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August 6, 2013 Issue

Clinical Practice Points

Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: U.S. Preventive Services Task Force Recommendation Statement

This guideline recommends that clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions.

Use this guideline to:

  • Review the definitions of risky or hazardous alcohol use, alcohol abuse, and alcohol dependence, which are available on the first 2 pages of the paper.
  • Review available methods to screen for problems with alcohol use (e.g., the AUDIT tool).
  • Review how a resident can arrange for behavioral counseling at your medical center to assist patients with problems related to alcohol use.
  • Get CME for yourself! After reviewing the USPSTF guideline, answer the brief quiz that accompanies the paper and claim your CME credit.

Mucosal Healing and Risk for Lymphoproliferative Malignancy in Celiac Disease. A Population-Based Cohort Study

This study found that the risk for lymphoproliferative malignancy was higher when a follow-up biopsy performed after the diagnosis has been established revealed persistent villous atrophy.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Review the symptoms, signs, and possible complications that should prompt consideration of celiac disease. Use the tables, figures, and teaching slides from a recent In the Clinic.
  • Ask your residents what the limitations are to a retrospective cohort like this one (e.g., how not knowing whether patients adhered to a gluten-free diet influences to whom these results apply—the authors discuss this on page 174)

Update in Women’s Health: Evidence Published in 2012

This concise update summarizes essential papers published in 2012 chosen for their clinical importance. Studies addressed the risks for venous thromboembolism, stroke, and myocardial infarction with combined oral contraceptives; medical therapy for uterine fibroids; screening for intimate partner violence; osteoporosis; and other topics. Also provided is a summary of recent guidelines on screening for cervical cancer and menopausal hormone therapy.

Use these summaries to:

  • Have a rapid-fire literature review of multiple important topics in women’s health.
  • Create a series of resident reports or journal clubs, each dedicated to an internal medicine subspecialty. At each, review the seminal points from key articles reviewed in this series (we’ve assembled these concise summary articles for you here).

In the Clinic: Acute Gastrointestinal Bleeding

Which patients with acute GI bleeding may be treated as outpatients? Which ones are at high risk for recurrent bleeding? Is nasogastric lavage really helpful? Use this concise and eminently practical review to answer these questions. It includes MKSAP questions—structure an interactive teaching session around them.

Use this review to:

  • Download the already completed teaching slide set that accompanies this review—you can pick and choose the slides you need for teaching or use the whole set. Mix in the already provided multiple-choice questions at key points, and you’re all set for a teaching session!
  • Review the differential diagnosis of acute GI bleeding.
  • Discuss appropriate initial interventions in all patients with acute GI bleeding.
  • Ask how patients being discharged from the hospital after a GI bleed should be followed. What instructions should they be given?
  • Get more CME for yourself by logging on and answering the questions you’ve just reviewed with your residents.


A 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine.

On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 128/84 mm Hg, pulse rate is 64/min, and respiration rate is 16/min; BMI is 23. No rash is noted. There is mild diffuse abdominal tenderness without peritoneal signs and no abdominal masses. Rectal examination is normal. Complete blood count and thyroid-stimulating hormone level are normal.

Which of the following is the most appropriate next step in management?

A. Breath test for bacterial overgrowth
B. Colonoscopy with random biopsies
C. Stool culture
D. Tissue transglutaminase antibody testing

Answer: D. Tissue transglutaminase antibody testing

Key Point: The American College of Gastroenterology recommends routine serologic testing for celiac disease in patients with symptoms of diarrhea-predominant or mixed irritable bowel syndrome.

Educational Objective: Evaluate for celiac disease in a patient with diarrhea-predominant irritable bowel syndrome.

This patient should undergo tissue transglutaminase antibody testing. The American College of Gastroenterology recommends routine serologic testing for celiac disease in patients who present with symptoms of diarrhea-predominant or mixed irritable bowel syndrome (IBS). Additionally, there is a well-established association between comorbid autoimmune disorders and celiac disease, especially type 1 diabetes mellitus and autoimmune thyroid disease.

Although some evidence suggests a role of small-bowel bacterial overgrowth in the pathogenesis of IBS, evidence is insufficient to warrant testing for this condition with a breath test.

Approximately 2% of patients with features of diarrhea-predominant IBS are found to have microscopic colitis. A history of nocturnal or large-volume diarrhea or a stool osmotic gap less than 50 mOsm/kg (50 mmol/kg) would make a compelling case for microscopic colitis. In the absence of these features, a colonoscopy and random biopsies might be indicated, but the yield is low.

In patients who meet clinical criteria for IBS without alarm features, routine testing with stool culture is unlikely to result in an alternative diagnosis. Similarly, other laboratory tests such as the erythrocyte sedimentation rate and thyroid-stimulating hormone have a low yield. Patients who should be considered for colonoscopy and additional evaluation with blood and urine studies include those older than 50 years or those with a short history of symptoms, documented weight loss, nocturnal symptoms, family history of colon cancer or rectal bleeding, and recent antibiotic use.

Ford AC, Chey WD, Talley NJ, Malhotra A, Spiegel BM, Moayyedi P. Yield of diagnostic tests for celiac disease in individuals with symptoms suggestive of irritable bowel syndrome: systematic review and meta-analysis. Arch Intern Med. 2009;169(7):651-658. PMID: 19364994

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.

From the Editors of Annals of Internal Medicine and Education Guest Editor, Erin Ney, MD, FACP Assistant Residency Program Director, Department of Internal Medicine, Thomas Jefferson University.


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