Rapid Access Clinic
The Rapid Access Clinic was designed to support patients needing urgent care for a wide variety of conditions including abdominal pain, nausea, heartburn, diarrhea, constipation, abnormal liver studies, low blood counts, intermittent blood in stool, losing weight, trouble eating, trouble swallowing, or severe irritable bowel. Individuals recently seen in an Urgent Care Center, Emergency Room or doctor’s office often need the quick attention of a specialist to ensure proper management.
We specialize in all major conditions associated with the gastrointestinal and liver systems. There are many occasions when an individual is not in need of hospitalization but doe need rapid evaluation by the specialists.
Rapid Referral offers immediate contact with the gastrointestinal specialist. Further tests and scheduling should occur within 24 hours of the initial call.
Common Conditions That We Treat
Abdominal Pain of Unknown Cause
As you can imagine, the causes of abdominal pain are many and could be due to a minor disturbance in the gastrointestinal tract or something bigger… that might be evolving into a larger problem. Our team can usually determine a short list of likely possibilities and initiate a treatment to get you feeling better.
It is important to understand the severity of abdominal pain and identify any “warning signs”. When abdominal pain symptoms are associated with tenderness to touch, fever, chills, or severe fatigue, the local emergency room might be a better option. Those patients may need hospitalization and the attention of a good surgeon.
Common Causes of Abdominal Pain
As you can imagine, the list of potential causes for abdominal pain is quite long. The location , associated symptoms, severity, quality, and time of onset are all clues as to the origin of pain. Be ready to answer lots of questions about the type of pain you are experiencing and any theories you may have as to the cause. On our list, we often think about stomach ulcers, severe acid reflux, gas , intestinal distension, gallbladder disease, gallstones, an inflamed pancreas, constipation, diverticulitis, appendicitis, colitis just to name a few. Occasionally, the pain is caused by a disturbance coming from another location within the abdomen such as the kidneys (kidney stones), uterus, or ovaries. In rare cases, abdominal pain can be caused by a ruptured artery – aortic aneurysm resulting in poor blood flow (ischemia) to the intestines.
Pain can sometimes be caused by inflammation in the rib cage or the abdominal wall muscles and not from within the abdomen. This is known as musculoskeletal pain.
To evaluate abdominal pain we often order tests such as: a blood count looking for signs of blood loss or infection, blood chemistry which might show abnormal electrolytes, an X-ray of the abdomen to see if there is an obvious blockage or signs of an ulcer in the intestinal tract. If these tests don’t give us answers, an upper and lower endoscopy might be a considered.
Endoscopy utilizes a fiberoptic, lighted scope to directly image the upper gastrointestinal system including the esophagus, stomach and duodenum. To examine the lower intestines a colonoscopy is performed to visualize the lining of the lower intestines. During an endoscopic procedure, the patient is sedated and monitored by an anesthesia team. During the endoscopy, the physician can directly visualize and take samples of the intestinal lining. We can easily identify ulceration, inflammation, signs of bleeding, cancers and other problems within the intestinal tract.
Abdominal CT or MRI scan might also be useful in evaluating abdominal pain and provides a more complete evaluation of the abdomen. CT/MRI scan can see a wide range of abnormalities like uterine cysts, cancers, kidney stones, intestinal blockage, inflammation in the intestinal wall, and evaluate a a wide range of organs including the spleen, liver, pancreas and others.
There is a very long list of potential causes for nausea and vomiting. To begin, the medical team will always want to know more about your symptoms …how long have they been occurring, how often, how severe, any signs of bleeding? Every individual’s story is unique, but there are certain clues that help us determine a likely cause. Very common causes of nausea and vomiting includes peptic ulcer in the esophagus, stomach or duodenum; gastritis which is an inflammation of the stomach lining; a “gi bug” or virus. Gastrointestinal bugs or more formally, a viral gastroenteritis , usually wreaks havoc for up to 14 days until finally resolved. In contrast, patients with peptic ulcer tend to have a longer history of stomach problems – even years. Patients with ulcers may recall taking antiacids in the past to help relieve symptoms and are often taking NSAID medications. NSAIDs are common pain relievers that reduce inflammation in the body. Examples includes Advil, Alleve, Ibuprofen, Goodys, and Asprin. However, NSAIDs are well known to cause ulceration in the intestines and symptoms of pain and burning in the abdomen.
Other possible causes of nausea and vomiting includes : a mechanical blockage of the intestinal tract either from cancer or scar tissue; underlying illness such as poorly controlled diabetes (DKA); underlying infection from a bacteria (sepsis); medication side effect from chemotherapy; a metabolic disorder; kidney failure; tumor in the brain; stroke. These individuals tend to be much sicker and require hospitalization.
When symptoms of nausea and vomiting are severe, dehydration may occur leaving the patient feeling lethargic, dizzy when standing up, short of breath or extremely fatigued and difficult to arouse. These individuals need immediate care at a local ER or Urgent Care.
A typical medical work up for persistent nausea and vomiting would include taking a medical history, review of medications, and a physical exam. Additional tests like basic blood laboratory studies, an abdominal US , X-ray, or CT scan may be useful. In many cases, an upper endoscopy is performed to look for peptic ulcers, malignancy or a blockage within the upper gi system.
We will often start several treatments to get you feeling better while we are trying to determine the cause. Medications to treat nausea, pain, and a possible ulcer are started right away.
Trouble Swallowing, Food Sticking – Dysphagia
The medical term for difficulty swallowing is called dysphagia. The possible causes of dysphagia are numerous and includes stricture or narrowing of the esophagus, abnormal contractions within the muscles of the esophagus (dysmotility), and occasionally anxiety and stress. In other words, trouble swallowing may be related to esophageal narrowing or may be related to the esophagus not functioning correctly – no physical blockage. Symptoms may range from mild to severe. In cases when an individual cannot swallow solids or liquids, hospitalization may be necessary.
In any patient with trouble swallowing it is important to rule out scar tissue, an esophageal ring, or malignancy. Typically, patients with trouble swallowing undergo lab work, X-rays, and an upper endoscopy to take a direct look at the lining of the esophagus. An upper endoscopy is good way to identify narrowing or food “stuck” in the esophagus. During the endoscopy procedure, a dilator can be used to gently open any narrowing.
Common Findings During Endoscopy
- Schatzki’s ring
- hiatal hernia
- inflammation (esophagitis)
- EOE (eospinophilic esophagitis)
- or just a large piece of food that the patient did not chew up well
Less Common Findings
- radiation damage and stricture
- mass within the chest pushing onto the esophagus
These are nonspecific symptoms that are often difficult to describe by the patient and can be mild or severe. A feeling that there is trapped gas, prolonged distension of the abdomen, a loss of appetite due to fullness are all common complaints. These individuals might be very constipated, have an intolerance to certain foods, or have an inflammatory condition within the intestinal tract. The list is very long, but with a few simple tests, we can usually sort this out.
For a patient with chronic abdominal bloating and fullness, we would want to identify any evidence of blockage in the intestinal tract and abdominal Xrays might be ordered. Basic blood lab studies would help identify a serious disturbance causing blood loss (anemia), malnutrition, dehydration, electrolyte or metabolic disturbance. A series of questions by the medical team should help point to a source, as well. For example, someone who hasn’t had a bowel movement in 2 weeks is either constipated or obstructed and an evaluation of the lower intestinal tract would begin. A patient who complained of heartburn and nausea after meals would have an evaluation of the upper gi system.
Unexplained Constipation or Diarrhea
Constipation and diarrhea are very common symptoms. Many patients live with these symptoms for years, never knowing when they will occur or why they occur. In some instances, the symptoms are new – possibly days, weeks or months. Symptoms may be mild and just a nuisance or severe causing malnutrition, dehydration and disability. It is very important to know if the diarrhea or constipation is associated with bleeding or weight loss, how long symptoms have been present and how frequent they occur. A recent use of antibiotics raises the risk of an infection known as C diff which can cause infectious diarrhea.
Any patient that is bleeding heavily, dizzy, light headed, in pain or feels very sick should go to their local ER prior to visiting our center.
For a patient with significant diarrhea of short duration – less than 2 weeks, we might obtain stool studies for bacteria, blood work to determine electrolyte disturbances, low blood count or infection. Most of these patients have a “gi bug” and can be managed with hydration, support, and medication. In a severe case, however, we will often treat with antibiotics and cover for typical intestinal infections. X-rays might also be ordered. If the patient is improving, we may just monitor closely until symptoms have resolved . If symptoms of diarrhea continue despite our treatment, more tests will be ordered. Endoscopy of the upper and lower tract can be very useful in discovering the cause of chronic diarrhea and to rule out an inflammatory conditions such as Crohn’s disease, ulcerative colitis or celiac sprue.
Inflammatory Bowel Disease (IBD) Crohn’s and Ulcerative Colitis
IBD is an autoimmune, inflammatory condition that is not caused by a bacterial infection. IBD or colitis causes abdominal pain, cramping, diarrhea and is a common cause for urgent consultation with a gi specialist. Individuals with IBD are usually taking an immunosuppressive medication to control symptoms, but sometimes they have what is called a” flare up”. During a flare, their symptoms begin to spiral out of control despite taking their usual home medications.. If a colitis flare goes untreated, it can become quite severe leading to hospitalization, and urgent surgery.
For any patient with a suspected colitis flare, we have to consider all possibilities – sometimes the increased symptoms are due to another cause and not IBD. Bacterial infection, medication interaction, dietary intolerance are all possibilities. A re-evaluation for bacterial pathogens may include an order for stool cultures to examine in the laboratory. Antibiotics are often given up front to cover for a possible bacterial infection. However, if the increased symptoms are due to autoimmune colitis and not a bacteria, a steroid taper is usually very effective. Steroids usually control IBD with a slow, gradual return to normalcy. Steroid doses usually start high and then decreased every week or two – this is why we call this a taper. Steroids are good for short term control of IBD. Longterm, other medications are very effective in controlling IBD with much lower side effect profiles when compared to steroids.
Unexplained Blood in Stool
Unexplained blood in the stool is very common. Blood seen in stool may be bright red, maroon or jet black (melena). The color of the stool is a clue to where the bleeding is coming from. Red blood often means a lower intestinal tract source such as, the colon, while black stool suggests bleeding from the upper intestinal tract -esophagus, stomach or small intestines. Maroon often means a heavy bleed – and could be from an upper , lower, or somewhere in between source.
So, the first question we will want answered is whether the stool appeared red, black, or maroon.
Next, we want to know – how much blood? A lot? That usually means a trip to the ER, particularly if the individual is feeling dizzy, light headed, lethargic or short of breath. That could mean serious bleeding requiring a blood transfusion and a need for emergency procedures.
If the patient, on the other hand, feels well, not dizzy or light headed and sees lower volume of blood in stool – then an outpatient evaluation in our center can be done safely.
For the patient that has seen blood in stool, we might order blood tests to determine if the bleeding has caused a significant derangement in their system. Usually with some basic questions, we can determine if the source of bleeding is from the upper or lower gi tract. Typically, we would order an endoscopy study to directly visualize the intestinal lining.
Common Findings on Endoscopy FOR Causes of Blood in Stool
- inflammation and ulceration
- hemorrhoids in the lower intestine
- cancers – anywhere in the gi tract
Anemia – Low Blood Counts
On occasion, an individual may be found to be anemic – their blood counts are low and they may have had no idea. There are multiple causes of a low blood count.
- Loss of blood – intestinal tract, urinary tract, respiratory system
- Failure to produce blood by the bone marrow
- Destruction of red blood cells due to infection or other processes in the blood stream
In most instances, when an individual is found to have a low blood count, a referral to the gi physician is made. It appears that the gi tract – esophagus, stomach, small intestines, colon are a common source of low level blood loss. This bleeding can occur so slowly, it goes unnoticed.
Other sources of bleeding that should be considered inludes the urinary tract, vaginal/uterine system in women, lungs, and nasopharynx.
For individuals with a significant drop in blood counts and no apparent cause, we must consider all the possibilities. In many, a complete evaluation of the intestinal tract will be needed – upper endoscopy, lower endoscopy, and possibly a PillCam.
The Pill Cam is a very useful test for identifying blood loss within the gi tract. The PillCam is a small tablet encasing a camera and radio receiver that can take pictures as it travels through the intestinal system. When the upper and lower endoscopy haven’t given the answers, a Pill Cam can be very useful in giving an extended viewing of the intestinal tract.
In cases where the gi tract appears clear of bleeding sources, a referral to other specialist might occur including a hematologist, urologist, pulmonary specialist, or ENT.
Abnormal Liver Enzymes on Lab Testing
There are many causes for abnormal liver enzymes, also known as “LFTs” and not an uncommon finding even on routine blood work. One of the most important pieces of information are – how does the individual feel, do they have yellow eyes or jaundice, pain in the abdomen, any history of liver disease, any recent travel, and is the individual physically ill with nausea and vomiting.
A list of common causes for increased liver enzymes includes- medication interaction, medication overdose (Tylenol), fatty liver, alcohol excess, recent viral illness, active infection in the body, gallstones or gallbladder attack.
Other less common possibilities include: autoimmune hepatitis, viral hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, Wilson’s disease, iron overload (hemochromatosis) , tumor in the liver, or chemotherapy side effect.
Patients who are jaundiced with yellow eyes, darkened urine may be referred for hospitalization if they appear ill, confused, fatigued, or imbalanced in some way. Patients that feel well and are not jaundiced will undergo a battery of tests looking for causes of liver enzyme elevation. An abdominal ultrasound is often preformed to study the liver and look for “stones” blocking the bile ducts or evidence of liver damage (cirrhosis) or tumor within the liver.
Usually with a few tests, the cause of the disturbance can be determined and corrected. Rarely, a patient must be referred to the hospital for more aggressive care. In some cases, patients are referred to a Liver Team specializing in transplant.