LKA Test Quiz – Testing

Incorrect. The correct answer is 3. Although the patient has a history of cardiovascular disease, he is not in shock and has no evidence of profuse / active bleeding. His baseline hemoglobin of 9 is probably adequate and does not indicate an immediate need for transfusion. Therefore, options 2 and 4 are incorrect. He appears to be fairly stable. There is no obvious need for an urgent EGD, so option 1 is not correct. EGD should be performed within 24 hours of presentation, so scheduling it for the following morning seems appropriate. That makes option 3 the best choice. IV PPI treatment can be started; oral PPI treatment is inappropriate in this situation as the patient will presumably be having EGD at some time. As an aside, this 70-year-old man should have been on oral PPI treatment at home given his age, his cardiovascular comorbidity and his (appropriate) use of low-dose aspirin.
Ref:Laine et al,  Updated ACG guideline on upper GI and ulcer bleeding. Am J Gastroenterol 2021; 116: 899 – 917
Ref:Mullady et al, AGA Clinical Practice Update on endoscopic treatment of non-variceal upper GI bleeding. Gastroenterology 2020; 159: 1120 – 1128

Incorrect. The correct answer is 2. When a 4 hour gastric emptying scan is performed, it needs to be off any opioids which the patient may be prescribed for pain complaints.  The patient is not considered refractory until there is documentation that the patient has failed a “gastroparesis diet” which consists of a low-fat, small molecule diet for at least four weeks.  Video capsule studies are not appropriate to measure motility but rather mucosal and luminal deformities and abnormalities.  Appropriate testing for gastroparesis includes a 4 hour gastric emptying scan  (not a 2 hour one).
Ref:  Lacy B et al. AGA Clinical Practice Update on Management of Medically Refractory Gastroparesis: Expert Review. Clin Gastro Hepatol Volume 20, Issue 3, March 2022, Pages 491-500.

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.  PPIs are a treatment for both erosive esophagitis and EoE, and can eliminate the endoscopic and histologic features of both diseases.  Consequently, it is inappropriate to make a diagnosis of NERD in an endoscopy performed for patients taking PPIs, since those patients might have erosive esophagitis that would apparent if PPIs were stopped.  Similarly, EoE cannot be excluded in a patient taking PPIs.  Indeed, the fact that both proximal and distal biopsies showed eosinophils in this patient (albeit less than the 15 eosinophils per high power field usually used as a cutoff to diagnose EoE) suggests that he may well have EoE that would be apparent if PPIs were stopped.  Current ACG guidelines recommend stopping PPIs for 2 to 4 weeks prior to diagnostic endoscopy for patients with GERD symptoms that have not responded adequately to PPIs.
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. 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