GI Specialist Interview: H. pylori, GERD, Celiac, Constipation & When to Refer
When should you manage a GI concern in primary care—and when should you refer to a GI specialist?
In this episode, I’m joined by gastroenterology nurse practitioner Paige Sosebee to talk about common GI concerns in primary care, including H. pylori, GERD, abnormal liver tests, celiac disease, chronic constipation, SIBO, and GI referrals. We talk about what primary care NPs can reasonably evaluate and manage, what testing is helpful before referring, and what a GI specialist wishes primary care providers knew before sending a referral.
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What We Cover
H. pylori testing, treatment, and referral
GERD and when to consider endoscopy
Elevated liver tests and alkaline phosphatase
Celiac disease testing
Chronic constipation
SIBO and intestinal methanogen overgrowth (IMO)
When to refer to a GI specialist
Timestamps
00:00 – Introduction
02:19 – Meet GI specialist Paige Sosebee, FNP
04:31 – H. pylori testing, treatment & referrals
13:20 – GERD, PPIs & when to consider endoscopy
20:06 – Alginate therapy for GERD
22:31 – Elevated liver tests & GI referrals
24:51 – Elevated alkaline phosphatase & imaging
30:00 – Celiac disease testing
41:10 – Chronic constipation
46:00 – SIBO & intestinal methanogen overgrowth (IMO)
52:50 – When to refer to a GI specialist
56:00 – Clinical resources for primary care NPs
Key Takeaways From a GI Specialist
H. pylori
Use a stool antigen or urea breath test when evaluating for active H. pylori infection; serology can't distinguish active from previous infection.
PPIs can cause false-negative stool or breath testing. Paige recommends holding the PPI for 2 weeks and antibiotics/bismuth for 4 weeks before testing.
You don't necessarily need to refer at the same time you order the initial test. Primary care can generally diagnose and treat an initial H. pylori infection and confirm eradication before referring if needed.
GERD
In patients with typical GERD symptoms and no alarm features, start with appropriate initial treatment rather than automatically referring to GI.
An 8-week PPI trial is commonly used before pursuing endoscopy in uncomplicated GERD.
Consider GI evaluation sooner when there are alarm symptoms or indications for Barrett's esophagus screening.
Abnormal Liver Tests
Don't automatically refer a single mildly elevated AST, ALT, or alkaline phosphatase. Repeat the testing and review medications, supplements, and other potential causes first.
Calculate a FIB-4 when appropriate to help assess fibrosis risk.
If hepatitis C antibody is positive, obtain HCV RNA to determine whether there is active infection before referring.
For an isolated elevated alkaline phosphatase, first determine whether it's likely hepatic or non-hepatic. GGT and/or alkaline phosphatase isoenzymes can help clarify the source.
Celiac Disease
Start with tTG-IgA + total IgA.
If the patient is IgA deficient, use appropriate IgG-based serology instead.
Make sure the patient is still eating gluten during the diagnostic evaluation. Starting a gluten-free diet first can normalize serology and intestinal findings and make celiac disease harder to confirm.
Chronic Constipation
For uncomplicated chronic constipation, make sure the patient has had an adequate trial of fiber and polyethylene glycol before referring.
Ask about medications, duration of symptoms, urge to defecate, and changes after childbirth—these can help identify drug-induced constipation, slow transit, or possible pelvic floor dysfunction.
GI may use transit studies, anorectal manometry, or defecography when the history suggests a motility or pelvic floor problem.
Making a Better GI Referral
A patient’s symptoms may feel urgent, but that doesn’t always mean the GI referral is medically urgent. GI offices independently triage the urgency based on the clinical information provided.
Examples Paige considers truly urgent include active/recurrent GI bleeding or imaging concerning for malignancy.
Complete the initial workup whenever possible. For example, if you've ordered stool studies for diarrhea, have the patient complete them before the GI appointment so the specialist can actually act on the results.
Resources mentioned in this episode:
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Liz Rohr (they/she) | Real World NP (00:01.568)
Welcome to the Real World NP podcast, where we share practical clinical education, real-world practice insights, and honest conversations to help nurse practitioners feel more confident, capable, and supported in practice. Real World NP is an ANCC accredited continuing education company supporting nurse practitioners, schools, clinics, and fellowship programs in bridging the gap between graduate education and real world practice.
Hello, hello. this week's episode is an interview with Paige Sosabee. She is a nurse practitioner in gastroenterology, and she is such a walking textbook. It was so fun to talk to her, and I could have talked to her for hours. It was it was just so lovely. So a little bit about Paige. So she became a registered nurse in 2013, earned her family nurse practitioner degree in 2018, and then most recently in August, completed her Doctor of Nursing Practice degree.
She's also pursuing certification in functional medicine through the Institute of Functional Medicine, and her passion for gastroenterology began during a student nurse practitioner rotation and has she's been dedicated to the field ever since. She spent the last six years in GI with the last three focused entirely on telehealth. Outside of her professional life, she's married and the proud parent of one child. A fun fact about her is that before entering the nursing field, she worked as a graphic designer, wedding photographer, and even a flight attendant.
So in this episode, we talked about a whole bunch of stuff. So we went through H. Pylori, testing and referrals and treatment, GERD and heartburn. We also got into liver testing, liver lab interpretation and referral and ordering imaging and some very pointed questions that I know that a lot of learners inside of the lab course have asked about and being slightly elevated Alc FOSS that's persistently there. we talked about celiac. I went to think about ordering celiac.
How to order it correctly, what not to do. And then lastly, we talked about constipation, chronic constipation, and diarrhea. And we touched on some pearls of practice when it comes to referrals and collaborating with GI specialists, as well as some resources to consult for our evidence-based practice. So without further ado, here is my interview with Paige. I'm so excited that we finally get to record this. Thank you so much for being here. Would you
Liz Rohr (they/she) | Real World NP (02:19.246)
care to share a little bit about your NP journey since where what you do now and kind of like how you got here from graduation. Absolutely. Liz, thank you so much for having me on your podcast. So I graduated with my family nurse practitioner degree in 2018. I went to work at an acute care clinic for a year and then I moved into specialty care. So I've been in gastroenterology since 2019 at a large academic center, which is wonderful because it gives a
all of us an opportunity to continue to learn. We run a fellowship program. There are medical students, PA students, nurse practitioner students. And then just this year I graduated with my doctorate of nursing practice. I forgot about that. Congratulations. Yay. Thank you, August. It feels wonderful to be done. But I moved straight into working on my functional medicine certification. Amazing. Just because there's even though I work in the insurance world, there are a lot of patients who would like
some alternatives to just traditional medication routes. And so I want to be able to offer that. Well, that's amazing. So what are some of the things that you see in your GI practice? Cause like before we started recording when we chatted before, one of the goals of the specialist interviews is to really connect primary care and specialty care a little bit better so that we can work better together.
So I would love to know like what are some of the things that you see in like your regular day working in GI? So my department sees hepatology. So they'll see elevated liver function, cirrhosis, anything having to do with the liver. And then we also have a clinic that sees inflammatory bowel disease that covers Crohn's, ulcerative colitis, and indeterminate colitis. Some of our providers will also see that on their individual schedules. I stick with general GI, so I see H. pylori.
Constipation, diarrhea, abdominal pain, acid reflux, colon cancer screenings, pretty much anything that doesn't fall under the headings of inflammatory bowel disease or hepatology. that's awesome. That's awesome. and I love that because like when I, you know, in primary care, I'm thinking about I'm like, my gosh, like who do I send my referrals to? And it really depends on the location, I think, and what people have accessibility for, but
Liz Rohr (they/she) | Real World NP (04:31.446)
you know, some when you have big a big academic center, you have the option of, you know, an IBD clinic and a hepatology clinic and a general GI, but sometimes it's just general GI and I'm like, I hope I'm sending them to the right place. So so yeah, so that's great to know. And one of the things that we had talked about is sharing about some you can either say pet peeves of referrals between primary care and GI or what are some opportunities for us to collaborate better. And I know you said you spoke with some of your colleagues
To see their opinions as well. I just love having an an opportunity to share these because I think that there's frustration on both sides, but really it's just an opportunity for us to work better together, not to like hate on each other. You know what I mean? I agree a hundred percent. It's really just an opportunity of this is our specialty. So there may be some things in the guidelines that you're not aware of that could make our jobs easier, your jobs easier, and make it easier on the patient when they get to us. Definitely. Definitely.
Yeah, so what are some of those things that you're that are coming up and you're like, I really wish primary care knew that. So one of the things has to do with the H. pylori testing and then the results. So when you do H. pylori testing, you have three choices. You have stool, breath, or serum. And so a lot of times you really want to understand the difference in that testing and what each one is good for. So only the stool and the breath test check for active infection. The serum test is an antibody test.
So if I have a patient who doesn't want to go off their proton pump inhibitor, then I will test their serum. But if the serum test comes back positive, I don't treat them. I require then that they go off of their PPI and then use the breath or stool test to check for an active infection. And I commonly see, and it's not just family practice, it it's other specialties as well, will check a serum H. pylori, even when the patient has said they have a history of H. pylori.
And then they'll treat them without checking for an active infection. And so, you know, for antibiotic stewardship, it would be really great if you don't treat them from just the serum test. And if they do report that they've ever had H. pylori, the serum test is never valid. If it's ever been positive in the past, it's not valid. It will always be positive for the rest of their life, more likely. And then for the stool and breath test, please don't check them when the patient is still on their PPI.
Liz Rohr (they/she) | Real World NP (06:43.916)
I get so many who come to me and they say, Well, my H. pylori test was negative. And I said, Well, did you stop your Omaprazol or pentoprazol or whatever it is? And they're No. And so then I have them stop it for two weeks. They also can't take peptobismol or antibiotics for four weeks prior. It can give a false negative. Now, if you get a positive, it's a true positive, but the negative is what you can't trust. Right. And so, you know, I'll retest them if needed. And then also if you do order the H. pylori test.
Please don't order referral to GI at the same time because primary is so capable of treating H. pylori at least the first time. You know, so wait, if it comes back positive and you're not comfortable treating, then you could refer to GI, or if it comes back negative and you don't need to treat them.
Then refer to GI because you ruled that that out. But a lot of times I see the orders concurrently placed and then the primary s gets the positive back and they send in treatment and then the patient comes to see me and there's nothing to do for them yet until we know if it worked. Totally. Do you have any do you have any pearls of practice around treating H. pylori? I've personally taken it taken it myself, but I've also prescribed it for patients and it's it's
Awful. Like the triple quadruple therapy. Like it's it's brutal. So I just I don't know if you have any thoughts about it or any guidance that you give your patients to help them tolerate it better or keep track of things and complete the series. There's not much for tolerating it better. I am a fan of probiotics. The American College of Gastroenterology does not recommend them anymore in their guidelines. There's not enough research behind it, but the little bit of research we have does show that, you know, they're helpful.
And they're not gonna hurt the patient. So I have them take a probiotic at least once a day, at least an hour after the antibiotics. Anecdotally, a lot of my patients tell me that it helps them tolerate the antibiotics better. I also explain to them that if they can't tolerate it, they need to let me know because we don't have that many options for H. pylori. Yeah. One of my favorites though is the high dose dual therapy. So if they're not allergic to penicillins, then you can do high dose amoxicillin with a proton pump inhibitor.
Liz Rohr (they/she) | Real World NP (08:47.744)
It is not approved in the US for first line therapy, but it is approved for salvage therapy. And it's my favorite salvage therapy because it's only two medications, so I get better compliance with it. Absolutely. Yeah, that's way better. Well, and also there was a recent study printed in the American College of Gastroenterology that showed that the newer medication, not a proton pump inhibitor, but VOQSNA has higher rates of success in treating with triple and quadruple therapy. So
If you can get that approved by their insurance, which is quite difficult, of course, it does have a higher rate the first time around. And so I will try to get that one approved first because I just want the chance of success to be the best possible since we only have a few choices. Absolutely. Absolutely. Any other thoughts you want to add about HP Lori, whether it's like the testing or I feel like it's a tricky thing sometimes for primary care 'cause, you know, I think a lot of people this could open up such a can of worms. There's so many things I want to talk to you about. But
So so often in primary care we see things like epigastric pain and reflux. And so yeah, where where are you sort of thinking about when it comes maybe we can just kind of touch on kind of segue into GERD and talking about H. pylori as well. But yeah, what are what are your thoughts about like general practices? It's like so if a patient probably are not seeing them until they've already seen primary care, but maybe even in urgent care too. Like any thoughts around
you know, thinking through f especially for newer grads, like how do we think through GERD versus H. pylori or any thoughts you have around that? Well, so a lot of times you're right, they come to me from the ER or urgent care. And 100% of the time they've been prescribed a PPI without being tested for H. p pylori. So while I want to test for H. p pylori, that's not usually the first thing I do because they've already started their PPI. And so I I could check serum like we talked about, but instead I usually just hold off on that.
Because if they fail their PPI trial, I'm gonna be ordering an upper scope anyway. And with the EGD, I can get biopsies to check for H. pylori. So in primary, I would say definitely go ahead and check. It's an inexpensive test to do, especially the stool version. And it rules that out for the patient before you start them on therapy. And then I usually do if I have any abdominal pain, especially if it's epigastric pain, any signs of reflux, any heartburn, any belching.
Liz Rohr (they/she) | Real World NP (11:08.406)
If they say they have a sour taste in their mouth, then I lean toward thinking it's GERD, but the research shows that could also be triggered by H. pylori. So it doesn't hurt to check for it. And as an aside when choosing between the stool and the breath tests, I learned something the hard way. I had a a positive breath test come to me from primary care. And I rechecked and it was positive again. And the patient ended up being treated three times.
before I decided I needed to get biopsies and culture them to see what they would respond to because we're running out of options here and I was going to send the patient to infectious disease. And so I needed to know exactly what it would respond to. And it came back that a patient did not have H. pylori. wow. And so I did a lot of research into this. And it turns out that with the breath test, there is a very, very rare false positive that is a different strain of Helicobacter.
That's not Helicobacter pylori and it doesn't require treatment. So when I see a positive for a breath test, then I usually order the stool test or vice versa so that I'm getting two different tests to see if it's a true positive if I've already treated them. Wow. And that way it just gives me a little bit of, you know, flexibility and understanding is this really a true positive for them, especially if they're not very symptomatic.
Absolutely. my gosh, I love that. You're like a walking textbook. I just want to keep asking you all the questions. I'll learn through experience, unfortunately. No, it's so true, especially those rarer cases. That's just how we have to do it. In my personal experience, a lot of the times it's the stool test because that's the cheapest one. But the breath test for people who are not familiar with it, basically they you just have them blow into a bag. Is it blow the bag first and then drink a substance and then blow into the bag again?
Is that how that test works? I believe so. And it can vary with the labs, but that's how my lab does it as well. No chewing gum, no drinking anything for two hours prior. So there's a little bit of prep to it that makes it a little more difficult than the stool test. Yeah. But people tend to hate stool tests though, at least in my experience. Like I'm not gonna do that. I order a lot of them and and my patients don't typically appreciate it. Yes, definitely not. So I wanna maybe let's chat about GERD.
Liz Rohr (they/she) | Real World NP (13:19.786)
Or reflux. Like I think that my experience in primary care is that so many people come in with heartburn and they think that it's just normal and they kind of brush it off, or they're taking just over-the-counters all the time. What are some thoughts? Like, so if I guess I'm thinking about patients that come in. So like maybe there's someone that has had heartburn, kind of self-diagnosed, they take over-the-counter all the different options. Are you sort of
So we sort of talked about the H. pylori part. What are some of the other things that you're talking about with patients if you're thinking about just like stubborn symptoms? One thing I love seeing is the primary starting them on a trial of a PPI and not referring them immediately. So if they get referred and I see them three days after they start their PPI, then I have a wasted a appointment where and it's wasted from the patient point of view because all I can do is educate them. So the American College of Gastroenterology in the absence of alarm symptoms.
requires an eight-week trial of a PPI prior to an EGD. And a lot of insurance companies follow those guidelines because they they're there for a reason. So in the absence of alarm symptoms, if you're under the age of 60, the chances of gastric cancer are very, very low. And so if you fail an eight week trial of PPI, and a failure is either it did not resolve the symptoms, or you made the diet and lifestyle changes and when you stopped the PPI, your symptoms returned. Either of those will count as a failure.
Then you qualify for the upper scope. Now, of course, that's in the absence of alarm symptoms. If the patient has globus, dysphagia, or and this is the other thing to talk about, chronicity of symptoms, then they need an upper scope. So varitesophagus screening is recommended at least once in a lifetime if the baseline symptoms stay the same. And those requirements are gonna be for someone who's had acid reflux for at least five years, someone who's over the age of fifty, Caucasian, central obesity.
A first degree relative with Barrett's esophagus, those are going to be the main alarm symptoms, and you're looking for at least two of them to indicate that they need an upper scope with or without that trial of a PPI. So if you have a patient who comes in and they're telling you, yes, I've been treating my heartburden with Tums four times a day for five years, and they're 50 years old or they have central obesity.
Liz Rohr (they/she) | Real World NP (15:35.928)
They need that referral to GI. Yes, you need to start them on the PPI, but they also need an upper scope to rule out Barit's esophagus. Definitely. That's super super helpful. And I on the note about PBIs and doing the trial, I think so. One of the things that I've kind of struggled with is like, so I have patients. So for example, if they're coming in with the symptoms, they're using, for example, Tums, we switch over to the PPI. and it's a twice-a-day and it's for, you know, the two months.
think it's I think one of the like one of the pieces of guidance that I've read about is about tapering off. And I just don't know like so if you take it for the the twice a day for the full time, so they're able to adhere to that, which I think people kind of struggle with sometimes. And then there's like a tapering off of like once a day for like a week and then off for a week. Is there any sort of evidence to pro to support that or in your anecdotal experience, is that really necessary to make sure that that's not like
considered a quote unquote failure. There is evidence to support it. I can't quote the evidence to you, but I've looked it up in the past and there's actually a website, I'll have to find it and send it to you for tapering all sorts of medications. It's wonderful. I use it. I have it bookmarked. But for PPIs, I typically if they're on twice daily and it's the high dose, then what I'll do is I'll say they're on forty milligrams of Pantoprazol. I'll drop them to twenty milligrams of Pantoprazole twice a day for two weeks.
And I typically do two weeks because in GI, by the time I see them, they've been on it for years. Yeah. So if you have someone who's been in on on it for years, you have to taper them more slowly than someone who's been on it for two months. And so I'll do twenty milligrams twice a day for two weeks, then twenty milligrams once a day for two weeks. Meantime I've added Femotidine twenty milligrams twice a day at that point. Then I take them down to twenty milligrams.
once a day every other day while they're still taking the Fomodidine twice a day. And then I have them stop the pantoprazol and continue the Fomodidine. And then if they're well controlled, we attempt to taper that. But I always tell them you stop at the point where you're no longer well controlled and you go back up a step and let me know and we'll stay there for a little while. And so that's how I taper it, but it really is based on how long they've been on it. Because if you do have someone who's been on it for five years,
Liz Rohr (they/she) | Real World NP (17:51.618)
They are gonna get refractory symptoms just because their stomach acid has been low for so long that when you stop that suddenly, you're gonna get symptoms. Absolutely. Absolutely. Yeah, and I was gonna ask you, do you have any thoughts about using the H two blockers instead of the PPIs? Is it really just that you're you're kind of like following the guidelines of the PPIs to bring it down initially and then you continue on Fomotidine? Like do you ever start people with the something like Fomotidine? I would prefer to start people.
on Fomodidine because H2 blockers have a lower risk of side effects. Right. But because I'm usually trying to meet the guidelines to get them an upper scope, I frequently end up starting them on a PPI just to meet guidelines and see and and I explain to them the reason being eight weeks of a PPI will heal a mild ulcer. It will heal heartburn.
So visualizing that isn't gonna do us much good. You know, patients think that the upper scope is the be all and all. Right. But it's great for getting biopsies, it's great for making sure you don't have cancer, it's good for finding unusual things, but if they have typical non-alarm symptoms, then diet lifestyle and short term medication is gonna be their best bet. Totally, totally. Yeah. And I've kind of I've kind of taken that same approach of like I'd really love to not do PPIs, but that is part of the guidelines.
And that is, like you said, the recommendation. If someone has traditional heartburn symptoms where they're talking about feeling pain in their esophagus or the heartburn or the reflux, then after I taper them from the PPI to an H two blocker, I will sometimes try alginate therapy for them because that acts as a raft and prevents the acid from going up into the esophagus. Wait, I don't I'm not familiar with alginate therapy. Can you tell me about that?
Absolutely. So it is approved in first line therapy, I believe, in Europe. And it's not recommended as first line therapy in the US. So I start with PPI or H2 blocker, but it works great. So it's usually a gel. One of the brand names is Reflux Gourmet, if I'm allowed to say that. But it you can look up different ones, but that that's how you can find the alginate therapy. There's also a UK version of Gavascon that puts alginate in it as well that you can
Liz Rohr (they/she) | Real World NP (20:06.114)
find online. So there are several different options for patients when I tell them about it. If they don't want to do the gel, you know, they can do a liquid, but it's made from seaweed and it basically acts as a barrier. So it creates a barrier basically toward the top of your stomach to prevent that acid from refluxing back up. But because it's just a gel and it's not really absorbed, it doesn't have as much of the risk of side effects. I love that. And because it's a seaweed therapy, it just lower risk. And for some patients it works perfectly.
And so I do like to try that just to see because it lowers their risk of having, you know, the the side effects that come from the lower stomach acid, the decreased calcium, magnesium, and B twelve absorption, things like that. Mm-hmm. my gosh, I love that so much. Thank you. So I'm wondering about so we we talked about HP Lurb, we talked about GERD. some of the other things that I know come up for me in addition are and that you had brought up as well, is talking about liver testing.
And then celiac testing. So I have some big feels about lab interpretation. Like that's I'm very passionate about that with the lab course materials that we have for interpretation of LFTs. But I think that one of the things so if we start there, one of the things that I I think I struggle with is I just like don't see what happens afterwards. Like sometimes I see the notes from GI, sometimes I don't. And then I'm kind of struggling. I'm like, do I send if I have the luxury of hepatology, do I send them there? Do I send them to G general GI? And like, did I make sure that I tested all the things that I need to test before I
go there. So I think that's that's where I'm kind of coming from with primary care. What are your thoughts about like liver testing and like the other side of that when you're receiving those patients? What what does that kind of look like for you? It it really does depend on the comfort level of the primary care provider because I have some who get a single elevated AST or ALT or alkaline phosphatase and they send them straight to GI. Please don't do that. At least repeat the testing three months down the road or one month down the road if it's
higher than you're comfortable with. If it's just mildly elevated, repeat it. Have them stop any of the liver toxic medications that you can see that they're on, especially supplements before repeating it. You know, no acetaminophen, no supplements. Check their medication list to see what might be a culprit there. Have them stop it. Repeat the testing in one to three months. And then also run a fib four. So you know you can get
Liz Rohr (they/she) | Real World NP (22:31.244)
Get that calculator from a lot of different places, and you just input a couple of liver numbers in their platelets, and it'll give you a score. If the Fib 4 is less than 1.3, it has ruled out advanced fibrosis, and that can actually be managed by primary. So it's basically going to be fatty liver at that point. Yes, you can get an ultrasound, you can make sure, especially if you're going to be sending them to GI, though in truth, if you're sending them to hepatology.
A lot of hepatologists will order a complete ultrasound, not just a write up or quadrant. So sending them without an ultrasound is also fine. And then also within liver are the hepatitis C antibody tests. So sometimes we'll see a positive hep C antibody and they didn't get a viral load before sending them to GI. And so then they come to GI, we run the viral load and they don't have an active infection. Right. So running a simple viral load will
possibly save the patient a trip to GI. And if we already have that result, then it allows us to start focusing on treatment plans. Absolutely. Absolutely. one of the things that comes up, so if people are looking for help with HEP B and Hep C labs, I do have that on my YouTube channel if you're looking for support with that. So now I have a question about just plain Alk FOSS. So Alk FOSS plus ultrasound question. If it is a minorly elevated Alk FOSS
You want to look at two things. Is it bone origin or liver origin? Yes. So a GGT, it's a useful test. It can indicate liver, but alk foss isoenzymes will fractionate it into liver and bone percentages for you. And so if your lab offers the isoenzymes test, you really want to order that. Because if you have a frail little lady who has osteoporosis and she has elevated AlkFOS,
It could be from not her liver, but from her bone. If you have someone, the same thing, I mean, if you can look at somebody who has ascites and it might be their heart, not their liver. Everyone sends them to GI. Yeah. But it's not always GI. So with mildly elevated Alc FOS, absolutely, before you even think of sending them to GI, fractionate it first and make sure that it's liver origin. Definitely, definitely. Thank you so much for that.
Liz Rohr (they/she) | Real World NP (24:51.098)
and I think that was another question that comes up, excuse me, a lot in the lab course from the lab course students is with the alcohol isoenzyme, so it kind of breaks down into liver versus bone. And so if it's a bone more, like if it's more towards that, it's typically we're sending them to endocrine to get some support with that. But like I'm just trying to remember some of the lab results we've gotten. So they'll do the GGT, they'll do the AlKfoss isoenzymes, and then it's sort of like still unclear is like is this a GI thing or not, or maybe it's just like only slightly elevated.
So like if it is more pointing towards the GI source, do we do an ultrasound before we send? Do we just send them? What do you have any thoughts about that? Or am I like splitting hairs here? Cause it's also okay if I'm splitting hairs. Cause for example, I had a I did an interview with a with a blood disorder, a bleeding disorder specialist, and I was asking these very, very nitty gritty questions and she was like, even hematologists don't know that. And I was like, Okay, well, that just makes me feel better because I feel like I need I just I think that's also a new grad thing, but it also clearly persists persists ten years later of like, what am I supposed to know?
You know, like where is the line? So if all these are too nitty-gritty, please stop at any time and be like, that's a GI thing. And this is coming from a general GI person. So I find that ordering an ultrasound is helpful. Now, if I'm sending one of my own patients over to hepatology, I go ahead and order the complete ultrasound. So if you are thinking about ordering the ultrasound and you think you can get insurance to approve the complete ultrasound versus just the right upper quadrant, and I'm not a hepatology specialist, but
From what I see with my coworkers, the complete ultrasound will be more helpful than just the right upper quadrant one. Cool. So I would lean that direction. You can also wait a lot. I they're gonna be ordering other tests. That's of course, but it's not like blood work where you might have missed one. I mean, generally they only order one imaging. So they get the ultrasound and then they get the fiber scan, which is sometimes done in the ultrasound department, sometimes done in the GI department. It depends. It my work, we have both options, so I can order it either way.
a lot of companies do not have that. And so it may specifically only be done through the GI department. Totally, totally. that just brought up another question. So this is a hepatology related question. So I think it would just be really validating if you're like, no, that's not even something I do. But I think that when we're when I'm going through the labs, when I have a question of hemochromatosis, I think that I think that's something that comes up where the ferritin is super high.
Liz Rohr (they/she) | Real World NP (27:12.692)
on labs and then I'm checking the ALT AST, like the liver enzymes. And then I'm like, do I send them to GI or do I send them to heme? And again, this might be a really nitpicky question, but this comes up in the lab course and it comes up for me a bunch where I'm just like, okay, I know that ferritin is like an, you know, is gonna reflect inflammation. But like when it is super high, I don't know. I think that's one of my worries is like I'm sending all these people to G and they're just like, what is this?
This does not belong here. So anyway, if you have thoughts about that again, you're not a G I you're not a hepatology specialist, but I don't know if you see that at all. I'm not gonna lie, when I see that I ask one of my coworkers. Do you want me to send them to you? Yes. Because they want it to be at a certain level. And I don't know what their threshold is for that because they look at several other labs to decide that. So if your company offers like GI E consults.
That is a perfect time to use the e consult because you're like, Hey, can you just review these labs and tell me if they need to see GI? Or do I need, you know, do I need to send them somewhere else because it's an acute phase reactant and you can see a reason for it that's not GI related? And if so, then you've saved everyone a visit to GI. But yeah, get them to weigh in or if you've, you know, made friends with a GI specialist over time that you can get them to consult on the case.
Be like, hey, is this something that you would see or should I send it elsewhere? Definitely. You know, at least in in my company, the specialists are really great about that. If I have a question about surgery, I'll send an email to one of the surgeons rather than just sending the consult first. Absolutely. And so don't be afraid to utilize your network, but also don't don't be be beating yourself up over not knowing the answer to that one because that is very nuanced with Ferritin because it can be so many different things.
Totally, totally. Well, thank you so much for that. I really appreciate it. 'Cause I think also my I I feel like that's really pushing the scope of primary care to get into the hemochromatosis workup. And I have a lot of I felt like this when I was in New Grad. I don't know if you felt like this yourself, but like I have a lot of I felt like this and I have a lot of my you know, learners in the courses and also mentees that are sort of just like just have that constant question of like, is is like what is the level of knowledge that I'm supposed to have? It just feels really unclear sometimes because it's like such a jack of all trades in primary care. So
Liz Rohr (they/she) | Real World NP (29:37.08)
So thank you for for sharing that. So that yeah, there's a lot of questions and it's like you just have to be like, Nope, that's not that's not our purview anymore. It it feels so desire to learn. It is. And it feels overwhelming and specialty too. And I only have one specialty to learn versus primary care. Totally. I mean, it takes a good solid three years before you stop feeling like an idiot no matter who you are. Hundred percent. Three year I don't know what it is about three years, but that's pretty much what everybody that I've that I know has always talked about. That three year mark feels so much better.
So thank you for that. So so any other thoughts about liver things that would be helpful to share or requests that you have? any thoughts like that? You really hit I'm really glad you brought up the alkaline phosphatase because I had forgotten about that one. But yes. Yeah.
You know, just a pearl there is just making sure it is GI, but otherwise, no, we covered Lover Great. That's awesome. So yeah, I think we also had on our list to talk about celiac testing. And I feel like I never get this right. I've read so many things and I feel like it changes all the time. And it's anyway, what are what's what's going on with celiac? When you see people, have they gotten testing? Are they coming to you for the first time? Like what state are they in when they get to you? Are they trying
interventions, like what do you see when someone's like like referral for celiac? What does that look like? So if the referral is for potential celiac, then they either have a family history of it or the primary did the serum celiac testing and it was elevated for some reason. And they're sending them to me. That's fine. A lot of times though I get referrals for abdominal pain, diarrhea, rashes, you know, something that appears to be celiac, but primary did the celiac testing and it was negative. So they send them to me.
And the first thing I notice is they didn't order an IgA with it. And so if you're doing IgA serum celiac testing, if you don't order the IGA, you don't know if their immune system is responding correctly. So you can have a patient who has celiac, but if they have a suppressed immune system, then the IgA testing will tell you that. And serum IgA testing is the preferred method, but if their IgA is too low, then you switch to IgG testing. So you really want to know.
Liz Rohr (they/she) | Real World NP (31:45.09)
Can we back up for a second? Where where do you start? Like let's if we just like start from nothing. So someone is like, I'm an NP student or I'm a new grad and I don't know how to approach this testing. What are what are the tests that you want that you want to see or you don't want to see at the very first pass? My first pass testing is an IgA and a TTG. Okay. Tissue transglutaminase, if you can pronounce that. It's a real tongue twister, but yeah, the IgA and the TTG. If the IGA comes back low, then
You can I typically will order an endomesial antibody, but you can also order a TTG that's IgG. Okay. So you do have that. You can also order the the deamodated gliadin peptide IgG, which is also another one that I frequently order. So endomesial antibody is usually pretty expensive. So honestly, I will default to the deamidated gliadin peptide because it's IgG. I've personally never ordered the TTG IgG testing, but it is available. Mm-hmm.
So, you know, the only time I would order more than the initial two tests to begin with, the IGA and the TTG, is if I have a patient who's had a positive in the past and it was negative for celiac when we did biopsies, or they have a family history in a first degree relative, then I might do a more inclusive celiac panel to make sure that none of them are popping positive. Just so I'm doing my due diligence because it
could be that one of them is more sensitive for this specific patient than another. And of course, as you know, you know, it's a genetic condition that gets turned on. So just because they were negative in the past doesn't mean they're going to be negative in the future. And so even if they've had a negative test several years ago, I may still retest them if their symptoms are continuing. Totally, totally. What about, and I might be mixing these things up, but I think that sometimes if patients are, for example, like they're worried about celiac,
they make some dietary changes to get rid of gluten and then they get the testing done. That's probably not going to be accurate, correct? It is 100% inaccurate. first off, the blood test is a screening test, not a diagnostic. So if it's positive, you need to send them to GI to get the biopsies to confirm it. Now occasionally we have a patient we can't do that. They're on blood thinners. They can't go off. Okay, we'll go ahead and treat you like your celiac without the confirmatory testing. But
Liz Rohr (they/she) | Real World NP (34:08.564)
If the patient gets a positive celiac and either they decide to go on a gluten-free diet or the primary mistakenly tells them, you need to go on a gluten-free diet, it's typically because they don't understand celiac is a very unique disease where the tests that we use to monitor how you're doing are the same ones that we use to screen or diagnose you. So in the absence of gluten, your body's inflammation in a perfect world will
reduce and return to normal and your body will heal itself. And so all these test results and the biopsies will then return to normal. So if you come in and you're on a gluten-free diet and you got your testing, we have two options and neither of them are very good. If patients are feeling better on a gluten-free diet, the last thing they want to do is a gluten challenge. Yes. For me to test them. So sometimes we just treat them as if they're celiac. I don't officially diagnose them, but I'm like,
Does it really matter if you're gluten sensitive or true celiac if you're gonna avoid it for the rest of your life anyway? You know, it may matter in the sense that they need to know because you have to carefully look at every single thing you put into your body if you're a true celiac versus gluten sensitivity is not necessarily causing the same level of damage, if any, at all. And so that's the the nuanced approach I take with them. But if they want to confirm the diagnosis for sure, then I'll do the gluten challenge, which is the
Equivalent of two slices of bread a day for two weeks. So you have to eat it doesn't have to be two slices. If you like croissants, if you like whatever it is, it needs to be the equivalent of two slices of bread a day for a full fourteen days before we test you. Oof. Which is brutal if you've gotten rid of gluten and then you add it back in and you have to do it for two weeks and you don't feel good. So yeah, that's a little pearl there. I think that some people mistakenly think that, like, you should just try gluten free and see if you feel better, that kind of thing. Right. and for go ahead.
sorry, I was just gonna say sometimes I've then done a genetic test if they really don't want to go on a gluten free diet. Having the gene doesn't rule in celiac, but not having the gene rules out celiac. So it may give them some answers. Well that's and so it you know, i it's not a hundred percent like you know, I I can't tell you if you do have celiac, but I can definitely tell you if you don't have the gene. And so sometimes I'll do that if they don't want to go back to feeling bad. Definitely. And so do you have thoughts about assessing for celiac?
Liz Rohr (they/she) | Real World NP (36:28.162)
I guess this kind of segues into the constipation diarrhea topic that we wanted to talk about. But look, what are you seeing what are what are you seeing your celiac patients presenting like? Is there a classic presentation? in your anecdotal experience, is it like, you know, a classic or is it subtle? And what are the things that we should kind of all be looking out for when it's in terms of the suspicion of celiac? Classic presentation is going to be either constipation or diarrhea with abdominal pain and with or without a rash. Now, if they have
been going for years with eating gluten and not been diagnosed, then symptoms can get much more serious where they have a lot of inflammation in their small bowel where you absorb most of your nutrients. So they get nutrient deficiencies, they get weight loss, and they get more and more ill appearing because they have constant inflammation. So in that case, their sed rate or their CRP may also be elevated. And even though that's not specific to GI, it's a good marker
you know, if they're now having whole body inflammation, it's gonna show up there. And I don't have a a typical patient. It's not like a patient comes in and I say, Yes, absolutely, you have celiac, but my patients that I end up diagnosing with celiac absolutely fit the mold of, you know, either constipation or diarrhea, abdominal pain, worse with eating, and then plus or minus the rash. So in hindsight, they fit the mold very well. Yes. But there are so, so many patients who
also have those symptoms that are not going to end up diagnosed with celia. Definitely. And then for the rashes, like are you seeing the same type of rash? Does it kind of look the same? Does it look different in different people? Like what are what are your experiences with that? Typically an erythematist rash that, you know, it's going to end up frequently on their arms and legs. Some patients, and you can Google it because it really does, it shows up kind of on extensor surfaces and everything. But
For some people who have been celiac undiagnosed for a long time, they are so sensitive that they may report a rash of someone touching them after they ate gluten. wow. And just that touch can be enough to cause a rash for them. And so that would be a huge red flag for me if somebody said, Hey, I get a rash when, you know, people just touch me, even if they haven't related it to gluten themselves. Ironically, if you accidentally send them to dermatology, because that may be their presenting symptom.
Liz Rohr (they/she) | Real World NP (38:57.056)
you can diagnose celiac through skin biopsy as well. I don't see it very often at all, but it can be done. I see. Yeah. And is it itchy usually or not itchy? That depends on the patient. Most of mine, it's itchy, but it really does depend on the patient. It's not gonna look it is not going to usually be pular or anything like that. And then I say that and you have the patient who has severe celiac and theirs is.
So it really does vary. But most of my patients who get the rashes, it's just erythematous, no weeping, no pustules. It's mild. And, you know, it it it comes when they eat gluten and then it goes away if they stop. Yeah. Yeah. And I just asked because it's like, you know, so often I feel like we we read about stuff and then like the way it presents in real life is so different. So sometimes it's super variable. Sometimes it is it stays pretty classic. So I appreciate that.
I have a question before we move on to constipation and diarrhea, but in terms of the gluten sens gluten sensitivity versus celiac, how do you like what what is that usually like? Is it the patients are they're symptomatic, but they're not officially diagnosed with it, but then they just d generally feel better when they avoid gluten and then there's, you know, no signs of inflammation on biopsy? Yeah. In the GI world.
Typically that's gonna be one hundred percent how it presents. And I tell them I'm like if you feel better off gluten, then you're sensitive to it. Can they get sensitivity tests? Yes, you know, you can go to allergy and get Ig A versus Ig G testing and you know, to see if it's an allergy versus a sensitivity. The blood testing for food sensitivities is not reliable yet. I tell my patients all the time, if you're gonna get it done and you can order it online, you can go to functional medicine. There are a lot of places where you can get it done.
It is not a hard and fast rule that you have that sensitivity. It's telling me that your blood is reacting to a food. And so I use it to guide an elimination diet if they come to me and they've had that testing done. And so we may we may discover that they have gluten sensitivity through that testing, but it's confirmed through an elimination diet. And so for a lot of my patients, I tell them to skip the cost of the testing and just do an extensive elimination diet.
Liz Rohr (they/she) | Real World NP (41:10.54)
Yeah, which is because that'll tell them what they're sensitive. Yeah. And people don't probably want to hear that, but it's probably the most effective. They want the easy answer, but the problem is the easy answer just leads to an elimination diet as well. Because when you get back that you're sensitive to forty foods, you can't avoid all forty of them. You need to find out what, you know, three, five, ten that you really do need to avoid. Yeah, exactly. I had a friend who has autoimmune and also some sensitivities and did that test and she was like, I'm allergic to everything. I'm like, hmm.
Yeah, it doesn't really it doesn't really work like that. But she's doing the elimination diet too. But yeah, in terms of constipation and diarrhea, what are what are you seeing in your clinic and like how what do they look like? What have they done so far, just anecdotally your experience? Anecdotally with constipation, I get a lot of, you know, chronic constipation where the patients never thought to mention it to their primary and then they're like, yeah, I've had constipation for twenty years. I'm only having a bowel movement every two weeks and it it's brutal for them.
the measures they'll go through to get that. And so, you know, if if you have a patient who's never tried anything over the counter, then before sending them to GI, please start them on Miralax and Fiber for at least a few weeks before they're going to have their appointment with us, because that's in the guidelines. So we're going to want to start with that before we move on to prescription or testing, because most of the testing, if it was going to be positive, you wouldn't be responding to Muralax and Fiber. And so you know with constipation,
If it's drug-induced constipation, you need to be aggressive with that. You don't need to be like, hey, trust some marillax. If they're on chronic narcotics, they need something that's gonna counteract that because it can quickly spiral. Mm-hmm. If they have chronic constipation since, you know, childhood, likely their colon is not moving, especially if they're telling you I don't have the urge to have a bowel movement. If they're telling you that their constipation got worse after they had children,
They could have pelvic floor issues and in GI we can test for those. So we can, you know, order defecography or anal rectal monometry or sitzmarker study to see how their colon moves, if their pelvic floor moves appropriately. And if not, then I refer them to pelvic floor physical therapy. If their colon itself is not moving, there's not as much that we can do about that. It's not a referral to pelvic floor therapy. We're
Liz Rohr (they/she) | Real World NP (43:33.25)
We're using medications and, you know, stimulation to try and get it moving through things that they eat. But the testing can definitely be helpful to tell you, you know, likewise, even on a simple sitz marker study, which primary can order, if you see all the sitz markers clustered at the outlet, then it's likely likely an outlet dysfunction. And that really hints at pelvic floor issues or recto seal or something along those lines versus a slow colon. So
Even with simple x-ray tests, you can get an idea of where you're headed and what further testing you need to do because I don't order interectal monometry or defecography testing lightly because it's not pleasant for the patient. Typically by the time they get to me, they are willing to do it because they've been dealing with constipation for at least a few years. But I really only do it if I have an end goal in mind of either I may need to send them to surgery, I may dis need to send them to therapy.
Because otherwise just doing it for the sake of the information isn't beneficial to the patient in my mind. Definitely. So thinking about constipation, like are there things that I don't know, just like it's are there things that we should kind of like make sure that we're I mean, watching for red flags. I don't know if you feel like you want to touch on any of those, but like what are are there any sort of questions that we should be asking or guidance we should be giving them aside from kind of the Miralax and Fiber conversation to start and conversations about fiber, like any other th any thoughts you have about that of like
I know, like pearls of practice when talking to patients about c their constipation. A lot of patients get very nervous around constipation. They're afraid they have cancer or a large polyp. And you know, according to the guidelines, constipation alone is not an indication for a colonoscopy. And so they come expecting a colonoscopy and are often quite surprised when that's not the first thing we do. What is an indication for colonoscopy is penciling of stools. So if you have a patient who has intermittent constipation,
That's not likely caused by a large polyp, but consistent penciling of stools, the stools trying to get around something in their colon. So that's more of a red flag to me than constipation. You know, sudden onset constipation where they can't have a bowel movement at all and they can't pass gas. I'm I'm worried about obstruction. Yeah. And so that is very different. But then if you just have the typical patient who's had
Liz Rohr (they/she) | Real World NP (45:54.272)
slightly worsening constipation over the years and now things they've been using aren't working, then yeah, start them with miralax and fiber if they haven't tried it. Also look at magnesium citrate if they have good kidney function, because magnesium citrate is a gut motility agent. And so that's that's why it works so well. And I start on four hundred milligrams at night.
before bedtime because for some it can help relax them and it helps with their sleep. And a lot of patients like that because you can get the powder and so you can titrate it down if it's too much for you or up a little. And so it's a little bit more flexible, just like the Miralax is, but some patients feel that it's more natural and they prefer that route over the mirror. So I'll I'll try either or those before moving to prescription if they're willing to. Definitely. Yeah. And
just like anecdotally I had somebody who someone I know personally who was sharing that she had just like chronic constipation her whole life and also had like a lot of issues with gas. And I think that she was she felt really dismissed for a really long time, about her symptoms and this finally kind of getting support and she ended up having SIBO as well. so I don't know if you have any thoughts up about SIBO. I think that there's I don't know a lot I don't feel super comfortable with it myself and I don't know if a lot of people know it, but
She ended up being prescribed medication for that and then as well as like a she ended up needing prescription medications for her chronic constipation. But anyway, do you have any thoughts about that to to share in terms of your experience with it or what the evidence supports or absolutely. So we have two different versions. Well, actually three if you really dig into it. So with small intestinal bacterial overgrowth or SIBO, you have hydrogen predominant and hydrogen sulfide predominant. They're both treated the same way. And then what used to fall under the SIBO umbrella as well was
A methanogen version and it's now its own separate intestinal methanogen overgrowth. Classic textbook symptoms are going to be if you see diarrhea, expect it to be C bone. If you see constipation, expect it to be the methane one. I see them both with both. So it no one ever fits the classic textbook presentation. But the reason you care about which one it is is because the treatment is slightly different. With methane, you're usually going to use two different antibiotics or two different botanicals.
Liz Rohr (they/she) | Real World NP (48:10.486)
versus just the one that you would use if it's hydrogen or hydrogen sulfide. And so yeah, if I have a patient who has had chronic constipation or diarrhea and they complain of bloating, that's gonna be one of the first things that I want to test for. However, while the testing is available and you can get it mail ordered to the patient's house if you're set up with a lab or your personal lab may do it. RGI lab used to do it, they don't anymore, so we mail order it. The diet beforehand can be quite extensive for the patient.
And if they have certain risk factors, like say they're quadriplegic or they have very weak lung muscles, they may not get a sufficient enough breath into the bags for them to get a measurement. So you may get back a not sufficient on your testing, and it's because their their lung capacity wasn't good enough for it. So you have to take that into account because it's a two hour test where they're breathing into the bag about every 15 minutes. And then those gases are measured for
How much hydrogen, hydrogen sulfide, and methane that they offput. And so if you go above a certain level, you're considered positive, but they have high rates of false negatives, actually. And so I'm not above treating a patient if they worsen with certain foods that are typical with SIBO and IMO, even if their test was negative, because certain risk factors will also
kind of guide you toward thinking any patient who's had bariatric surgery is gonna be at increased risk because, you know, the way they're now structured is different. And any changes in your anatomy can cause kinks where bacteria can hide out and grow. Also, constipation is its own risk factor, not just a sequela of the condition, because slow gut motility, if you think about fermentation, you know, you're
leaving things stationary for a while is the same way with SIBO and IMO. If you have slow gut motility, then you're leaving things stationary for too long. And so you're giving the bacteria a chance to multiply without flushing them out of your system. Also if somebody has an elevated folate, that can happen in SIBO. And so that's a a test that primary often will see. And so if you do see that and your patient does complain of those symptoms, just kind of a a pearl of
Liz Rohr (they/she) | Real World NP (50:32.834)
you may want to start thinking of treating them for bacterial overgrowth or sending them to GI for the confirmatory testing. Yeah, I think it's just super helpful to hear more about it because I think it's not really on people's radar and from what I've seen. So it's just kind of like it's almost my takeaway is just knowing that it exists and that's sort of at least for my newer grads, like I I really emphasize that they learn the kind of core basics. And then once they have more experience, they expand their practice a little bit more.
So I feel like most of my like I've only seen SIBO testing done in GI. But like I feel like it might be in a situation of somebody if they're like very passionate about GI, they want to expand their practice, they can do a little bit more. But it's just to to share that for reference for the for the newer people that it's not necessarily routine to test for SIBO. It's just important that we recognize that it exists. In fact, if I have a patient from primary who has been treated by primary, I have 100% of the time seen them treated empirically versus seen them treated
after testing, unless I tested them and their primary is just retreating them. Because you know, if if you have a patient with bariatric surgery, they may get it more than once. And having had it once is its own risk factor for getting it again. Yeah. Also, interestingly enough, the gold standard test is actually a jejunum biopsy. We don't do that in my department. I've never seen it done. I've never had a single patient who's had it done. It is not available. So if
your new grads go to up to date or, you know, open evidence, wherever they're getting their resources and they see that as gold standard, please understand that referring to the them to GI will likely not get that test completed. They'll likely still get a breath test. Right. And that's I just love I love these interviews so much because it's like the there's it's just such a process to go from, you know, the the book learning to the real world actual practice of like what makes sense, how people present.
like how healthcare works. So that's really helpful to hear. And I want to be mindful of your time. So I think we can we can wrap up here. Are there any sort of last like pearls of practice or thoughts you have that you haven't gotten to share? maybe just like a if you have like a a brief thing about referrals. I think I don't I don't know if we got to a ton of what you wanted to talk about. You and your colleagues wanted to talk about with referrals, but two things on referrals.
Liz Rohr (they/she) | Real World NP (52:49.536)
I know that patients can be very insistent about their referrals. They've been suffering with these symptoms for so long and we truly want to help them. But a lot of times primary does get pushed into a corner where they they feel the need from the patient's point of view to list their referral as urgent. And w what they what you may not realize is at least in my department, when it comes to us, we review the urgency of the referral. And so that sets the patient up.
for disappointment because we likely will not consider it urgent if you did not originally consider it urgent before the patient started pushing for the change in urgency. It also sets them up to expect anything that I order to be completed urgently. And procedures and referrals are two separate sets of things. And so anything that I order, I have to set the urgency for that. It's not based on what the referral was. And so a little bit of education on the primary side
could be very helpful for setting some realistic expectations. Even if you still set the urgency, you could be like, hey, they may review this and feel that it's not urgent, or it may not mean that everything that's ordered will be urgent. That just this just may get you seen sooner. Right. And there's a difference between urgency, like it's very valid that they feel like their issue is urgent. I agree, it feels really urgent. You're really suffering and urgency in the medical world means danger.
And so this is not dangerous. That's some of the conversations I have with patients and it's like validating their feelings and I'm on the same side as them, but it's like it's it's about danger. And the patients who are in front of you have more life-threatening conditions. And in the GI world, you're exactly right. It is about danger. The the things that I list is urgent. Okay, a patient with a known history of a GI bleed and I'm trying to keep them out of the hospital again. Right. Their procedures are going to be urgent because we're trying to stop
another bleed that they already have happening. So I gotta get them in within a couple of days to keep them from ending up in the hospital getting another blood transfusion. Or a patient who has imaging that indicates cancer, I need to get them in for a biopsy immediately because the entire treatment plan rests on us getting an accurate diagnosis. And so you're right, you know, I I am not downplaying how urgent the patient feels it is. I just feel that they need their expectations. yeah.
Liz Rohr (they/she) | Real World NP (55:14.946)
To to be realized that, you know, it's a whole different set of urgency from where we're sitting because we're trying to to keep people out of the hospital. Definitely. and that also brings up the other thing about referrals is some GI departments have availability sooner than others, but for those that do have sooner availability, if you're fortunate enough to work in an area that does, getting an urgent referral for diarrhea.
And then not telling the patient they need to get their stool testing done first that you order it if you do order it is not helpful for the patient because then they come to me and I say, you turned in your stool testing today. I can't do anything until I see those results because I might be treating you for something, or I might be doing more extensive work up because you don't have an infection or a parasite, virus, bacteria, anything like that. And so I think also just letting the patient know that.
Yes, we put in an urgent referral, but please make sure you get the testing done at least three or four days prior to your appointment. We'll make their appointment more beneficial for them. Definitely. Definitely. Awesome. Well, thank you so much for your time and all of your wisdom you shared. I just I can't wait to share this with the people. But yeah, any any other kind of like last thoughts you want to share? Are you familiar with open evidence? No, I actually I was gonna ask you about that. Tell me.
it was shared with me. So I believe it's the Mayo Clinic has gone into an agreement with several journals. And it is an AI driven, research-based resource. It is free to anyone with an NPI number. So you just go to open evidence and you input your NPI number and they'll give you an account. And I use it a lot of times, you know, of course I use up to date as well. I use the ACG website for their guidelines. And I use open evidence and I'll compare it.
To see, you know, what I like is open evidence will show me the resources it's pulling from so I can see how recent they are. Does this show more recent evidence than, you know, something else? And so it's a really great free resource for new grads. I love that. That's wonderful. And for the students, NPI is national provider indicator? I don't remember what the I stands for. Identifier? Which you get when you have a license. I think it's identifier. Yes. It's national provider something. Something. Yes. you don't have one of those yet, but when you're a graduate, you will.
Liz Rohr (they/she) | Real World NP (57:31.49)
When you get your license, you will. Well, thank you so much for having me on your podcast. I've really enjoyed this chance to just talk to you and I love what you do for new grads. Thanks. Thank you so much for being here. You have just such great wisdom to share. So I appreciate it. Thanks for spending this time with us on the Real World NP podcast. We're so glad you're here. If you haven't grabbed your copy of the ultimate resource guide for the new NP, head over to realworldnp.com/guide.
To explore courses, resources, and more, you can also find that all at realworldnp.com. Until next time, take care.
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