PANCE - Nausea, Vomiting, Diarrhea

Here are key facts for PANCE from the Nausea, Vomiting, Diarrhea tutorial, as well as points of interest at the end of this document that are not directly addressed in this tutorial but should help you prepare for the boards. See the tutorial notes for further details and relevant links.

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1. Vomiting: Forceful eviction of the stomach contents caused by contractions of the GI tract and muscles of the thorax 2. Regurgitation: Ejection of food from the esophagus 3. GI motility disorders: Damaged nerves or mechanical obstruction prevent normal passage of food 1. Pharmacologic causes: Antibiotics, opioids, antidepressants, vitamins and mineral supplements, NSAIDs, chemotherapy 2. Neurologic causes: Motion sickness, central nervous disorders (migraines, infections, increased intra-cranial pressure) 3. Mechanical causes: Mechanical GI obstructions including adhesions, volvulus, foreign bodies, hernias, tumors 4. Physiologic causes: Early pregnancy hormonal changes during first trimester 1. Malabsorptive: Lactose intolerance, celiac disease 2. Inflammatory: Inflammatory bowel disease (Crohn's disease, ulcerative colitis), microscopic colitis 3. Exocrine dysfunction: Pancreatic insufficiency leading to steatorrhea 4. Infectious: Gastroenteritis from norovirus, rotavirus, E. coli, Salmonella, Shigella, and Campylobacter 1. Vomiting-related: Aspiration, dehydration, electrolyte imbalance, undernutrition, and esophageal tears 2. Diarrhea-related: Malabsorption of nutrients, dehydration, and electrolyte imbalances

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1. Esophageal achalasia: Heartburn, chest pain, and regurgitation due to sustained lower esophageal sphincter contraction from damaged esophageal nerves 2. Gastroparesis: Early satiety, heartburn and vomiting resulting from vagus nerve damage and loss of stomach muscle function 3. Cyclical vomiting syndrome: Recurring severe episodes of vomiting triggered by stress and excitement, often beginning in childhood 1. Steatorrhea: Oily, foul smelling, yellowish stools that float due to high fat content, characteristic of pancreatic insufficiency 2. IBD differentiation: Crohn's disease presents with mucous diarrhea while ulcerative colitis presents with bloody diarrhea 3. Carcinoid syndrome: Watery, loose stools with flushing, wheezing, and valvular heart disease in 30-40% of neuroendocrine tumor patients 1. Intestinal ischemia: Nausea, vomiting and bloody diarrhea when mesenteric arteries become blocked 2. Functional bowel disorders: Irritable bowel syndrome results from disordered brain-gut communication 3. Endocrine disorders: Thyroid disorders, adrenal insufficiency, and diabetes can present with GI symptoms 1. Motion sickness: Results from mismatch between expected and experienced sensory inputs 2. Morning sickness: Can occur any time of day during early pregnancy due to hormonal changes 3. Mechanical vs. functional: Distinguish obstructive causes from motility disorders

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Below is information not explicitly contained within the tutorial but important for PANCE. 1. History and physical: Key elements to differentiate between various causes 2. Laboratory evaluation: Appropriate testing based on suspected etiology 3. Imaging studies: Indications for radiographic and endoscopic procedures 1. Antiemetics: Mechanism of action and appropriate selection 2. Antidiarrheals: Indications, contraindications, and cautions 3. Disease-modifying therapies: Treatment of underlying conditions 1. Red flags: When to seek immediate medical attention 2. Self-care measures: Dietary modifications and hydration strategies 3. Prevention strategies: Reducing risk of infectious causes 1. Pediatric patients: Assessment and management considerations 2. Geriatric patients: Medication interactions and comorbidity management 3. Pregnant patients: Safe evaluation and treatment approaches