Recap the top pearls from recent shows on Chronic Diarrhea, Dementia, OHS, and MSK (Shoulder, Hip, and Knee).. It’s Tales from the Curbside! (TFTC), our monthly series providing a rapid review of recent Curbsiders episodes for your spaced learning.
Note: No CME for this mini-episode but visit curbsiders.vcuhealth.org to claim credit for #267 Chronic Diarrhea, #268 Dementia, and #269 OHS, and #274 MSK Triple Distilled.
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with Dr. Iris Wang production and graphics by Dr. Elena Gibson
Matt’s Pearl – Suspect osmotic diarrhea when diarrhea gets better while fasting. A stool osmotic gap >75-100 can confirm the diagnosis. Common causes are laxatives, medications, or carbohydrate malabsorption e.g. lactose or fructose. Non-osmotic diarrhea (gap <50) has a differential diagnosis that includes Celiac, IBD, IBS, Infection and malabsorption of bile acids (<100 cm bowel resected → overproduction bile acids) or fat (>100 cm bowel resected → net loss bile acids). Functional diarrhea (a disorder of the gut brain axis) is a diagnosis of exclusion.
Paul’s Pearl – Functional diarrhea is now “disorders of the gut brain axis”. Rule out celiac and inflammatory bowel disease. Check endoscopy for malabsorption or microscopic colitis.
Paul’s Pearl – Floating stool means there is gas—if looking for fat, ask if stools are greasy and difficult to flush—best indicator is oil droplets
Matt’s Pearl – Don’t forget to ask about conditions (e.g. pancreatic surgery, cholecystectomy, ileal Crohn’s), and medications (e.g. metformin, SSRIs, chemo agents) that contribute to diarrhea. A 48 hour fecal bile acid collection is recommended before empirically starting cholestyramine due to frequent dosing, bad taste, and binding of other meds.
Matt’s Pearl – The FODMAP diet should be a temporary experiment and done under the guidance of a nutritionist. It’s too restrictive and patients would otherwise be at risk for nutritional deficiencies. Stanford FODMAP diet handout
with Dr. Josh Uy production and graphics by Dr. Emi Okamoto
Matt’s Pearl – Decide whether dementia is “slow or fast”. Patients who walk and talk slow probably have Parkinson’s with dementia or Lewy Body Dementia (LBD). Cognitive impairment precedes Parkinsonism in LBD whereas the opposite occurs with Parkinon’s disease. Patients who walk and talk at normal speed likely have frontotemporal dementia (FTD) vs Alzheimer’s disease. FTD mainly occurs in patients younger than 65 years old.
Paul’s Pearl – I love Josh’s approach, including the idea of the triad visit. He makes the point that you should separate your evaluation of cognitive issues and psychiatric issues during the initial evaluation, and talk to BOTH the patient AND the caregiver. He also makes the point to name dementia without fear and without shame, and to assure the patient that there are ways to deal with their symptoms regardless.
Matt’s Pearl – Donepezil and Memantine: These meds are not worth tolerating side effects! Donepezil can cause GI upset, and bradycardia. Tell the patient to focus on maintaining a rich and active life. Ensure they are safe and provide support to their caregiver. The meds are just icing on the cake.
with Dr. Aneesa Das production and graphics by Dr. Cyrus Askin
Matt’s Pearl – The pathophysiology of OHS includes the triad of leptin resistance (decrease respiratory stimulation), extrathoracic chest wall restriction, and airway obstruction. Up to 70-90% with OHS have OSA.
Paul’s Pearl – The higher the AHI, the more likely there is OHS, and you need obesity, hypercapnia, and to rule everything else out. I also appreciated the point that the role of the PCP here is to help treat obesity.
Matt’s Pearl – CPAP is adequate for many patients without acute respiratory failure. Many patients do not require supplemental oxygen. O2 should never be given as monotherapy, and the ongoing need can be evaluated by repeat sleep studies after a few months of therapy.
Production by Dr. Molly Hueblein and graphics by Dr. Matt Watto
Matt’s Hip Pearls – Press on the greater trochanters to check for GTPS. Perform the windshield wiper test to check for hip OA. Consider low back etiology if those tests are normal. Hip surgery works really well for OA! Patients over 60 years old should be considered for hip replacement.
Paul’s Knee Pearl – When imaging the knee, be sure to include the merchant/sunrise view, and specify that AP and lateral are done in standing/weight bearing views. Ideally, the patient would have the knee in 30 degrees flexion as well. In terms of treating DJD of the knee, topical NSAIDs are good, as is PT. Acetaminophen, unfortunately, is not so useful.
Matt’s Shoulder Pearls – The two main buckets include whether or not passive ROM remains intact. When not intact consider Frozen Shoulder vs OA (abnormal xray). Look to the rotator cuff if ROM remains intact. Test* for weakness and suspect a full-thickness rotator cuff tear if present. Tests* should include: Internal/external rotation lag tests and/or Empty Can (Job’s test). Everyone else can get PT, NSAIDS, ice/heat, and tincture of time.
Listeners will review tops pearls from recent curbsiders episodes
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Drs. Watto and Williams report no relevant financial disclosures.
Watto MF, Williams PN. “#275 TFTC #5: Chronic Diarrhea, Dementia, OHS, MSK”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date May 26, 2021.
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