A 54-year-old man presents to the clinic for epigastric discomfort during the previous month. He states he has not vomited, but reports of having epigastric pain that worsens after most meals. The patient states that his stool “looks black sometimes.” The patient does not report of any weight loss. He has a past medical history of gastroesophageal reflux disease, diabetes mellitus, peptic ulcer disease, and Crohn’s disease. The patient takes over-the-counter ranitidine, and holds prescriptions for metformin and infliximab. The blood pressure is 132/84 mm Hg, the heart rate is 64/min, the respiratory rate is 14/min, and the temperature is 37.3°C (99.1°F). On physical examination, the abdomen is tender to palpation in the epigastric region. Which of the following is the most appropriate next step to accurately determine the diagnosis of this patient?

Treat with PPI, clarithromycin, and amoxicillin before doing lab and imaging tests

Serology for Helicobacter pylori

A 28-year-old graduate student visits the university health clinic for 3-weeks of epigastric pain that worsens with meals, associated with retrosternal pain, early satiety, and bloating. She denies vomiting blood or blood in her stool. She has been consuming large volumes of caffeinated-drinks and fast-food for a month, as she has been studying for her tests. Her family and personal history are unremarkable with no history of gastrointestinal cancer. Her vital signs are within normal limits. Physical examination is only positive for a mild epigastric tenderness. Which of the following is the most appropriate approach in this case?

Fecal antigen testing for Helicobacter pylori

A 58-year-old man presents to the emergency department with a 1-day history of difficulty swallowing. He also mentions that he has been frequently experiencing moderate to severe burning pain localized to the epigastric region for the last 3 weeks. The patient denies any history of vomiting, hematemesis, or black-colored stools. His past medical history is significant for gastroesophageal reflux disease diagnosed 10 years ago, for which he has not been compliant with medications. He has seen multiple physicians for similar complaints of retrosternal burning with regurgitation over the last 10 years but has not taken the medications suggested by the physicians regularly. He has never had a colonoscopy or endoscopy. He does not have any other known medical conditions, but he frequently takes over-the-counter analgesics for the relief of muscular pain. On physical examination, his vital signs are stable. Physical examination is normal except for the presence of mild pallor. Examination of the chest and abdomen does not reveal any abnormality. Which of the following investigations is indicated as the next step in the diagnostic evaluation of this patient?

Upper gastrointestinal endoscopy

Ambulatory 24-hour pH monitoring

Intraluminal impedance monitoring

Barium radiography of esophagus, stomach, and duodenum

A 58-year-old man presents to the Emergency Department after 3 hours of intense suprapubic pain associated with inability to urinate for the past day or two. His medical history is relevant for benign prostatic hyperplasia (BPH) that has been under treatment with prazosin and tadalafil. Upon admission, he is found to have a blood pressure of 180/100 mm Hg, a pulse of 80/min, a respiratory rate of 23/min, and a temperature of 36.5°C (97.7°F). He weighs 84 kg (185.1 lb) and is 175 cm (5 ft 7 in) tall. Physical exam, he has suprapubic tenderness. A bladder scan reveals 700 ml of urine. A Foley catheter is inserted and the urine is drained. Initial laboratory tests and their follow up 8 hours after admission are shown below. Admission 8 hours after admission Serum potassium 4.2 mmol/L Serum potassium 4.0 mmol/L Serum sodium 140 mmol/L Serum sodium 142 mmol/L Serum chloride 102 mmol/L Serum chloride 110 mmol/L Serum creatinine 1.4 mg/dL Serum creatinine 1.6 mg/dL Serum blood urea nitrogen 64 mg/dL Serum blood urea nitrogen 62 mg/dL Urine output 250 mL Urine output 260 mL A senior attending suggests a consultation with Nephrology. Which of the following best justifies this suggestion?

Estimated glomerular filtration rate (eGFR)

Serum blood urea nitrogen (BUN)

A 42-year-old woman presents for a follow-up visit. She was diagnosed with iron deficiency anemia 3 months ago, for which she was prescribed ferrous sulfate twice daily. She says the medication has not helped, and she still is suffering from fatigue and shortness of breath when she exerts herself. Past medical history is remarkable for chronic dyspepsia. The patient denies smoking, drinking alcohol, or use of illicit drugs. She immigrated from Egypt 4 years ago. No significant family history. Physical examination is unremarkable. Laboratory findings are significant for the following: 3 month ago Current Hemoglobin 10.1 g/dL 10.3 g/dL Erythrocyte count 3.2 million/mm3 3.3 million/mm3 Mean corpuscular volume (MCV) 72 μm3 74 μm3 Mean corpuscular hemoglobin (MCH) 20.1 pg/cell 20.3 pg/cell Red cell distribution width (RDW) 17.2% 17.1% Serum ferritin 10.1 ng/mL 10.3 ng/mL Total iron binding capacity (TIBC) 475 µg/dL 470 µg/dL Transferrin saturation 11% 12% Which of the following is the next best step in the management of this patient’s most likely condition?

Helicobacter pylori fecal antigen

A 55-year-old man presents to urgent care for weakness and weight loss. He states for the past several months he has felt progressively weaker and has lost 25 pounds. The patient also endorses intermittent abdominal pain. The patient has not seen a physician in 30 years and recalls being current on most of his vaccinations. He says that a few years ago, he went to the emergency department due to abdominal pain and was found to have increased liver enzymes due to excessive alcohol use and incidental gallstones. The patient has a 50 pack-year smoking history. His temperature is 99.5°F (37.5°C), blood pressure is 161/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 95% on room air. Physical exam reveals an emaciated man. The patient has a negative Murphy's sign and his abdomen is non-tender. Cardiopulmonary exam is within normal limits. Which of the following is the next best step in management?

Right upper quadrant ultrasound

Smoking cessation advice and primary care follow up

Functional GI disorders for USMLE Step 2 CK: High-Yield Internal Medicine Lessons

Functional GI Disorders - The Gut's Acting Up

Chronic GI symptoms without structural or biochemical abnormalities; a disorder of the gut-brain axis.
Irritable Bowel Syndrome (IBS): Per Rome IV criteria, recurrent abdominal pain ≥1 day/week for 3 months with ≥2 of:
- Related to defecation
- Change in stool frequency
- Change in stool form (appearance)
Functional Dyspepsia: Postprandial fullness, early satiety, or epigastric pain without structural disease.

⭐ Red flag symptoms argue against a functional diagnosis: new onset age >50, unintentional weight loss, nocturnal diarrhea, rectal bleeding, iron deficiency anemia.

Irritable Bowel Syndrome (IBS) - The Grumpy Bowel

Chronic functional GI disorder with recurrent abdominal pain and altered bowel habits, without an identifiable organic cause.
Pathophysiology: Visceral hypersensitivity, altered gut motility, gut-brain axis dysregulation, and psychosocial factors.
Diagnosis of Exclusion: Based on Rome IV criteria, after ruling out organic disease. Red flags warrant further investigation (e.g., age >50, rectal bleeding, weight loss).
Subtypes: IBS-C (constipation), IBS-D (diarrhea), IBS-M (mixed).

⭐ Rome IV Criteria: Recurrent abdominal pain (≥1 day/week for the last 3 months) associated with two or more of the following: related to defecation, change in stool frequency, or change in stool form.

Gut-brain axis dysfunction in IBS pathophysiology

Functional Dyspepsia - The Upset Stomach

*Chronic or recurrent epigastric pain/burning, postprandial fullness, or early satiety with no evidence of structural disease. Diagnosis based on Rome IV criteria (symptoms for ≥3 months, onset ≥6 months prior).

Key Symptoms: Postprandial fullness, early satiation, epigastric pain/burning.
Initial Workup: Rule out organic causes. Endoscopy is key if alarm features are present.

Functional Dyspepsia and Irritable Bowel Syndrome Criteria

⭐ High-Yield: Functional dyspepsia is a diagnosis of exclusion. The absence of findings on upper endoscopy in a patient with chronic dyspeptic symptoms is a classic presentation.

Diagnosis & Management - Sorting It All Out

Initial Approach: Rule out organic causes. Focus on identifying alarm features.
- ⚠️ Alarm Features: Age >50, weight loss, nocturnal symptoms, rectal bleeding, iron deficiency anemia, family hx of IBD/cancer.

Management Strategy
- Lifestyle: Reassurance, education, stress reduction. Low FODMAP diet for IBS.
- IBS-D: Loperamide, Eluxadoline, Rifaximin, Alosetron.
- IBS-C: Fiber, osmotic laxatives (PEG), Lubiprostone, Linaclotide.
- Pain/Bloating: Antispasmodics (Dicyclomine), TCAs (Amitriptyline), SSRIs.

⭐ Rome IV Criteria for IBS: Recurrent abdominal pain at least 1 day/week in the last 3 months, associated with ≥2 of: related to defecation, change in stool frequency, or change in stool form.

Rome IV Diagnostic Criteria for Irritable Bowel Syndrome

High‑Yield Points - ⚡ Biggest Takeaways

Irritable Bowel Syndrome (IBS) diagnosis hinges on Rome IV criteria: recurrent abdominal pain related to defecation, stool frequency, or form.

Always rule out organic disease by screening for alarm features like weight loss, rectal bleeding, or anemia.

First-line management is lifestyle and dietary modification (e.g., low-FODMAP diet) and fiber.

Functional dyspepsia features chronic epigastric pain or discomfort without any identifiable structural cause on endoscopy.

Visceral hypersensitivity is a core pathophysiologic mechanism underlying these disorders.

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