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We sought to summarize current recommendations for the diagnosis of diarrhea-predominant irritable bowel syndrome (IBS-D) and describe available management options, highlighting a newer US Food and Drug Administration (FDA)-approved agent, eluxadoline.Literature on IBS-D was assessed up to January 2020 using PubMed, with key search terms including "IBS-D diagnosis", "IBS-D management", and "eluxadoline".IBS is a common gastrointestinal disorder affecting up to 14% of US adults and is particularly prevalent in women and those aged under 50. Symptoms include abdominal pain associated with altered bowel habits (i.e. diarrhea and/or constipation subtyped based on the predominant stool pattern). As IBS-D is challenging to manage with varying symptom severity, effective treatment requires a personalized management approach. Evidence-based therapeutic options endorsed by the American Gastroenterological Association and the American College of Gastroenterology can be used to effectively guide treatment. Dietary and lifestyle modifications, including adequate hydration, reducing caffeine and alcohol intake, and increasing soluble fiber intake may lead to symptom improvement. Over-the-counter medications such as loperamide are frequently recommended and may improve stool frequency and rectal urgency; however, for the outcome of abdominal pain, mixed results have been observed. Several off-label prescription medications are useful in IBS-D management, including tricyclic antidepressants, bile acid sequestrants, and antispasmodics. Three prescription medications have been approved by the FDA for IBS-D: alosetron, eluxadoline, and rifaximin.IBS-D can be effectively managed in the primary care setting in the absence of alarm features. Benefits and risks of pharmacologic interventions should be weighed during treatment selection.

Background and Objectives: Reports of innovations in evidence-based medicine (EBM) training have focused on curriculum design and knowledge gained. Little is known about the educational culture and environment for EBM training and the extent to which those environments exist in family medicine residencies in the United States. Methods: A literature review on this topic identified a validated EBM environment scale intended for learner use. This scale was adapted for completion by family medicine residency program directors (PDs) and administered through an omnibus survey. Responses to this scale were analyzed descriptively with program and PD demographics. An EBM culture score was calculated for each program and the results were regressed with the correlated demographics. Results: In our adapted survey, family medicine PDs generally rated their residencies high on the EBM culture scale, but admitted to challenges with faculty feedback to residents about EBM skills, ability to protect time for EBM instruction, and clinician skepticism about EBM. In linear regression analysis, the mean summary score on the EBM scale was lower for female PDs and in programs with a higher proportion of international medical school graduates. Conclusions: To improve the culture for EBM teaching, family medicine residency programs should focus on faculty engagement and support and the allocation of sufficient time for EBM education.

PURPOSE: Electronic application (app)-based treatment is promising for common diseases with good conservative management options, such as urinary incontinence (UI) in women, but its effectiveness compared with usual care is unclear. This study set out to determine if app-based treatment for women with stress, urgency, or mixed UI was noninferior to usual care in the primary care setting. METHODS: The URinControl trial is a pragmatic, noninferiority randomized controlled trial in Dutch primary care including adult women with 2 episodes of UI per week. From July 2015 to July 2018, we screened 350 women for eligibility. A stand-alone app-based treatment with pelvic floor muscle and bladder training (URinControl) was compared with usual care according to the Dutch general practitioner guideline for UI treatment. Outcomes measured were change in symptom severity score from baseline to 4 months (primary outcome), impact on disease-specific quality of life, patient-perceived improvement, and number of UI episodes. Noninferiority (

Background: Personal sun protection and patient counseling patterns among primary care providers is an important topic that has not previously been studied in great detail. Our report evaluates the relationship between sun protection habits among providers, patterns in discussions with patients about sun protection, and prior education on this topic during medical training. Methods: An online survey was sent to family medicine faculty and house officers. Four survey questions about personal sun protection and patient counseling habits were provided. Participants were then asked whether they had received formal education concerning sun protection during their medical training. Results: Our results suggest that providers who received formal education on sun protection during their medical training were more likely to personally use adequate protection and counsel their patients on this topic. Conclusions: This study highlights the importance of sun protection education among primary care providers. Our findings suggest that improving education on this topic among physicians may lead to increased awareness among both patients and providers. Productive discussions about sun protection in the primary care setting has the potential to improve sun protective habits among patients, which can in turn decrease the incidence of skin cancer.

Urinary retention is the acute or chronic inability to voluntarily pass an adequate amount of urine. The condition predominantly affects men. The most common causes are obstructive in nature, with benign prostatic hyperplasia accounting for 53% of cases. Infectious, inflammatory, iatrogenic, and neurologic causes can also affect urinary retention. Initial evaluation should involve a detailed history that includes information about current prescription medications and use of over-the-counter medications and herbal supplements. A focused physical examination with neurologic evaluation should be performed, and diagnostic testing should include measurement of postvoid residual (PVR) volume of urine. There is no consensus regarding a PVR-based definition for acute urinary retention; the American Urological Association recommends that chronic urinary retention be defined as PVR volume greater than 300 mL measured on two separate occasions and persisting for at least six months. Initial management of urinary retention involves assessment of urethral patency with prompt and complete bladder decompression by catheterization. Suprapubic catheters improve patient comfort and decrease bacteriuria and the need for recatheterization in the short term; silver alloy-coated and antibiotic-impregnated catheters offer clinically insignificant or no benefit. Further management is decided by determining the cause and chronicity of the urinary retention and can include initiation of alpha blockers with voiding trials. Patients with urinary retention related to an underlying neurologic cause should be monitored in conjunction with neurology and urology subspecialists.

INTRODUCTION: Millions of patients take prescription medications each year for common urological conditions. Generic and brand-name drugs have widely divergent pricing despite similar therapeutic benefit and side effect profiles. We examined prescribing patterns across provider types for generic and brand-name drugs used to treat 3 common urological conditions, and estimated economic implications for Medicare Part D spending. METHODS: We extracted 2014 prescription claims and payments from Medicare Part D and categorized oral medications used to treat 3 urological conditions, namely benign prostatic hyperplasia, erectile dysfunction and overactive bladder. We examined claims and payments for each medication among urologists and nonurologists. Lastly, we estimated potential savings by selecting a low cost or generic drug as a cost comparator for each class. RESULTS: There were significant differences in prescribing patterns across these conditions, with urologists prescribing more brand-name and expensive medications (p

PURPOSE:The purpose of this guideline is to provide a clinical strategy for the diagnosis and treatment of erectile dysfunction. MATERIALS AND METHODS:A systematic review of the literature using the Pubmed, Embase, and Cochrane databases (search dates 1/1/1965 to 7/29/17) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of erectile dysfunction. Evidence-based statements were based on body of evidence strength Grade A, B, or C and were designated as Strong, Moderate, and Conditional Recommendations with additional statements presented in the form of Clinical Principles or Expert Opinions. RESULTS:The American Urological Association has developed an evidence-based guideline on the management of erectile dysfunction. This document is designed to be used in conjunction with the associated treatment algorithm. CONCLUSIONS:Using the shared decision-making process as a cornerstone for care, all patients should be informed of all treatment modalities that are not contraindicated, regardless of invasiveness or irreversibility, as potential first-line treatments. For each treatment, the clinician should ensure that the man and his partner have a full understanding of the benefits and risk/burdens associated with that choice.

Introduction: The irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) are associated with substantial symptom and disease burden. Although typically classified as distinct diseases, symptoms frequently overlap. Aim: The objective of this study was to characterize symptom and disease burden in IBS-C and CIC sufferers and examine a subset of CIC sufferers with abdominal symptoms. Methods: In a US population-based survey, respondents meeting the Rome III criteria for IBS-C or CIC rated symptom frequency and bothersomeness, missed work and disrupted productivity, and degree of obtaining and satisfaction with physician care. CIC respondents were analyzed in two subgroups: those with abdominal symptoms ≥once weekly (CIC-A) and those without (CIC-NA). Results: Of the 10,030 respondents, 328 met the criteria for IBS-C and 552 for CIC (363 CIC-A; 189 CIC-NA). All symptoms were significantly more frequent in IBS-C vs. CIC respondents (P

A novel explanatory model, Rome IV diagnostic criteria,and evidence-based therapeutic guidelines are making it easier to care for patients with this complex disorder.

Background: Primary care providers inevitably care for prostate cancer survivors. However, few comprehensive resources exist to aid them in providing the most up-to-date and evidence-based care. To meet this clinical need, we examined and updated the Michigan Cancer Consortium prostate cancer survivorship guidelines. Methods: Using an expert panel and focus groups comprised of prostate cancer stakeholders, we updated the Michigan Cancer Consortium's 2009 Guidelines for the Primary Care Management of Prostate Cancer Post-Treatment Sequelae. Results: The guideline recommendations were modified to serve as a point-of-care resource and to facilitate care transitions between specialty and primary care. The modified recommendations were approved by the Michigan Cancer Consortium and now include the following elements: (1) patient-reported symptom assessment, (2) distinctions between medical and self-management strategies for prostate cancer treatment-related side effects, (3) recommendations for involv...

Testosterone replacement therapy (TRT) has been used in millions of men worldwide to treat diminished libido and erectile dysfunction, and to improve strength and physical function. The estimated likelihood of adverse effects of long-term TRT is still essentially unknown, as overall high-quality evidence based upon prospective randomized trials to recommend for or against its use in most men with testosterone deficiency (TD) is lacking. Evidence to suggest that TRT increases cardiovascular morbidity and mortality risks is poor, as results vary across study populations and their baseline comorbidities. While TRT may increase serum prostate-specific antigen levels in some men, it often remains within clinically acceptable ranges, and has not been shown to increase the risk of prostate cancer. Current literature supports that TRT does not substantially worsen lower urinary tract symptoms, and may actually improve symptoms in some men. Limited evidence suggests that TRT may initially worsen obstructive sleep apnea in some men, but that this is not a longstanding effect. TRT may result in erythrocytosis in some men, however long-term studies have not reported significant adverse events (e.g. cerebrovascular accident, vascular occlusive events, venous thromboembolisms). Future research will require dedicated focus on evaluation of large, multiethnic cohorts of men through prospective trials to better elucidate both risk and hazard ratios of TRT as it relates to cardiovascular disease, prostate cancer, lower urinary tract symptoms, obstructive sleep apnea, erythrocytosis, and other to-be-determined theoretical risks in men both with and without cardiovascular risk equivalents.

Erectile dysfunction (ED) is the inability to achieve or maintain an erection sufficient for satisfactory sexual performance. It is common, affecting at least 12 million U.S. men. The five-question International Index of Erectile Function allows rapid clinical assessment of ED. The condition can be caused by vascular, neurologic, psychological, and hormonal factors. Common conditions related to ED include diabetes mellitus, hypertension, hyperlipidemia, obesity, testosterone deficiency, and prostate cancer treatment. Performance anxiety and relationship issues are common psychological causes. Medications and substance use can cause or exacerbate ED; antidepressants and tobacco use are the most common. ED is associated with an increased risk of cardiovascular disease, particularly in men with metabolic syndrome. Tobacco cessation, regular exercise, weight loss, and improved control of diabetes, hypertension, and hyperlipidemia are recommended initial lifestyle interventions. Oral phosphodiesterase-5 inhibitors are the firstline treatments for ED. Second-line treatments include alprostadil and vacuum devices. Surgically implanted penile prostheses are an option when other treatments have been ineffective. Counseling is recommended for men with psychogenic ED.

Proton pump inhibitors are highly effective acid suppressants with decades of use highlighting positive outcomes in millions of patients worldwide, and they offer minimal risk of adverse events. PPIs are considered overutilised when prescribed without an appropriate indication, when patients are left on them 'indefinitely' without appropriate indications and when they are continued after being utilised for most cases of hospital SUP. While several adverse outcomes have been linked to PPI therapy, most data are from retrospective observational studies that may be subject to confounding and bias.

Veterans Affairs Center for Clinical Management Research; Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Division of Gastroenterology, St Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada; Departments of Family Medicine and Urology, University of Michigan Medical School, Ann Arbor, Michigan; and Division of Gastroenterology, McGill University, McGill University Health Centre, Montreal, Quebec, Canada

The purpose of this guideline is to provide a clinical framework for the diagnosis and treatment of Peyronie's disease.A systematic review of the literature using the PubMed®, EMBASE® and Cochrane databases (search dates 1/1/1965 to 1/26/15) was conducted to identify peer-reviewed publications relevant to the diagnosis and treatment of PD. The review yielded an evidence base of 303 articles after application of inclusion/exclusion criteria.The systematic review was used to create guideline statements regarding treatment of PD. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high quality evidence; high certainty), B (moderate quality evidence; moderate certainty), or C (low quality evidence; low certainty). Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional consensus statements related to the diagnosis of PD are provided as Clinical Principles and Expert Opinions due to insufficient published evidence.There is a continually expanding literature on PD; the Panel notes that this document constitutes a clinical strategy and is not intended to be interpreted rigidly. The most effective approach for a particular patient is best determined by the individual clinician and patient in the context of that patient's history, values, and goals for treatment. As the science relevant to PD evolves and improves, the strategies presented here will be amended to remain consistent with the highest standards of clinical care.

Although administration of stress ulcer prophylaxis (SUP) has been recommended for specific patients in the intensive care unit (ICU) setting, this practice has been extrapolated to care of non-ICU patients without evidence to support need or efficacy.To examine the practice of SUP in non-ICU patients in a university hospital setting, with specific attention to resource utilization.Retrospective chart review of adult non-ICU admissions to one family medicine and five general internal medicine teaching services over a consecutive 4-month period. Proportion of patients prescribed SUP was ascertained after exclusion of patients admitted on antisecretory therapy (AST) or prescribed AST for non-SUP indications. Annual cost estimates were calculated assuming full compliance.Of 1,769 patient admissions, 22% received SUP and 54% of these were discharged home on AST. None of these patients met evidence-based criteria for appropriate SUP. Inpatient SUP cost Dollars 11,024 over the 4 months of the study (Dollars 44,096 annually), and outpatient costs based on discharge prescriptions were Dollars 16,924 (Dollars 67,695 annually), yielding a total cost expenditure of Dollars 27,948 (Dollars 111,791 annually).SUP is overutilized in the non-ICU setting, and patients are often discharged unnecessarily on AST, resulting in significant cost expenditure. Interventions to ensure appropriate use of SUP should decrease resource expenditures without detrimental impact on quality of care.

Proton pump inhibitors (PPIs) remain the superior choice worldwide in antisecretory therapy in the evidence-based treatment of upper gastrointestinal disorders including gastroesophageal reflux disease, erosive esophagitis, dyspepsia and peptic ulcer disease. PPI overutilization in ambulatory care settings is often a result of failure to re-evaluate the need for continuation of therapy, or insufficient use of on-demand and step-down therapy. Nonjudicious use of PPIs creates both preventable financial as well as medical concerns. PPIs have been associated with an increased risk of vitamin and mineral deficiencies impacting vitamin B12, vitamin C, calcium, iron and magnesium metabolism. While these risks are considered to be relatively low in the general population, they may be notable in elderly and malnourished patients, as well as those on chronic hemodialysis and concomitant PPI therapy. No current evidence recommends routine screening or supplementation for these potential vitamin and mineral deficiencies in patients on either short- or long-term PPI therapy. Reducing inappropriate prescribing of PPIs can minimize the potential risk of vitamin and mineral deficiencies.

Introduction Direct observation of clinical skills is vital to medical student development. However, direct observation of medical students by faculty is often sporadic, undocumented, and unstandardized. We sought to increase feedback to students and help students recognize they are receiving feedback. The purpose of this resource was to teach intentional, systematic feedback on clinical skills that is standardized within all required clinical clerkships. Methods This resource provides the direct observation curriculum and the observation forms used in the required clerkships, including surgery, internal medicine, psychiatry, neurology, pediatrics, obstetrics and gynecology, family medicine, and emergency medicine. For the purpose of direct observation, the clerkships developed and adopted an assessment checklist for a problem-focused history (e.g., abdominal pain), organ-specific physical examination (e.g., abdominal exam), and an advanced communication skill (e.g., information sharing). Results Before the implementation of systematic direct observation, 71% of students reported direct observation of history examination and 82% direct observation of physical examination (average across all required clerkships). After implementation, 92% reported direct observation of history and 96% for physical examination. Discussion Implementation of a systematic program for direct observation of clinical skills can effectively increase direct observation of clinical skills. Furthermore, at the end of the clinical year, we can ensure that the major patient problems and the key portions of the physical examination have been observed and formative feedback provided by faculty.

Urinary incontinence is a common problem in both men and women. In this review article we address treatment of the various forms of incontinence with conservative treatments, medical therapy, devices and surgery. The US Preventive Services Task Force, The Cochrane Database of Systematic Reviews, and PubMed were reviewed for articles focusing on urinary incontinence. Conservative therapy with education, fluid and food management, weight loss, timed voiding and pelvic floor physical therapy are all simple office-based treatments for incontinence. Medical therapy for incontinence currently is only available for urgency incontinence in the form of anticholinergic medication. Condom catheters, penile clamps, urethral inserts and pessaries can be helpful in specific situations. Surgical therapies vary depending on the type of incontinence, but are typically offered if conservative measures fail.

Urinary incontinence is a common problem in both men and women. This review article addresses its prevalence, risk factors, cost, the various types of incontinence, as well as how to diagnose them. The US Preventive Services Task Force, the Cochrane Database of Systematic Reviews, and PubMed were reviewed for articles focusing on urinary incontinence. Incontinence is a common problem with a high societal cost. It is frequently underreported by patients so it is appropriate for primary-care providers to screen all women and older men during visits. A thorough history and physical examination combined with easy office-based tests can often yield a clear diagnosis and rule out other transient illnesses contributing to the incontinence. Specialist referral is occasionally needed in specific situations before embarking on a treatment plan.

Proton-pump inhibitors (PPIs) remain the leading evidence-based therapy for upper gastrointestinal disorders, including gastroesophageal reflux disease, dyspepsia, and peptic ulcer disease. The effectiveness of PPIs has led to overutilization in multiple treatment arenas, exposing patients to an increasing number of potential risks. The overutilization of PPIs in ambulatory care settings is often a result of failure to re-evaluate the need for continuation of therapy, or insufficient use of on-demand and step-down therapy. PPI overutilization in the inpatient setting is often a result of inappropriate stress ulcer prophylaxis (SUP) in nonintensive care unit patients, and failure to discontinue SUP prior to hospital discharge. Potential consequences of prolonged PPI therapy include hypergastrinemia, enterochromaffin-like cell hyperplasia, and parietal cell hypertrophy, leading to rebound acid hypersecretion. PPIs have been linked via retrospective studies to increased risk of enteric infections including Clostridium difficile-associated diarrhea, community-acquired pneumonia, bone fracture, nutritional deficiencies, and interference with metabolism of antiplatelet agents. Reducing inappropriate prescribing of PPIs in the inpatient and outpatient settings can minimize potential for adverse events, and foster controllable cost expenditure.

The adult well male examination should incorporate evidence-based guidance toward the promotion of optimal health and well-being, including screening tests shown to improve health outcomes. Nearly one-third of men report not having a primary care physician. The medical history should include substance use; risk factors for sexually transmitted infections; diet and exercise habits; and symptoms of depression. Physical examination should include blood pressure and body mass index screening. Men with sustained blood pressures greater than 135/80 mm Hg should be screened for diabetes mellitus. Lipid screening is warranted in all men 35 years and older, and in men 20 to 34 years of age who have cardiovascular risk factors. Ultrasound screening for abdominal aortic aneurysm should occur between 65 and 75 years of age in men who have ever smoked. There is insufficient evidence to recommend screening men for osteoporosis or skin cancer. The U.S. Preventive Services Task Force has provisionally recommended against prostate-specific antigen-based screening for prostate cancer because the harms of testing and overtreatment outweigh potential benefits. Screening for colorectal cancer should begin at 50 years of age in men of average risk and continue until at least 75 years of age. Screening should be performed by high-sensitivity fecal occult blood testing every year, flexible sigmoidoscopy every five years combined with [corrected] fecal occult blood testing every three years. [corrected]. The U.S. Preventive Services Task Force recommends against screening for testicular cancer and chronic obstructive pulmonary disease. Immunizations should be recommended according to guidelines from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

To determine the prevalence and economic effect of inappropriate proton pump inhibitor (PPI) use in an ambulatory care setting.Retrospective medical record review of random sample with subgroup analysis.Patients were categorized according to appropriateness of pharmacotherapy based on documented upper gastrointestinal tract diagnoses, gastrointestinal or extraesophageal symptoms, or gastroprotection. Adverse events potentially associated with PPI use were identified.Of 946 patients in an ambulatory care setting, 35.4% were given PPI therapy for an appropriately documented upper gastrointestinal tract diagnosis, 10.1% received PPIs empirically for symptomatic treatment based on extraesophageal symptoms, 18.4% received PPIs for gastroprotection, and 36.1% had no documented appropriate indication for PPI therapy. In a subgroup analysis, 48.6% of patients across all 4 categories received PPIs without documentation of reevaluation of upper gastrointestinal tract symptoms, accounting for 1034 patient-years of PPI use. The total cost of inappropriate PPI use was $233,994 based on over-the-counter PPI costs and $1,566,252 based on average wholesale price costs. Potentially related adverse events in this cohort included Clostridium difficile–associated diarrhea (6 cases) and community-acquired pneumonia (1 case), but no cases of hip fracture or vitamin B12 deficiency were identified.Proton pump inhibitors are often overused in the ambulatory care setting without documented valid indications. Inappropriate use of PPIs is associated with substantial cost expenditure and with the potential for adverse events.

Erectile dysfunction (ED) is the most common sexual problem in men. The incidence increases with age and affects up to one third of men throughout their lives. It causes a substantial negative impact on intimate relationships, quality of life, and self-esteem. History and physical examination are sufficient to make a diagnosis of ED in most cases, because there is no preferred, first-line diagnostic test. Initial diagnostic workup should usually be limited to a fasting serum glucose level and lipid panel, thyroid-stimulating hormone test, and morning total testosterone level. First-line therapy for ED consists of lifestyle changes, modifying drug therapy that may cause ED, and pharmacotherapy with phosphodiesterase type 5 inhibitors. Obesity, sedentary lifestyle, and smoking greatly increase the risk of ED. Phosphodiesterase type 5 inhibitors are the most effective oral drugs for treatment of ED, including ED associated with diabetes mellitus, spinal cord injury, and antidepressants. Intraurethral and intracavernosal alprostadil, vacuum pump devices, and surgically implanted penile prostheses are alternative therapeutic options when phosphodiesterase type 5 inhibitors fail. Testosterone supplementation in men with hypogonadism improves ED and libido, but requires interval monitoring of hemoglobin, serum transaminase, and prostate-specific antigen levels because of an increased risk of prostate adenocarcinoma. Cognitive behavior therapy and therapy aimed at improving relationships may help to improve ED. Screening for cardiovascular risk factors should be considered in men with ED, because symptoms of ED present on average three years earlier than symptoms of coronary artery disease. Men with ED are at increased risk of coronary, cerebrovascular, and peripheral vascular diseases.

Gastroesophageal reflux disease typically manifests as heartburn and regurgitation, but it may also present with atypical or extraesophageal symptoms, including asthma, chronic cough, laryngitis, hoarseness, chronic sore throat, dental erosions, and noncardiac chest pain. Diagnosing atypical manifestations of gastroesophageal reflux disease is often a challenge because heartburn and regurgitation may be absent, making it difficult to prove a cause-and-effect relationship. Upper endoscopy and 24-hour pH monitoring are insensitive and not useful for many patients as initial diagnostic modalities for evaluation of atypical symptoms. In patients with gastroesophageal reflux disease who have atypical or extraesophageal symptoms, aggressive acid suppression using proton pump inhibitors twice daily before meals for three to four months is the standard treatment, although some studies have failed to show a significant benefit in symptomatic improvement. If these symptoms improve or resolve, patients may step down to a minimal dose of antisecretory therapy over the following three to six months. Surgical intervention via Nissen fundoplication is an option for patients who are unresponsive to aggressive antisecretory therapy. However, long-term studies have shown that some patients still require antisecretory therapy and are more likely to develop dysphagia, rectal flatulence, and the inability to belch or vomit.

Cirrhosis and chronic liver failure are leading causes of morbidity and mortality in the United States, with the majority of preventable cases attributed to excessive alcohol consumption, viral hepatitis, or nonalcoholic fatty liver disease. Cirrhosis often is an indolent disease; most patients remain asymptomatic until the occurrence of decompensation, characterized by ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, or variceal bleeding from portal hypertension. Physical examination of patients with cirrhosis may reveal a variety of findings that necessitate a hepatic- or gastrointestinal-based work-up to determine the etiology. Some patients already may have had laboratory or radiographic tests that incidentally uncovered signs of cirrhosis and its comorbidities. No serologic or radiographic test can accurately diagnose cirrhosis. A significant correlation has been demonstrated between persistently elevated liver function tests and biopsy-proven underlying hepatic disease; thus, a more targeted serologic work-up is indicated in patients whose liver function test results are persistently abnormal. Unnecessary medications and surgical procedures should be avoided in patients with cirrhosis. Referral for liver biopsy should be considered only after a thorough, non-invasive serologic and radiographic evaluation has failed to confirm a diagnosis of cirrhosis; the benefit of biopsy outweighs the risk; and it is postulated that biopsy will have a favorable impact on the treatment of chronic liver disease.

Major complications of cirrhosis include ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, portal hypertension, variceal bleeding, and hepatorenal syndrome. Diagnostic studies on ascitic fluid should include a differential leukocyte count, total protein level, a serum-ascites albumin gradient, and fluid cultures. Therapy consists of sodium restriction, diuretics, and complete abstention from alcohol. Patients with ascitic fluid polymorphonuclear leukocyte counts of 250 cells per mm3 or greater should receive empiric prophylaxis against spontaneous bacterial peritonitis with cefotaxime and albumin. Patients who survive an episode of spontaneous bacterial peritonitis should receive long-term prophylaxis with norfloxacin or trimethoprim/sulfamethoxazole. Patients with gastrointestinal hemorrhage and cirrhosis should receive norfloxacin or trimethoprim/sulfamethoxazole twice daily for seven days. Treatment of hepatic encephalopathy is directed toward improving mental status levels with lactulose; protein restriction is no longer recommended. Patients with cirrhosis and evidence of gastrointestinal bleeding should undergo upper endoscopy to evaluate for varices. Endoscopic banding is the standard treatment, but sclerotherapy with vasoconstrictors (e.g., octreotide) also may be used. Prophylaxis with propranolol is recommended in patients with cirrhosis once varices have been identified. Transjugular intrahepatic portosystemic shunt has been effective in reducing portal hypertension and improving symptoms of hepatorenal syndrome, and can reduce gastrointestinal bleeding in patients with refractory variceal hemorrhage. When medical therapy for treatment of cirrhosis has failed, liver transplantation should be considered. Survival rates in transplant recipients have improved as a result of advances in immunosuppression and proper risk stratification using the Model for End-Stage Liver Disease and Child-Turcotte-Pugh scoring systems.

The primary treatment goals in patients with gastroesophageal reflux disease are relief of symptoms, prevention of symptom relapse, healing of erosive esophagitis, and prevention of complications of esophagitis. In patients with reflux esophagitis, treatment is directed at acid suppression through the use of lifestyle modifications (e.g., elevating the head of the bed, modifying the size and composition of meals) and pharmacologic agents (a histamine H2-receptor antagonist [H2RA] taken on demand or a proton pump inhibitor IPPI] taken 30 to 60 minutes before the first meal of the day). The preferred empiric approach is step-up therapy (treat initially with an H2RA for eight weeks; if symptoms do not improve, change to a PPI) or step-down therapy (treat initially with a PPI; then titrate to the lowest effective medication type and dosage). In patients with erosive esophagitis identified on endoscopy, a PPI is the initial treatment of choice. Diagnostic testing should be reserved for patients who exhibit warning signs (i.e., weight loss, dysphagia, gastrointestinal bleeding) and patients who are at risk for complications of esophagitis (i.e., esophageal stricture formation, Barrett's esophagus, adenocarcinoma). Antireflux surgery, including open and laparoscopic versions of Nissen fundoplication, is an alternative treatment in patients who have chronic reflux with recalcitrant symptoms. Newer endoscopic modalities, including the Stretta and endocinch procedures, are less invasive and have fewer complications than antireflux surgery, but response rates are lower.