LKA Test Quiz – Testing

Incorrect. The correct answer is 2.  The ACG GERD guideline specifically recommends that patients who have extraesophageal manifestations of GERD without typical GERD symptoms (like heartburn and regurgitation) should undergo reflux testing for evaluation before PPI therapy.  Furthermore, the guideline does not accept a diagnosis of LPR based solely on laryngoscopy findings, it suggests that upper endoscopy should not be used as the method to establish a diagnosis of LPR, and it does not recommend manometry as a diagnostic test for GERD.
Ref: ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Katz PO et al. AJG 2022:117:27

Incorrect. The correct answer is 4. The patient’s presentation is strongly suspicious for celiac disease (CeD), but details of the prior evaluation are unknown. The patient is also on a gluten-free diet and has negative celiac disease serologies. To determine if the patient is at risk for CeD, then HLA DQ2 andDQ 8 should be ordered as a next step. If these haplotype markers are negative, then the diagnosis of CeD is remote, and one can proceed to evaluate for causes other than CeD. Breath hydrogen testing is unnecessary, even as a next step if the genetic markers are negative, given the non-response to rifaximin. Testing stools for possible pathogens would be a logical next step, and small bowel radiology would be unlikely to be beneficial and expose the patient to unnecessary radiation.
Ref: Leonard MM. Et al. AGA Clinical Practice Guidelines: Update on the Evaluation and Management of Seronegative Enteropathies: Expert Review. Gastro;2021;160: 437-444.

Incorrect. The correct answer is 4. For a patient with suspected benign gastric outlet obstruction, ruling out H pylori infection as a reversible cause of peptic ulcer disease as well as NSAID and tobacco avoidance are all first step recommendations.
Ref: ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction . Jue  TL et al, GIE 2021 volume 93, pages 309-322

Incorrect. The correct answer is 3. The patient probably has functional dyspepsia – long duration of symptoms / normal EGD. Biopsies should have been taken at EGD. Unfortunately, for some reason, they were not. The diagnosis of H. pylori infection should not be based only on a positive serological test. While serology has good negative predictive value (i.e., a “negative” result is probably a true negative), its positive predictive value in this country is unacceptably low. Therefore, a positive serological test should be confirmed with a test of active infection – either a urea breath test or a fecal antigen test. On that basis, option 1 is incorrect; treatment should not be initiated at this stage but should be based on a test of active infection. (As an aside, this triple combination should NOT be used for H. pylori infection unless it is known that the patient‘s H. pylori strain is clarithromycin-sensitive.) Option 2 is also incorrect; this patient may have H. pylori infection. That needs to be confirmed with a test of active infection. If she is H. pylori-positive, she should be offered treatment. It would be premature to conclude that treatment for H. pylori infection is unnecessary. Empiric treatment with a PPI might help her symptoms (assuming she had not tried this before, which seems unlikely). However, determination of H. pylori status takes precedence – and empiric use of a PPI would interfere with the ability to do that with a urea breath test or fecal antigen test.
Ref: The 2017 ACG and Canadian Association of Gastroenterology joint guideline. Management of Dyspepsia. Moayyedi PM et al.  Am J Gastroenterol 2017; 112: 988 – 1013

Incorrect. The correct answer is 1. This case scenario illustrates a patient with progressive weight loss and diarrhea from a presumed infectious, autoimmune, or malignant etiology. The differential is broad and includes Crohn’s Disease, Whipple’s Disease, eosinophilic enteritis, HIV, intestinal mycobacterial infection,  common variable immunodeficiency (CVID), SIBO, autoimmune enteropathy, and giardiasis. The next best step to elucidate this situation is a small bowel biopsy. Special PAS staining should be ordered to determine of foamy macrophages are seen consistent with Whipple’s disease or mycobacteria avium infection.
Ref: Leonard MM. Et al. AGA Clinical Practice Guidelines: Update on the Evaluation and Management of Seronegative Enteropathies: Expert Review. Gastro;2021;160: 437-444.