PANRE/PANCE – Gastroenterology part 1 – GERD

by Isabella on June 8, 2012

So before I start writing a study guide for myself, let me tell you a bit about how this happened.  I have been a Physician Assistant for 6 years.  All 6 years have been spent in a Family Practice setting, which I love, and I have been fortunate enough to have two amazing jobs.  My first job was at Jackson Medical Group in Santa Barbara CA, and I credit  Medical Director Dr. Douglas Jackson for teaching me how to practice medicine the correct way, the honest way and the compassionate way.  I’ve always told myself that if I am ever even 1/8  as good as he is, I will die a happy PA :)

My second job has been at Alps Family Physicians in Wayne NJ, and again, I am a lucky girl, working with some amazing doctors, nurses and staff.  The doctors I work with are talented, smart, attentive and great at what they do. It is truly awesome to work in an environment where I can constantly learn.

And now…after 6 years of practicing medicine at these wonderful jobs…it is time for re-certifying.  The last time I took the exam was 2006…and thankfully…I scored in the 99th percentile….but nevertheless I am not looking forward to studying again…but a girl’s gotta do what a girl’s gotta do :)  As I mentioned in a previous post, I lost all my books in a flooded basement, and my attempt at finding new books was unsuccessful so here I am…making my own review course for myself…and whoever else wants to read it.

Ok, so lets start.  Most review books usually start with cardiology, but I am not a big fan of cardiology, so I’ll start with Gastroenterology which has so many fun diseases to talk about (my favorite being IBS…all the pooping and the not pooping….it’s like a tummy with a dilemma).  I will post a GI topic or two or three every day, and then once we’re done with GI, we’ll move on to something else.  I will try to be as concise as possible but relay all the important information. I will follow the NCCPA blueprint but if you have suggestions for topics in each section that I did not cover that you think will be useful or needed in the PANRE, let me know, and I will discuss it.  So here we go…..


GERD: Gastroesophageal reflux disease

  • GERD occurs when acid or stomach content and rarely bile, reflux up from the stomach into the esophagus, creating damage.
  • Causes/conditions associated with GERD:
    • relaxed Lower Esophageal sphincter – sphincter connecting esophagus to stomach loses tone and allows acid to travel upward
    • delayed gastric emptying – when the stomach doesn’t empty at it’s normal physiological rate which creates distention in the stomach – food and acid put pressure against the LES and stomach content refluxes up
    • Obesity and metabolic syndrome – increased fat around the midsection puts pressure on intraabdominal organs as well as decreases tone in LES
    • Hiatal Hernia
  • Symptoms:
    • heartburn is the most common presenting symptom of GERD.  Occasionally patients complain of dysphagia and regurgitation.
    • Symptoms are usually worse after eating and worse when laying down (patients complain of nighttime symptoms)
    • occasionally patients will complain of hoarseness, chronic cough, and chest pain, bitter taste in mouth, bad breath (halitosis), and difficulty swallowing.
  • Complications from GERD:
    • if untreated, can lead to Barrett’s esophagus, as well as esophageal carcinoma
  • Diagnosis:
    • usually the diagnosis is made based on the presenting history of heartburn that is worse post meals and with laying down, that is alleviated with sitting or standing and consumption of an antacid.
    • Physical exam: usually non contributory but occasionally mild epigastric tenderness is present
    • Endoscopy is recommended for  patients over age 45, patients with new onset symptoms, patients who are not responsive to treatment.
    • Upper GI barium swallow – can be useful as a less invasive test before endoscopy- will show inflammation, strictures, masses, hiatal hernia
    • If a patient has been treated and is unresponsive, it would be wise to order:
      • CBC for iron deficiency anemia and inquire if they are having dysphagia, weight loss, pain with swallowing – as those can be signs of potential adenocarcinoma
    • make sure to order and EKG to rule out cardiac pathology – especially in an older patient
  • Treatment:
    • Conservative treatment involves: smoking cessation, weight loss, elevating head of bed when sleeping, avoidance of spicy foods, tomato based products, coffee and last meal to be 3 hours before sleep, as well as avoidance of alcohol.
    • Medical treatment
      • Antacid – tums
      • H2 blocker (receptor antagonist) – 1st line treatment in mild cases
        •  Zantac (ranitidine)
        • Pepcid (Famotadine)
      • PPI (proton pump inhibitor) – (Dexilant, Nexium, Aciphex)
        •  Prilosec (omeprazole) 20 mg daily in am on empty stomach
        • Protonix (Pantoprazole) 40 mg daily in am on empty stomach
        • Prevacid (Lansoprazole) 30 mg daily in am on empty stomach
      • occasionally in clinical practice both a PPI and an H2 blocker will be given (one in the am and the latter in the pm)


  • Andrea

    This is a great review! I love the humor you put into it! I am a visual learner, and your comics are exactly what my mind used to do to topics!! Sometimes I wails draw them out like yours (although mine were very lame!). This has been a long, difficult journey for me. I had 2 children during my 3 year program, commuted from San Francisco to Detroit every week for a year and a half, moved from San Fran to Detroit to New York, was put on bedrest with my 2nd pregnancy which delayed my graduation! Through all of that, I have finally graduated on May 12, 2012! What stands between me and working now is my certification! I am so nervous to take this exam!! I don’t get much time to study but I want to take this exam and get it over with! I will be using this blog as a study aid! So thank you for writing it!! :)

    • Isabella

      Congratulations on graduating!! That sounds like a tough road you’ve been on, but it also sounds like you are that much stronger for having taken it! Look at it this way, not only do you have an amazing profession now, you have two wonderful kids, and if that is not true joy, I don’t know what is! :) One day you’ll tell your kids how hard you worked and how they were with you every step of the way, and they’ll be SO proud! :)

      I will try to make comics for every section, but truthfully, some sections can’t be made humorous no matter what you draw ;) I’ll keep writing and you keep reading :) I’ll try to do a question bank as well.

  • Mary

    Thank you so much for posting these! This will be my 3rd attempt at taking the PANCE. I graduated in 2008 and I am now very discouraged and not motivated to really study since no one is studying along side of me, so this may actually help me. I have such a hard time finding the time to study because I am a full time mommy to my 17 month old. When do you find time? My toddler barely naps which does not help :/

    • Isabella

      Hi Mary,
      Thank you so much for your comment, it encourages me to continue writing. Don’t be discouraged, just keep trying and eventually you’ll do it. As to finding time to study, mostly at night when the baby is asleep,and during his short naps. I understand how hard it is, I didn’t have a baby when I studied for the PANCE 6 years ago and it took me a whole month. For this PANRE it helps that I’ve been a practicing PA for 6 years, but I still need the review. My advice is to take it one topic at a time, and then test yourself on it. The way I did it for the PANCE is I actually wrote questions for myself as I was studying, and wrote multiple choice answers, one that I think would trip me up, and then the correct one. I’ll try to make a similar style question bank for these topics and then post them. If you have any questions on the topics, feel free to ask.

  • Mary

    Thank you so much Isabella! Looking forward to your q bank along side your study guide :)

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