Dr.

MO SOBHY [GASTROENTEROLOGY]
 Dr. MO SOBHY [GASTROENTEROLOGY]

Gastroentrology
Key points:

1- Any GIT station, you should explore presenting complain,

then ask about these
(abdominal pain- diarrhea- constipation- vomiting- Fever) if
you have one of the symptoms ask about the others.
2- When you are thinking about differentials of abdominal
symptom, then think of what’s in the abdomen
A- GIT :
 Difficulty on swallowing
 Pain on swallowing
 Abdominal pain
 Nausea
 Vomiting
 Diarrhea
 Constipation
 Fever
B- Urine:
 Pain on urination
 Smelly urine
 Colour of urine
 Blood
 Fever
 Frequency
 Urgency
 Nocturia
 Dr. MO SOBHY [GASTROENTEROLOGY]

C- Female genital:
 Period questions
 Sexual history
 Exclude pregnancy
 Procedure in the front passage
3- FLAWS (must be asked)
4- If the station is diarrhea or constipation you must ask about
THYROID
5- Always ask about the risk factors for which the patient is
having this condition
6- On examination you must check ( observations/ tummy/
back passage).
7- In management of most GIT cases you should focus on
lifestyle modifications
8- Any diarrhea case you must ask about :
VVIMP:
 Dehydration
 Contact history
 Travel history
Dr. MO SOBHY [GASTROENTEROLOGY]

Scenario 1 (constipation due to Codeine):

You are an FY2 dr in the orthopedic
department 85 yrs old Tanya has had hip
operation one week ago, since then she is
having constipation. Take history and address
her concern.
Hi, how can I help you??

Can you plz tell me what do you mean by constipation

a- Is it that you don’t pass stool at all OR

b- You strain to pass stool?

 Explore constipation
 Then ask about the rest of GIT symptoms
(any tummy pain/ diarrhea alternating/ vomiting/ fever/
nausea)
Then the DDS of constipation:
1- Intestinal obstruction (abdominal pain/ vomiting/
constipation/ no flatus)
2- Bowel cancer (Alternative bowel habits/ blood in stool/
FLAWS)
3- Rectal cancer (tenesmus feeling of opening bowel but
nothing comes out)
4- Anal fissure (pain in the back passage on defecation/
fresh blood sticking on stool)
Dr. MO SOBHY [GASTROENTEROLOGY]

5- Haemorrhoids (fresh blood splashing in the toilet/

mass on the back passage)
6- Medications (mainly codeine and morphine)
7- Medical conditions (mainly thyroid hypothyroidism)
8- Inflammatory bowel disease (FLAWS/ mucous in stool/
mouth ulcers/ joint pain)
9- Life style causes (immobility/ dehydration/ diet)

FLAWS

P2
 Have you had this constipation before
 Any medical condition? 5 mainly conditions mainly
thyroid

P3
DESA

You must ask about diet and fluids

MAFTOSA
Medications: patient will mention that is on the
codeine (explore)

It is a must to ask patient, if she developed

constipation before or after using codeine

Examinations
Observation

Tummy
Dr. MO SOBHY [GASTROENTEROLOGY]

Back passage (examiner will tell you hard stool in

rectum)

Provisional DX: I think codeine could be the reason

why you are having constipation (Open BNF) and show
the patient

N.B:

1- make sure when you are taking hx if you ask a

question, don’t repeat it again.

2- Maximum 4 or 5 differentials, but you must ask

about the most dangerous first

Management (ARMMS):

Advice Risk factors

Advice about diet Diet

Plenty of fluids Dehydration

Mobilization Immobilization

Stop the medication and Medication that patient is

assess the pain and using
prescribe another one

Medications:

1- Laxatives (oral) : lactulose/ bisacodyl

2- Suppository: bisacodyl
Dr. MO SOBHY [GASTROENTEROLOGY]

3- Enema: Docusate
4- Mannual evacuation

Multidisciplenary team: (MDT)

Multidisciplerny team for pain relief to replace codeine or
pain team

Investigation:
Blood: FBC- U&E- electrolyte- TFT- serum ca
X-ray abdomen

Safety netting: (FLAWS)

And if constipation continuous after all these methods
then Colonoscopy.

Scenario 2 (Eldery lady constipation &here

you are talking to the nurse)
87 yrs old Maria, was admitted in orthopedic
department due to fall, she is drowsy, talk to
nurse looking after and discuss management
Note :
1- You are talking to nurse, so your IPS marks will be in
the way you are talking to nurse, if she’s done anything
praise her
 Dr. MO SOBHY [GASTROENTEROLOGY]

2- Here presenting complain is (drowsy??) make sure you

explore drowsiness and ask about fever to exclude
infection or sepsis.
3- In this scenario drowsiness and constipation will be
due to codeine again
4- The nurse has examined the patient and when you ask
her about the findings she will tell you NO hard stool
found (plz praise her)
 Hi iam dr…, how may I call you??
 How are you doing?? (IPS with nurse)
 How can I help you ??
 May I know the name of the patient? Age?
 Why is she in the hospital?
 What’s wrong with her? (drowsy & constipation)
 Explore constipation same as previous station
 What do you mean by constipation?
 Then 5 symptoms (any tummy pain/ diarrhea/
vomiting/ nausea/ fever)
 DDs for constipation:
1- Intestinal obstruction
2- Bowel cancer
3- Tenesmus

Exactly same as previous station

Note: pt is not opening bowel at all

Pt is also having diarrhea (overflow diarrhea)

FLAWS
 Dr. MO SOBHY [GASTROENTEROLOGY]

P2
 Past history of presenting complin
 Past medical conditions (5 conditions mainly thyroid)

P3
DESA (vimp diet, exercise ask about mobility)

MAFTOSA (Co-codamol): explore medication and has

constipation started before or after

Note:

Be careful patient here hasn’t had operation

Examination:
You’ll ask nurse have you examined her? She’ll say yes then ask
what are the findings? ((No hard stools))

Then you must verbalise examination (observations/ tummy/ back

passage)

Provisional D: Iam suspecting that the constipation could be due

to Co-codamol also drowsiness and had diarrhea am suspecting
that it could be due to overflow diarrhea

Note :

Here there is no hard stool, so here no enemas, only laxatives oral

&suppository also you must say if patient continue to have
constipation after medication ((COLONOSCOPY))

Management (ARMMS):
 Dr. MO SOBHY [GASTROENTEROLOGY]

Stop the medication and assess the pain and prescribe another
one Medication that patient is using

Advice Risk factors

Advice about diet Diet

Plenty of fluids Dehydration
Stop medication and assess pain Co-codamol
and give alternative
Mobilization I’ll speak to the Immobilization
orthopedics and physio to see
when we can start mobilizing
her

Medication:

1-oral laxatives if fails

2- suppository if fails

3-enema

Investigations:

Blood: FBC/ U&E/ TFT/ serum ca

X-ray abdomen

Multisiceplenary team:

1- Pain team
2- Physio to start mobilization

Safety netting:
 Dr. MO SOBHY [GASTROENTEROLOGY]

Must mention flaws and colonoscopy

Scenario 3 ( Diarrhea IBS)

50 yrs old man presented to the hospital (GP) with
history of passing loose stool, take hx , discuss
further management
 Hi, how can I help you?? diarrhea
 Explore diarrhea TRAC (timing/ relation to anything/
amount/ colour- consistency- nature- blood)
 Ask about rest of symptoms?? (constipation, tummy pain,
vomiting, fever)
 Then DDS of diarrhea
Acute diarrhea up to 3 weeks Chronic diarrhea > 3weeks
1- Gastroenteritis (fever/ 1- Bowel cancer
vomiting/
diarrhea/contact hx/
travel hx)
2- Medications Abs, PPIs, 2-Rectal cancer
Cemetidine
3-Laxative abuse 3- IBD
4- Alcohol 4-IBS
5-malabsorption
6-colonic polyps

Questions for DDs:

1- Bowel cancer:
 Diarrhea alternating with constipation
 Loss of weight
 Dr. MO SOBHY [GASTROENTEROLOGY]

 Loss of apetite
 Blood in stool
 Abdominal pain
 Anemia symptoms
2- Inflamatory bowel disease:
 Abdominal pain
 Weight loss
 Mucous in stool
 Joint pain
 Mouth ulcers
 Eye manifestations
 Cutaneous manifestations

N.B: exclude dehydration

3- Irritable bowel syndrome:

 Alternating bowel habits

 Abdominal pain
 Bowel problem (bloating)
 Change of bowel habit
N.B: symptoms more than 6 months not less
4-Diverticulosis:
 Left sided pain, relieved by defecation
 Altered bowel habits
 Risk factors: low fibre diet, obesity, smoking
5- Malabsorbtion:
 Stool difficult to flush
 Offensive smelly stool

FLAWS
Dr. MO SOBHY [GASTROENTEROLOGY]

P2:
 Pat hx of presenting complain
 Past medical conditions (5 conditions mainly thyroid)

P3:
DESA

 Diet in details caffeine, dairy products, bread, carbonated

drinks.
 Smoking

MAFTOSA
 Medication
 Travel hx is a must in diarrhea
 Contact hx is a must here
 Stress
Examination:
1-Observation
2-Tummy
Provisional DX:
You have a condition that affects your bowel, it’s a group of
symptoms (abdominal pain, bloating, change in bowel
habits) main risk factor is stress
Management:
VVVIMP to address stress
1- Advice:
 Healthy diet
 Plenty of fluids
Dr. MO SOBHY [GASTROENTEROLOGY]

 Address cause of stress and try to tell the patient

that it is the cause
2- Risk factors:
 Diet
 Dehydration
 Stress
3- Medication:
 Anti spasmodic : Mebeverine/ desipramine
 Anti diarrheal: loperamide
 Anti anxiety medication
4- Multi disciplinary team:
 Inv: routine blood (FBC/ U&E/ cholesterol/ TFT/ LFT)
 Stool culture
 If symptoms aren’t relieved after medications
(flexible sigmoidoscopy- colonoscopy- X ray-CT)
5- Safety netting:
Always safety nett for cancer FLAWS

Scenario 4 (IBD inflammatory bowel disease):

You are an FY2 dr in medicine department 55 yrs
old female, persistent to the hospital with hx of
loose stool for the last 2 months
Hi, how can help you?? Diarrhea
Explore diarrhea? TRAC
Ask about the rest of the symptoms:
 Dr. MO SOBHY [GASTROENTEROLOGY]

 Constipation
 Vomiting
 Fever
 Abdominal pain
 ALWAYS EXCLUDE DEHYDRATION

DDs same as the previous IBS but,

 Abdominal pain mainly (left lower part of tummy)
 Alternative bowel habit
 Redness/ pain in the eyes
 Joint pain
 Rashes
 Mouth ulcers
 Weight loss

Then carry on with the same DDs as previous IBS

P2:
 Past hx of presenting complain
 Past medical conditions (5)

P3:
DESA

MAFTOSA
(Abs/laxatives)/ travel hx and contact hx

Examination:
 Dr. MO SOBHY [GASTROENTEROLOGY]

 Observation
 Tummy (superficial palpation/ Mild tenderness left iliac
fossa)
 Back passage (no findings)

Provisional Dx: Auto-immune conditions where the body

defense mechanism attack it’s own cells by mistake.

A condition of the bowel where a part of your bowel is swollen

Management:
Unfortunately no cure for this condition

1- Admit + referral to gastro-enterologist

2- Senior
3- Investigation
 Blood (FBC/ RBS/ U&E/ cholesterol/ tumour marker)
 Stool culture
 X-ray abdomen
 Colonoscopy : camera test where we’ll pass a tube
with a camera on top through back passage
(patient will refuse use our refusal trick questions)
 If alternative to colonoscopy (Barium enema) : special
dye x ray but it’s not as good as colonscopy as we take
tissue sample
4- Sytpomatic and lifestyle:
 Amin-salicylate or corticosteroids to reduce
inflammation
 And immune-suppresants to reduce activity and
immune system
 Dr. MO SOBHY [GASTROENTEROLOGY]

 DESA: mainly diet

5- Specialist:
Gastro-entrologist who will do colonoscopy and explain it if
the patient is not responding to medication then surgical
removal of affected part
6- Safety netting:
FLAWS

Scenario 5 ( diarrhea bowel cancer):

You are an FY2 dr in emergency department 65
yrs old Scott presented to the hospital with
diarrhea
Hi , how can I help you?? Diarrhea
Explore diarrhea TRAC
Ask about the rest of GIT symptoms (constipation/ vomiting/
abdominal pain/ fever)
DDS!! Same as diarrhea in previous stations (acute &
chronic)

But bowel cancer symptoms:

1- Alternative bowel habits

2- Blood in stool
3- Loss of weight
4- Lumps and pumps
5- Loss of appetite
6- Ask about tenesmus
 Dr. MO SOBHY [GASTROENTEROLOGY]

7- You will have family hx and smoking

FLAWS (VVIMP in case u forget)
P2:
 Have you had this problem before?
 Medical conditions (5) mainly thyroid

P3:
DESA (DIET & SMOKING you must explore as it is risk
factor)

MAFTOSA (ABS, laxatives, F hx of bowel cancer)

Note:

Always in case of diarrhea ask about dehydration

1- Have you been feeling thirsty?

2- Dry mouth??
3- Reduced amount of urine?
4- Dizzy or about to faint

Examination:
 Observation
 Tummy
 BMI
 PR

Provisional DX: best case scenario it could be polyps which

are bening growth, worst case scenario it could be something
sinister which I would like to do further investigations to exclude
cancer
 Dr. MO SOBHY [GASTROENTEROLOGY]

Management:
1- Admit
2- Senior
3- Investigations:
 Blood: FBC/ RBS/ U&E/ tumour markers
 Stool culture
 Abdominal x-ray
4- Symptomatic (fluids +pain killers if in pain)/ lifestyle mainly
smoking
5- Specialist gastroenterologist (colonoscopy)
Do you know what colonoscopy is?
NO, it’s a camera test where there is a flexible tube with a
camera at the end of it will be passed through your back
passage to have a good look into your colon and get a tissue
sample
If patient refused??
Use our approach
 Why?
 Address concern
 Life threatening
 Benefits
 Senior
 If still refuse offer barium enema but we can’t take
tissue sample
6- Safety netting :
Metastasis (any lumps anywhere in the body, bleeding
anywhere)
Dr. MO SOBHY [GASTROENTEROLOGY]

Scenario 6 (diarrhea Gastroenteritis):

You are an FY2 dr in the A&E Lilly middle aged
lady presented to the hospital with diarrhea and
vomiting take hx and manage her
Hi , how can I help you?
Diarrhea ?? explore (TRAC)
Vomiting? Explore (TRAC)
Ask about the rest of GIT (abdominal pain/ constipation/
fever)
Then DDS : as previous stations of diarrhea (acute &
chronic)
But focus on presenting complain of Gastro-enteritis
So any gastroenteritis findings
Symptoms:
1- Diarrhea
2- Vomiting
3- Fever
4- Abdominal pain

Complications:

Questions of dehydration ‫و هللا العظيم هتنسي‬

1- Feeling thirsty
2- Not passing enough urine
3- Feeling dizzy or about to faint
Risk factors: ‫و هللا و هللا مهمه يا ابني جدا‬
1-travel hx in MAFTOSA
 Dr. MO SOBHY [GASTROENTEROLOGY]

2-Contact HX

3-Eating out in a resturant

FLAWS

P2:
 Have you had this condition before?
 Medical conditions (5) mainly thyroid

P3:
 DESA: eating outside
 MAFTOSA: (Abs/ laxatives) , travel , contact hx , eating out

Examination:
 Observations (exclude dehydration)
 Tummy

Provisional DX:
Gastroenteritis is a condition of your gut where there is
inflammation or swollen wall of you gut, it is self limited condition
as it’s viral infection

Management:
1- Admit only if patient shows signs of severe dehydration :
lethargy/ drowsy/ dizzy/ tiredness)
2- Senior
3- Investigations
 Blood: FBC/ U&E/ infection markers
 Stool culture
 Dr. MO SOBHY [GASTROENTEROLOGY]

 ABG for dehydration

4- Symptomatic +life-style
 Paracetamol for fever
 ORS: oral rehydration solution unless patient can’t
tolerate oral fluids and severe dehydration then IV
fluids
 Hygiene
 Washing hands
 Avoid eating out
 Advice about contact
 Sick note if working

I highly advice you to notify your employer as it’s highly

contagious

Also I highly encourage if you should tell health and safety to

notify about the restaurant

6-Safety netting:

 Persisting symptoms
 Signs of severe dehydration come right away

Scenario 7 (Dysphagia Oesophageal cancer):

50 yrs old, male present with dysphagia take hx
examine , discuss management you are FY2 in
emergency department
Hi, how can I help you? Difficulity swallowing
Explore
 Since when ? (acute- chronic)
Dr. MO SOBHY [GASTROENTEROLOGY]

 How did it start?

 Did it start with liquid first or solid first?? (cancer/
achalasia)
 Do you have any pain during swallowing? Exclude
infection
 Is it worse towards end of the day ? (Myathenia gravis)
 As it is accompanied with difficulity in talking? (Multiple
sclerosis &stroke)
Then ask about the rest of GIT symptoms?
(tummy pain , vomiting &diarrhea fever)
DDs difficulity of swallowing?
 Two from outside:
1- Corrosive have you ingested by any chance any
chemicals
2- Did you have any procedures done recently?
 Two from inside:
1- GERD heart burn worse on lying down /belching/ hx
of spicy food / smoking/ alcohol
2- Cancer oesophagus:
Dysphagia start with solid
FLAWS
Family HX
Smoking
Progressive in nature
Other DDS:
1-stroke (FAST): facial weakness & difficulity of swallowing/
arm weakness/ slurred speech
2-Achalasia: dysphagia start with liquid
 Dr. MO SOBHY [GASTROENTEROLOGY]

3-Diffuse oesophageal spasm : intermittent / cold and hot

food make it worse

4-Oesophagitis (pain on swallowing)

5-Globus hystericus: do you have a sensation of a lump in

your throat / Mood

6-Pharyngeal pouch : Bad breath / food particles on pillow in

the morning

7-Stricture: long term GORD or instrumentation

FLAWS

P2:
 Have you had any problem in swallowing before?
 Medical condition (5)
P3:
DESA :smoking is vvvimp
MAFTOSA: family history vvvimp
You must ask the patient about signs of dehydration as he hasn’t
been eating
Examination:
 Observation
 Neck
 Chest
 Tummy
 Arm pits

Provisional Dx: breaking bad news ( 2 warning shots + news)

 Dr. MO SOBHY [GASTROENTEROLOGY]

Do you have any idea?

Will best case it could be … worst case , as you mentioned that

you have lost weight and started difficulity of swallowing with
solids then liquids so I am treing to exclude cancer

Management:
(urgent referral within in 2 weeks)

1- Admit
2- Senior
3- Investigations (routine blood mainly FBC/ tumour markers)
4- Symptomatic : stent with a tube to help swallow/ IV fluids
5- Specialist: gastroenterologist endoscopy then explain ( a
camera test , tube with large camera on it’s end will pass
through your mouth & tissue sample will be taken

If it is cancer plz dr tell me what’s going to happen?

Either surgery or chemotherapy depending on the stage

6- Safety netting: lumps any where in your body

Scenario 8 (GORD):
Ryan 54 yrs old male with a complaint &
indigestion, talk to him & address his concern
Hi, how can I help you? Heart burn
Explore heart burn (SOCRATES)
Make sure you exclude MI does this pain go to your left hand
left jaw, lt shoulder
 Dr. MO SOBHY [GASTROENTEROLOGY]

Then ask about the rest of GIT symptoms

 Nausea
 Vomiting
 Constipation
 Diarrhea
 Difficulity of swallowing
 Fever
If you have any positive symptoms explore
DDS:
GORD (our station ask in details)
1- Symptoms :
Heart burn
Sour taste of mouth
Bad odour of mouth
Pain on swallowing
Bloating belching
Sore oesphageous
2- Risk factors:
Spicy food
Smoking
NSAIDS
Stress
Alcohol
3- Complication:
Barret’s oesphageous
Cancer oesphageous
So again FLAWS
Oesophageal cancer:
 Dr. MO SOBHY [GASTROENTEROLOGY]

Difficult swallowing
FLAWS
Family hx
Gastric ulcer / peptic ulcer:
Tummy pain
Have you been dx with PU
Gastric carcinoma:
Weight loss
Lumps and pumps
FLAWS
P2:
 Past history of presenting complain
 Past medical conditions (5)
P3: DESA (Diet spicy food/ stress or strength ex/ smoking/
alcohol)
MAFTOSA (medications NSAIDs/ family hx/ stress)
Examination:
 Observations
 Neck
 Chest
 Abdomen

Provisional Dx: gastro- oesophageal reflux disease a

condition where acid reflux or leak from stomach into food pipe
leading to unpleasant sensation in your mouth

Management:
1- No admission
 Dr. MO SOBHY [GASTROENTEROLOGY]

2- Senior
3- Investigation: blood all routine including FBC‫هامه هامه‬
ECG to exclude MI
4- Symptomatic and lifestyle :
PPI like omeprazole / your job here mainly life style
DON”T
Spicy food
Alcohol
Smoking
Stress advice
Take medications without GP advice
DO
Small frequent meal well before bed time
Plenty of fluid
Raise your head by putting extra pillow

Scenario (9) colorectal polyp ( colposcopy):

You are an FY2 in surgery Alice 55 yrs old,
bleeding per rectum 6 weeks ago, she has
undergone sigmoidoscopy 2 weeks ago and it
shows polyps, your consultant require
colonoscopy ( she has her referral letter in
which it shows finding of sigmoidoscopy)
*Hi, iam dr…., are you.?
Dr. MO SOBHY [GASTROENTEROLOGY]

*I can see from my notes that you have undergone

sigmoidoscopy 2 weeks ago has anyone explained the
results for you? No,
* would you like me to explain the findings?
Well, it shows polyps which are small growth on the inner
lining of the large intestine or rectum

*well coming to the sigmoidoscopy?

 How did the procedure go?

 Did you have any pain?
 Any challenges during the procedure?

(vimp as your’ll address any chalanges during next

procedure)

Can you plz tell me

Past :
Why did she came for sigmoidoscopy?

P1: DDS: quickly mainly FLAWS

P2/ P3/ MAFTOSA

Present:
How are u now?

as she is having bleeding per rectum ; so ask do you feel

dizzy / drowsy / about to faint

Future:
 Dr. MO SOBHY [GASTROENTEROLOGY]

(Management)
Which is discussing colonoscopy

So let’s start hx

 What made you come for sigmoidoscopy

 Dr , I had bleeding per rectum:
*Explore bleeding?
*Any bleeding anywhere? else TRAC (timing/ relation
to trauma/ amount/ colour)
* bleeding disorders?
* do you feel dizzy & fainting
* FLAWS (cancer) + change in bowel habbit

P2:
 Past hx of presenting complain
 Past medical conditions? (blood disease)

P3:
DESA (diet / smoking)

MAFTOSA :
Medication hx (blood thinners)

Family hx of bowel caner?

Present: how are you feeling now ? (dizziness/ fainting)

 well, my consultant thinks that as we found polyps in
lower part of reaction so we would like to make sure that
you don’t have any polyps up your colon
Dr. MO SOBHY [GASTROENTEROLOGY]

 but why did you perform a procedure when you know

that you may do another one? ( patient asked)
 I totally appreciate your concern, well we always like to
start with the least invasive and least preparation
procedure such as sigmoidoscopy
 Then if me find any lesions, we like to investigate further
 Q: are they cancereous?
Well, although most types of polyps are called adenomas
which are bengnin but there is a chance that they may
turn into cancereous. So we want to make sure you are
safe and we make sure we remove any polyps
So is it okay to go ahead with the procedure ? ( clear
concent)
1) If patient say yes so explain
 Before procedure (prep)
 During procedure
 After procedure (safety netting) : bleeding /
fever/ driving
2) If patient say No
 Go with refusal approach

If patient saying yes:

Before procedure:
1- Fasting for 8 hours
2- Laxatives to clear bowel
3- I.V fluids (fluids through veins)
During procedure:
1- Sedatives through your veins
 Dr. MO SOBHY [GASTROENTEROLOGY]

2- Numbing gel around your back passage

3- It’s a long thin tube flexible with a camera inside it, it
passess through your back passage into your colon to
visualize the inside of the colon and take tissue sample

Ask procedure:

1- Bleeding
2- Infection (fever)
3- Driving
4- FLAWS

Scenario 10 ( Coeliac disease)

What is coealiac?

Autoimmune condition, where body defence mechanism attack

it’s own cells in coeliac the immune system mistakes substance
found in gluten as a threat to the body leading to damage in the
surface of small intestine & disturn the body ability to absorb
nutrients from food

symptoms:

food containing gluten can trigger symptoms (GIT symptoms) :

diarrhea/ abdominal pain/ indigestion/ bloating/ sometimes
constipation (general symptoms)

weight loss/ fatigue / itchy rash (dermatitis herpetiforms)

gluten containing food ( cereals / wheat / barely)

like pasta- cakes- cereals

 Dr. MO SOBHY [GASTROENTEROLOGY]

two lines to understand ‫كلمتين حلوين هتفهم الدنيا‬

a patient come with iron deficiency anemia treated with iron : no

response to treatment

so, you may think & the reason why he is not responding

causes:

Malabsorption of iron due to inflammation of small intestine

So endoscopy will be indicated if refusing (use the trick)

Make sure similar steps as before

Past:
*What made you come (tirdness)

*Iron anemia (medication) compliance (P2- P3- MAFTOSA)

Present:
How is he at the moment?

Future:
managment
endoscopy

before : sedative/ gel / prep

during: sedative/ gel/ explain/ procedure

After: bleeding/ infection/ driving

 Dr. MO SOBHY [GASTROENTEROLOGY]

Middle age female , Dx with iron deficiency anemia

on iron tab, despite mediaction , condition is not
improving, she has undergone some tests tissue
transglutaminase (+ve), so endoscopy is planned,
talk to her address her concern
Hi, I can see from my notes that you are coming for follow up of
your condition?

I can see that you have been diagnosed with iron deficiency
anemia & tissue transglutaminase +ve

Did anyone explain about condition but is it okay if we have a chat

about the condition (past/ present/ future)

Past:
 What made you come from first place?
 Tiredness? Explain
 Symptoms of anemia? SOB/ heart racing ( explore)
 Then what happened?? Was given iron tablet
 Explore iron (since when/ dose/ did you take it as
prescribed)

P2:
 Past hx of presenting complain
 Past medical conditions
P3:
DESA
 Dr. MO SOBHY [GASTROENTEROLOGY]

MAFTOSA (make sure the patient is not on blood thinners / FH

of coeliac)
Present:
How are you feeling now?
Future:
(management : procedure + council patient about his condition)
 So you presented with iron deficiency anemia
 We usually treat with iron tab & advise about diet
 Many causes why pt has iron iron deficiency
 We performed (tissue transglutaminase) : +ve
 As it can give false +ve , so we highly recommend
endoscopy
 Have heared about it? No
 Explain endoscopy
A camera test, where a tube passess through your
mouth into your stomach & your bowel and take tissue
sample

(is it okay to go a head with procedure ) clear concent

Endoscopy:

Before procedure:

1- Empty stomach
2- Gluten containing food to stimulate the process
3- Abx to protect against infection

During:

1- Sedatives I.V
 Dr. MO SOBHY [GASTROENTEROLOGY]

2- Numbing gel on your mouth or spray 15- 60 minutes

After:
1- Bleeding
2- Infection ( fever)
3- Driving bring relative with you
4- SOB
5- Chest pain
Dr. MO SOBHY [GASTROENTEROLOGY]