honest, when I see acute pancreatitis on somebody’s list, I immediately look to see if they are npo, if they are not allowed to eat anything, because that’s my often the assumption. But tell us about how acute pancreatitis presents
Lauren Campitelli: yeah, so the most common causes of acute pancreatitis would be gallstones or alcohol use. I think it’s an interesting one to talk about because I think whenever you learn about it, you typically think in your mind that it’s gonna be a very obvious presentation. This patient’s gonna have epigastric pain that radiates to the back.
They’re gonna have nausea and vomiting. And while that certainly is the case in a lot of patients, it’s not always, we actually had an interesting case where we had a patient with a longstanding history of gastroparesis. She came to the hospital complaining of epigastric abdominal pain. She said, feels a little different than my gastroparesis, but I think that’s what it is.
She ended up having a very severe acute pancreatitis. I think it’s an interesting talking point and just something we have to keep in our minds [00:44:00] that some patients don’t always present very acutely. They don’t always have that classic pain that radiates to the back.
Dr. Hare: working in family medicine myself, knowing that , one of the things that happens a lot is someone comes in and says, yeah, I’ve got this abdominal pain, but I have this, but I have a history of cholelithiasis, for instance.
you know, it feels a little different this time, but you know, I have, I have those gallstones and, and that’s something that is easy to. Overlook the potential for it being something else, especially when these ducts are involved and have the potential to cause more significant issues in other organs around that biliary tree.
Lauren Campitelli: Right? And that is something we see all the time in the clinic and we have to kind of parcel through with thorough questioning. So even a lot of patients who have gerd, they will attribute maybe their chest pain. So whenever you’re questioning a patient in the office, what brings on your so-called gerd?
And sometimes they say just exertion. So we always have to keep our [00:45:00] minds open. Is this an exacerbation of gerd? Is it worsening, you know, whenever they eat or is it worsening whenever they’re up and walking around 50 feet? So something we always have to keep in mind. Yeah, it’s
Dr. Hare: been a, a, something that I have spent more and more time thinking about with GI module here in, in our teaching in the PA school, is the idea that GI has such vague presentation sometimes that you, the history has to be so complete.
If you miss history questions that are pertinent to whatever might be going on for them, you might miss the, the ultimate answer there. You know, and of course the potential for that to become acute and acute abdomen can certainly cause some significant m and m in those cases. And of course the imaging side of things to, to make sure that you’re not missing something is also So crucial
A consistent theme in GI medicine . Okay. And the last one you have on your list for cases is Diverticular disease. This one, you know, I, it’s interesting that this used to be considered a [00:46:00] dietary concern. Something that, well, this, this person has been eating seeds and nuts, things of that nature.
And that was thought to be causative for some cases of diverticulitis. Diverticular D disease. I’ve seen some studies recently that have shown that isn’t less so, less concerning now with the seeds and nuts and things of that nature and the diet that can cause those kind of pocket conditions.
What do these patients generally look like when they walk in the door? Or do they walk in the door?
Lauren Campitelli: That’s a good question. So it’s variable depending on the patient.
I will see patients who come into the office with a nondescript left lower quadrant pain. Some patients who will come in and say, well, I had this and it got better. And sometimes people will even present in the hospital setting more acutely ill. Or even with a diverticular bleed. It is very variable.
Even just the presentation with diverticulitis, you know, the classic cases left lower quadrant pain. But yeah, it, I think that is an interesting thing to touch on are the, the dietary changes. So we used to think [00:47:00] that eating seeds, nuts, popcorn, could lead to flares of diverticulitis, but we don’t really find that to be true anymore.
Whenever you look at the most recent data, we’re not really sure what causes flares of diverticulitis. We do know that decreasing. Heavy, high fatty foods in the diet, decreasing red meat and increasing exercise and fiber can help decrease flares of diverticulitis. But we don’t typically recommend to patients that they refrain from eating fruits with seeds popcorn anymore.
Now we certainly have patients who’ve had diverticulitis that say when they eat those things, they have some GI upset, in which case certainly continue to avoid those, but it’s not something that we blankets tell people to avoid anymore.
Dr. Hare: diverticular pain that those patients usually experience on presentation is that an acute kind of presentation or is that something that patients like to walk into the clinic with.
Lauren Campitelli: I think it depends on the patient, and I think it depends on if they’ve ever had diverticulitis [00:48:00] before. You’ll find that that’s one of those things. A lot of patients with abdominal pain will say, well, I have this pain, but it’s just my diverticulitis. So if it’s a patient who’s had experience with that before, they will usually, and even the data supports this now, switch themselves to a clear liquid diet for a few days.
If their pain is still present or worsening, that’s when they’ll typically start antibiotic therapy. If it’s their first case of diverticulitis, oftentimes patients will present to the emergency department or present for a more acute visit with this pain. But a lot of patients are aware of diverticulitis.
Everyone knows someone who’s had it. So for the most part, people are very familiar with that. But the things that we have to always keep in the back of our minds are ruling out a micro perforation or an abscess. It’s not uncommon to see a patient who has been on antibiotics, They feel that they’re improving, but they still could have a complication like that.
Dr. Hare: So on antibiotics from a diverticular issue. Right. you do an [00:49:00] empiric antibiotic for a diverticular potential abscess?
Lauren Campitelli: So, that’s a good question. A lot of people will treat diverticulitis flares empirically. I tend to have the patients come in for an acute visit, again, just so you can feel their abdomen.
I actually had a case fairly recently where I saw a patient, she was started on antibiotics already. She was feeling a little bit better when I pressed on that abdomen. She was uncomfortable. And another thing that kind of tipped me over to want to get an image was that she had a fever of 1 0 1. And although she was feeling better, she was on antibiotics, she actually had a micro perforation with an abscess.
So it’s just, I can never really fully rule that out just based on the patient’s symptoms and if they’re improving or not.
Dr. Hare: And so how, common is it to go straight to the antibiotic in that situation? in a diverticular abscess?
Lauren Campitelli: in the outpatient setting, that usually will depend on the size. If it’s very, very small and the patient is starting to feel better, sometimes we will have them do a longer course of antibiotics.
But typically we will have them go to the emergency department and actually have a [00:50:00] drain place to drain that abscess.
Dr. Hare: And do you bring them inpatient during that time, I assume? Typically, yeah. Yep. And then what’s your first line empiric
Lauren Campitelli: a lot of times we opt for Zosyn.
That’s something that we typically leave up to the surgeon at that point because they’re the ones that will guide management with any sort of abscess or perforation at that point.
Dr. Hare: How often do you see, and I just wanted to throw my own differential in here. How often do you see reflux disease in your service?
Lauren Campitelli: All day. All day. I will say a lot of my visits are for reflux disease. Okay. It is a very common complaint in the clinic. And a very important one.
Whenever you take into consideration the side effects that we can see from proton pump inhibitors and how long patients need to be on therapy, we see a lot of that, especially gerd, that is refractory to treatment. A lot of primary care physicians are comfortable treating gerd, but whenever a patient has been on multiple PPIs or a PPI twice daily, and they’re still having a lot of symptoms, that’s often when we will see these patients.[00:51:00]
And again, we take those red flags into consideration. Has the patient had an endoscopy? Do they need an upper endoscopy? And that’s something that will maybe even lead us to diagnosis of Barretts, which I think is a good topic to discuss. Barretts is something that we, as a practice follow long term.
So if we see someone with a diagnosis of Barretts, we will repeat an upper endoscopy in one year and then every three years after that to make sure there’s no dysplastic change that needs treated.
Dr. Hare: I had this question asked of me, and I did not know the answer to it. What does it look like?
What does Barretts look like on an E G D?
Lauren Campitelli: So Barretts you’ll typically see described as salmon colored mucosa and sometimes even in, an irregular Z line. So that Z line is where the esophageal tissue meets the stomach tissue, but the biopsy is really what’s most important there. And the biopsy, they will note intestinal metaplasia with or without dysplasia, hopefully without.
Mm-hmm.
Dr. Hare: the presenting symptoms for reflux disease, [00:52:00] in my experience, have been, are, are highly variable. Some, some patients having significant symptoms, some patients have little to no symptoms of reflux and it’s discovered later on. what sort of odd presentations do you see in, in these patients
Lauren Campitelli: So some of the outliers are certainly chronic cough. Mm-hmm. We will see patients who say, I’ve seen ear, nose and throat. I’ve seen pulmonology. I’ve had this cough for years. It gets worse when I lie down. And that will often lead to a diagnosis of gerd typically, that cough will improve over time with appropriate management, whether it be with PPI or Pepcid.
Mm-hmm.
Dr. Hare: About horse voice. Is that possible?
Lauren Campitelli: Yeah, so we will see patients who present with hoarseness. Typically at that point, they’ve actually already seen ear, nose, and throat, and the ear, nose and throat doctor, if they’ve done a scope, will say, looks like acid damage.
They’ll refer the patient to us and we’ll do a full endoscopy. And that’s something that typically will improve with [00:53:00] PPI therapy as well. Something that we also see in the office is chest pain, which is a little daunting to see in the outpatient setting. As a GI physician assistant, we don’t have EKG in the office.
So whenever you see a patient with chest pain, you have to be really careful and go back to your history. Is it worsening with exertion or is it worsening when you lie down at night after you have a, you know, a big meal. And typically we will always discuss with the patient that they should also discuss their symptoms with their family doctor loops their family doctor in to make sure they wouldn’t benefit from any cardiac testing.
Dr. Hare: And I’m sure they appreciate having you in the GI service coming from the emergency room because you probably have seen some chest pain
Lauren Campitelli: oh, absolutely. And it’s not something typically, once the patients are getting to us, for the most part, they have had a cardiac evaluation that has been negative and that’s how they end up seeing us for chest pain that may or may not improve with treatment of their [00:54:00] gerd.
But there was one patient very specifically that comes to mind. I was sitting down with her and I asked her, what brings on your chest pain? And she said, it’s only when I walk, I get so short of breath and I have such bad chest pain, I can’t even cook breakfast. And I thought this might not be the right place for right now.
I’m happy to order an endoscopy once we make sure everything else looks okay. But I think we need to do some due diligence here first.
Dr. Hare: Yeah it sounds like it. I talk with students about the possibility of PRN treatments like Tums in Mylanta, , calcium and mag as both treatment and diagnostic in those moments.
So if you can give someone a PRN and acid and it really makes that feel better, more or less immediately, it’s likely to be stomach acid in that moment and refluxate?
Lauren Campitelli: . I do like to use that trick sometimes with patients. I tend to use that trick more so in patients who have upper abdominal pain, and their imaging has been negative or, and we’re not really sure what’s causing their symptoms.
So I will tell them, [00:55:00] take a Pepcid, take some Tums and let me know what happens. That’s often a, a nice little trick to use.
Dr. Hare: Yeah, it’s Probably more of a emergency room or a primary care trick than it would be for, for you all given what you have at your disposal and gi.
But it is kind of an, an interesting and simple trick. That’s a rural medicine trick probably as well. How about H two blockers that used to be the mainstay of treatment for reflux and acid diseases. What are the current uses of H two blockers in
Lauren Campitelli: general? So we tend to use H two blockers.
It really depends on the frequency of symptoms. If a patient is having two plus days a week where they’re suffering from reflux disease, we’ll typically start them on a ppi. We will often also use Pepcid in conjunction with PPIs. So in our patients who are having. Reflux disease that is very hard to treat.
We will use, say, Protonix once or twice a day, and then maybe even a Pepcid at night. So if a patient’s saying, you know, I feel great for most of the day, but when I go [00:56:00] to lay down at night, I have awful reflux. Or they wake up with reflux, we’ll have them take some Pepcid at night or maybe even before lunch.
But if they’re having symptoms once every two weeks or just once a week, typically, that’s when we would use Pepcid.
Dr. Hare: And so it becomes a PRN treatment. And you have to, in some ways, I suppose if someone is suffering significantly enough from reflux and GERD that they will be able to anticipate then when those moments are occurring and, and get after it with a, with a an H two blocker, my experience has always been it’s difficult to get a patient to anticipate the moments
Lauren Campitelli: I will often tell my patients to try to take Pepcid even before a meal. So if they know they’re going to go out to dinner and have spaghetti or have a glass of wine, take some Pepcid 10 to 60 minutes before that meal to try to hopefully ward off any symptoms. But we will have patients who we will have take, take Pepcid on a scheduled basis once or twice a day.
Dr. Hare: In my patient population [00:57:00] in the psych hospital, it, a difficult get sometimes to have that anticipation of, of the issue. And it is so much easier to prescribe a once a day ppi, I think for a lot of folks, and certainly for a lot of patients who, for whom compliance and that anticipatory dosing can be difficult.
Lauren Campitelli: Yeah, and we try to limit the use of PPIs if we can. The main complication that we worry about is a long-term risk of osteoporosis because as we’re decreasing the amount of acid in the stomach or decreasing absorption of magnesium, vitamin D and calcium. So that is something that we have to worry about on those patients that maybe have reflux.
But if they take a three month period of a PPI and they’re feeling a lot better, can we taper them off of it? Some patients are very resistant to tapering off, or they try and their symptoms return. And certainly our Barretts patients, we keep on PPI therapy indefinitely, but for those patients, if we’re able to get their reflux disease under control, we certainly like to limit the PPIs as much as we can.
Dr. Hare: B12 absorption impacted by PPIs.[00:58:00] I think it is. It’s already difficult to get good B12 absorption of course. . We’d like to keep an eye on that In my setting certainly as well.
Okay. good information here. I would like to kind of finish off if you would, with the discussion of the potential referrals because family medicine is where we come from in physician assistant studies. We like to talk about the general aspect of things. When do family medicine, PAs, or emergency room PAs in, in some situations geriatricians pediatricians use your service and where would we consider using your service?
the first one you have on the list is the one we were just talking about, and that’s refractory gerd.
Lauren Campitelli: Yeah, we see a lot of refractory GERD referrals from primary care, whether it’s that the patient needs an upper endoscopy or they’ve already had one and the PCP just really doesn’t know where to turn.
So sometimes we will do a bravo pH capsule where we actually attach a capsule to close to the GE junction that measures episodes of reflux to see if [00:59:00] the patient’s symptoms are correlating with true episodes of acid reflux. Well, so that’s something that we will often do if we’re having a patient with refractory gerd, depending on what their endoscopies have looked like.
So that’s something that we see a lot. Is that an office procedure? That is something that’s done in the GI suite, so it’s done at the time of an upper endoscopy.
Dr. Hare: Interesting. Okay. The next one on the list that you have is rectal bleeding. And I think this is probably one of those conditions that is gonna spur a lot of folks to seek immediate help
what happens in the family medicine side and then how, what do those patients look like arriving at your service?
Lauren Campitelli: So usually on the family medicine side, I think what they take into consideration is, has the patient had a colonoscopy? And if so, how Recently?
I think a lot of times when they send a patient to gi it’s that they’re not necessarily comfortable making a call of, well they had a colonoscopy two years ago, do they need another one? Mm-hmm. So that’s something that we do see a lot. A lot of times primary care physicians are comfortable treating rectal [01:00:00] bleeding initially, or they’re comfortable ordering a colonoscopy directly without the patient having to see GI first.
Mm-hmm. But it’s those patients that have had a colonoscopy fairly recently or their bleeding has returned or become more severe, that we will see patients in the office and we see a lot of self-referrals for rectal bleeding as well.
Dr. Hare: Persistent nausea and vomiting. What’s your differential list for persistent nausea and vomiting?
Lauren Campitelli: That is a tough one. I will say that is, that is one that we see a lot even in the emergency room, but certainly in the outpatient GI setting. Something that we diagnose a lot is actually gastroparesis. Mm-hmm. I think that’s, that’s sometimes a difficult one because when you think of gastroparesis, you often think of what are the risk factors?
Do they have diabetes? Do they have some sort of neuropathy? But a lot of cases of gastroparesis are idiopathic. We just don’t know why the patient has them. So if you have a patient with persistent nausea, vomiting, especially if they’re describing fullness or at least satiety, tidy vomiting of what looks like food shortly after meals, then that’s a [01:01:00] patient that we, you know, will consider for gastroparesis testing.
we see a lot of even cyclic vomiting. That was something I saw in the emergency department quite frequently. Cannabinoid Hyperemesis.
It’s a very difficult conversation to have with patients, especially because they find that when they use marijuana products, they feel better. So how do you tell a patient who feels better when they do that? That that could be the cause of their symptoms? And unfortunately, it’s not an immediately gratifying thing to stop using marijuana products.
It usually takes weeks or a few months for them to notice a significant improvement in their symptoms. So that’s something very difficult and a difficult conversation to have.
Dr. Hare: The next one on the list is on the other side, persistent diarrhea and or constipation. And I’m assuming that IBS is gonna be on a high on the list there.
Lauren Campitelli: Yeah. So I b s. That’s something, again, a lot of primary care physicians are comfortable, or physician assistants are comfortable treating at first, but it’s whenever we get into the realm of nothing seems to be working, where do we go from [01:02:00] here? A lot of PCPs or primary care PAs are very comfortable, ordering stool studies, ordering even Ermine or MiraLax for constipation.
But in those patients, especially patients with ibs, it’s a somewhat frustrating process to find that medication and the regimen that works well for them. And it’s very different and variable for everyone.
Dr. Hare: The ones that I have the most difficulty with are the ones that swing back and forth between diarrhea and constipation, because you just me as well, don’t know what’s gonna show up.
Yeah.
Lauren Campitelli: That is one of the hardest to treat. Yeah.
Dr. Hare: And then the last one, everybody’s favorite abdominal pain. determining just how urgent the concern is in abdominal pain is something that we talk about a lot here. Abdominal pain can have a lot of really significant and difficult causes associated with it.
where do you start with that? When you get an abdominal pain patient, what’s your approach?
Lauren Campitelli: I will say a lot of our abdominal pain patients come in with a fairly significant workup already, whether it’s from primary care Okay. [01:03:00] Or they’re a referral from the emergency department. The ER told them to follow up with us.
Typically, these patients have some baseline labs for comparison. They have some abdominal imaging. That’s when we kind of have to start thinking out of the box. So whenever you have a patient who’s had a lot of testing, whether it be from primary care or the emergency department, you just have to think, what are we missing?
Mm-hmm. If it’s upper abdominal pain with bloating and nausea, could it be SIBO? That’s something that I was not at all familiar with until I started working in gi. Okay. So describe that if you would. Yeah. So SIBO is small intestinal bacterial overgrowth. A lot of the bacteria in our gut should be limited to the colon, but for some people they have that colon bacteria kind of creeps up the small bowel and can cause a lot of uncomfortable GI symptoms.
Nausea, abdominal pain, vomiting. The more common and more prominent symptom is bloating because we have an increase in bacteria throughout the small intestine that feed on carbs. So [01:04:00] whenever patients eat, they get really uncomfortable. Now that’s actually diagnosed through a breath test where we have a patient take lactulose, which was very carb heavy.
Yeah. And do a breath test to see how much hydrogen they’re producing in their breath. Oh, that’s interesting. So those are things that, you know, we kind of have to think outside of the box. And even if a PCP or primary care PA thinks that maybe they think that in their note, it’s in their differential, they’ll typically send the patient to us to consider testing once it’s kind of getting into that realm
Dr. Hare: oh, see, now you’re making me more, more interested in GI because I do appreciate that the, the Sherlock Holmes aspect of digging into things and trying to find those, those aspects, those, the little thing that that tips you off as to what might be going on. As opposed to just throwing all the tests at them.
Lauren Campitelli: Right. And I think it’s a good mix between structural issues, but also functional things like sibo, things like ibs. there’s a lot to figure out. And usually if, you know, if you can spend the time with a patient and ask them a lot of questions and just let them talk, usually it’ll lead you [01:05:00] down a path.
Might not always be a hundred percent correct,
Dr. Hare: but, and then so one last question for you about the abdominal pain as you describe, as we’re describing it, and this probably is more of an an emergency room setting kind of a thing. Tell me about the rebound tenderness and guarding. What goes along with those peritoneal signs as diagnoses that you get concerned about in that, that acute abdominal pain patient?
Lauren Campitelli: So whenever you examine a patient that has those signs on exam, the things you have to be very wary of or any sort of perforation. Most recently, the one that comes to mind, we had a patient with a perforated ulcer and she seemed tough.
You know, she wasn’t complaining of a lot of pain, but whenever you examined her abdomen, you just knew that there was something surgical there. So certainly any sort of perforation is something that you have to keep very high on your differential. The other thing, kind of the flip side of that, not necessarily related to exam, but actually something out of proportion to [01:06:00] exam is mesenteric ischemia.
I think that that’s something we added to our must not miss diagnosis because that is something that is easy to miss. Mm-hmm. Maybe a diagnosis on the flip side where a patient’s abdominal exam might be more benign, but their pain is very significant would be mesenteric ischemia.
So that’s something we also have to keep in the back of our minds. If you see a patient in the office setting or the ER setting, just because their imaging is normal and you press on their abdomen and everything feels soft and feels okay, they could still have some sort of mesenteric ischemia. Usually in that case when it’s so acute and onset as opposed to chronic where they may have collaterals formed.
It’s usually a very acute and severe presentation.
Dr. Hare: And that, often comes along with clotting, right? Clotting elsewhere in the body
Lauren Campitelli: typically. Yeah. So, Whenever you look at a patient, usually it’s a patient who has other sort of risk factors, atherosclerotic disease a significant smoking history.
Those are the things that you would take into consideration.
Dr. Hare: And, and usually an older patient or a patient with some [01:07:00] coagulopathy maybe. Sure. Maybe an untreated coagulopathy going on. It has been a joy to talk to you as, as always appreciate you coming back and talking with us.
I’m sure our listeners appreciate it as well. And well looking forward to hearing how the years in gi treat you thanks very much for your time today, Lauren. Of course.
Lauren Campitelli: Thanks for having me.
Dr. Hare: many thanks to our esteemed guest, Lauren. Campitelli, GI PA.
That’s it for now. Be sure to check out the podcast [email protected]. For more episodes, show notes and full transcripts of every show. Email us at Contactbeexcited@ gmail.com with questions, comments, or future show suggestions. And of course follow us on Facebook and Instagram at Be Excited Podcast for news, new episode, notifications, and maybe a picture or two.
Thanks for listening and remain excited.
