LKA Test Quiz – Testing

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 3. Prolonged QT is a potential side effect for many medications used to treat gastric dysmotility.  Many pro motility agents as well as off-label domperidone come with the potential side effect of prolonging the QT interval and therefore should not be used in this setting.  Opioids should not be used to treat any symptom in a patient with documented gastroparesis as opioids can make the dysmotility worse.  Serotonin and norepinephrine reuptake inhibitors have been used in certain patients with some success and is safe for patients with a history of prolonged QT.
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 is on chronic antibiotics for over a year and is at high risk for Clostridium difficile (C. difficile) colonization and infection. The stability of gastrointestinal symptoms on antibiotics makes sudden worsening of diarrhea unlikely to be due to small intestinal bacterial overgrowth (SIBO) and more likely from C. difficile. Patients with inflammatory bowel disease are more frequently colonized with C. difficile which is a more serious and life-threatening condition to consider than SIBO.  If the stools are C. difficile negative, then a flare of Crohn’s disease and/or SIBO become more of a consideration.
Ref: Quigley AMM. Et al. AGA Clinical Practice Guidelines on Small Intestinal Bacterial Overgrowth: Expert Review. Gastro;2020; 159:1526-1532

Incorrect. The correct answer is 2.  Recurrent symptoms in this patient could be due to incomplete disruption of the LES; persistence of spastic contractions in the esophageal body; procedure-induced anatomical distortion/scarring of the esophagus; development of erosive reflux esophagitis/peptic stricture; blown-out myotomy (BOM); or fundoplication problems such as  slippage or herniation.  Although all of the above listed tests, as well as endoscopy, might have a role in the evaluation of this patient, the current ACG guidelines recommends TBE as the first-line test in evaluating continued or recurrent symptoms after definitive therapy for achalasia.
Ref: ACG Clinical Guideline: Diagnosis and Management of Achalasia. Vaezi MF et al. Am J Gastroenterol 2020;115:1393-1411.

Incorrect. The correct answer is 4. The 2021 ACG guideline on upper GI and ulcer bleeding did not issue a formal recommendation about pre-endoscopic PPI therapy. There was no available evidence that it benefited important clinical outcomes (e.g., re-bleeding and mortality). There was, however, evidence that it might have a modest reduction in the need for endoscopic hemostatic therapy among patients with ulcer bleeding. It might also benefit some patients in whom EGD was going to be delayed or was unavailable. It does not reduce transfusion requirements, so option 3 is incorrect. There is no evidence that it has any role in initial resuscitation or that it influences requirement for PPI therapy following EGD making options 1 and 2 also incorrect.
Ref:  Updated ACG guideline on upper GI and ulcer bleeding
Laine et al, Am J Gastroenterol 2021; 116: 899 – 917
Ref:AGA Clinical Practice Update on endoscopic treatment of non-variceal upper GI bleeding. Mullady et al, Gastroenterology 2020; 159: 1120 – 1128