LKA Practice Exam #2 This quiz covers questions 16-30 in the LKA Primer Page 1 of 15 16. A 67 year-old patient with newly diagnosed metastatic pancreatic adenocarcinoma is referred for consideration of therapy for symptoms of severe gastric outlet obstruction. CT scan reveals a dilated and fluid filled stomach with near complete obliteration of the small bowel lumen in the second portion of the duodenum. The patient’s daughter is getting married in 2 weeks and their primary goal is to be able to eat with their family and to attend this ceremony. They would prefer to avoid surgery and chemotherapy treatments and would opt for palliative treatments aimed at improving quality of life. You recommend which of the following? 1. Surgical gastrojejunostomy 2. Pancreaticojejunostomy (Whipple surgery) 3. Percutaneous endoscopic gastrostomy tube placement for nutrition 4. Endoscopic duodenal self-expanding metal stent placement Page 2 of 15 17. A 35-year-old patient with constipation-predominant irritable bowel syndrome (IBS-C) presents with bloating and a 19 mm Hg rise in hydrogen above baseline at 90 minutes after administering 20 grams of lactulose ( this is a borderline test for SIBO= small intestinal bacterial overgrowth). What is the most appropriate next step in the management of this patient? 1. Non-absorbable antibiotics for a 7–10-day course for SIBO. 2. Discuss treatment options for constipation. 3. Investigate the possible underlying causes of SIBO. 4. Institute a gluten-free diet for SIBO. Page 3 of 15 18. A 45-year-old patient with fibrostenosing Crohn’s Disease presents with worsening diarrhea. I year ago he had an ileocolonic resection for obstructive symptoms and a side-side ileo-colonic anastomosis was performed. After this procedure he was put on rotating antibiotics and his symptoms were well controlled for the past year. However, in the past 2 weeks he developed sudden worsening of diarrhea and weight loss. Which of the following is the most appropriate first step in your evaluation? 1. Breath hydrogen testing. 2. Stools for bacterial culture and sensitivity. 3. Small bowel contrast radiology. 4. Clostridium difficile stool testing. Page 4 of 15 19. A 53-year-old Caucasian male who works as a farmer and presents with an unremarkable past medical history presents to your office with fevers, arthralgias, progressive diarrhea, cough, photosensitivity, and 10-pound weight loss over 2-months. The physical exam is remarkable for shoddy lymph nodes in his neck. His white blood count and differential are normal. No travel outside of the USA. No pertinent family history. Colonoscopy to the cecum a year ago for routine screening was unremarkable. What is the most appropriate next step in the management of this patient? 1. Upper endoscopy and biopsy of the small intestine. 2. Serum total IgA antibodies. 3. Antibodies to tissue transglutaminase (tTG), deamidated gliadin peptide (DGP), and anti-endomysial antibody (EMA). 4. Implementation of a diet restricted in gluten. Page 5 of 15 20. A 34-year-old patient with a 12-year history of celiac disease (records of the evaluation are not available) presents to your office with a 6-month history of diarrhea and bloating after meals. Her primary care provider recently prescribed empiric treatment with rifaximin 550 mg twice daily for ten days without benefit. The patient is on a strict gluten-free diet. Total IgA antibodies are low and serological testing is negative for IgG antibodies to tissue transglutaminase (tTG), deamidated gliadin peptide (DGP), and anti-endomysial antibody (EMA). Which of the following is the most appropriate next step in your evaluation? 1. Breath hydrogen testing. 2. Stools for bacterial culture and sensitivity. 3. Small bowel contrast radiology. 4. HLA-DQ2 and DQ8 testing. Page 6 of 15 21. A 22-year-old patient presents to your clinic with a history of bloating that has not been previously evaluated. The patient has a history of Hashimoto’s thyroiditis, and the recent discovery of iron deficiency anemia with a ferritin of 40 ng/mL. Family history of colon polyps or cancer is unknown as the patient was adopted as an infant. What is the most appropriate first step in evaluating this patient for her iron deficiency anemia? 1. Upper endoscopy and biopsy of the small intestine. 1. Upper endoscopy and biopsy of the small intestine. 3. Colonoscopy. 4. A trial of oral iron therapy for a month followed a repeat ferritin level. Page 7 of 15 22. A 53-year-old male is placed on 81 mg daily aspirin and 75 mg clopidogrel daily after placement of a cardiac stent 3 years ago. Other past medical history is unremarkable. He now presents with a marked anemia (hemoglobin of 6.2 g/dL) and low ferritin (12 mg/mL). His review of systems is otherwise negative. Following transfusions of three units of packed red blood cells, he undergoes an upper endoscopy to the 2nd portion of the duodenum and colonoscopy to the cecum with an excellent bowel prep both of which were unremarkable. Numerous biopsies were taken from the duodenal bulb and gastric antrum, and corpus during the exam which were also unremarkable. What is the next step in the evaluation of his anemia? 1. Fecal immunochemical testing for occult gastrointestinal bleeding. 2. Celiac serologies. 3. Video capsule endoscopy. 4. A repeat ferritin level followed a trial of oral iron therapy for a month. Page 8 of 15 23. A 34-year-old female patient with a 12-year history of celiac disease and gastroesophageal reflux disease on pantoprazole 40 mg daily presents to your office for a 2nd opinion for asymptomatic anemia (hemoglobin 9.1 g/dL, Ferritin 40 mg/mL). Her menstrual cycles are regular and without heavy bleeding. Her diet is gluten-free but westernized with respect to red meat intake three times weekly. She underwent bidirectional endoscopy by another provider that was unremarkable (no biopsies taken), followed by negative wireless capsule endoscopy. Total IgA antibodies are low and serological testing is negative for IgG antibodies to tissue transglutaminase (tTG), deamidated gliadin peptide (DGP), and anti-endomysial antibody (EMA). Which of the following is the most appropriate next step in your evaluation? 1. Lactulose breath hydrogen testing. 2. Stools for occult blood. 3. Stools for H. pylori stool antigen. 4. Gastrin and anti-parietal cell antibodies. Page 9 of 15 24. An 82 year-old female is admitted to the intensive care unit with jaundice and septic shock requiring escalating doses of two pressor medications. She has developed complete heart block which is being managed with a temporary pacemaker and she has been placed on therapeutic heparin and antiplatelet medications given concern for cardiac ischemia. A bedside ultrasound shows choledocholithiasis. The safest approach to biliary decompression for this patient is: 1. Surgical bile duct exploration 2. Endoscopic retrograde cholangiopancreatography with sphincterotomy 3. Broad spectrum oral antibiotic alone 4. Percutaneous biliary drain placement Page 10 of 15 25. A 65 year-old man with no past medical history presents to the emergency department with fever, right upper quadrant pain and jaundice undergoes ERCP. The patient’s vital signs are stable and he is not requiring any medications for blood pressure support. Findings on cholangiogram include multiple mobile sub-centimeter filling defects suggestive of choledocholithiasis. Treatment should include: 1. Placement of a plastic bile duct stent and return for stone removal at a later date 2. Placement of a covered metal bile duct stent 3. Cholangioscopy with electrohydraulic lithotripsy (EHL) for stone removal 4. Biliary sphincterotomy and stone extraction Page 11 of 15 26. A 45 year-old male presents with necrotizing pancreatitis. He is on hospital day 3, with a heart rate of 110, elevated WBC of 21K, and serum creatinine of 2.1 (baseline 1.0). He complains of fatigue, and abdominal pain that is controlled with PCA opioids. He denies any nausea or vomiting. CT shows necrosis involving the body and tail with extension into the left paracolic gutter. Total collection size approximately 18 cm. What is the next best step in management? 1. Trial of oral feeding 2. Total parenteral nutrition (TPN) 3. Open necrosectomy 4. Antibiotic coverage with meropenem 5. Referral to interventional radiology for percutaneous drainage. Page 12 of 15 27. A 57 year-old female presents with acute pancreatitis and systemic inflammatory response syndrome (SIRS). She is medically managed with pain control, intravenous fluids, and enteral nutrition after failing oral challenge. By hospital day 23, she develops acute abdominal pain and clinical deterioration and a CT shows gas in a collection of peri-pancreatic necrosis. What is the next best step in management? 1. Initiate antimicrobial treatment 2. Increase intravenous fluids 3. Plan for endoscopic transmural necrosectomy 4. Refer for surgical debridement 5. Hold TPN Page 13 of 15 28. A 60 year-old female with breast cancer was found to carry the BRCA2 mutation. She presents now to discuss whether she should under pancreatic cancer screening. After counseling with her the benefits and risks, she would like to pursue screening. Select the correct screening option. 1. CT pancreas protocol, annually 2. Endoscopic ultrasound, every 6 months 3. Endoscopic ultrasound, alternating with MRI every 6 months 4. MRI every 2 years 5. MRI every 1 year Page 14 of 15 29. A 73 yo male presents to discuss whether he should undergo pancreatic cancer screening. His father died from pancreatic cancer at the age of 54. What is the most appropriate screening option? 1. CT pancreas protocol 2. MRI/MRCP of the pancreas 3. PET/CT 4. Endoscopic ultrasound 5. No screening Page 15 of 15 30.A 50 year-old male with alcohol and tobacco abuse who presents to your clinic after 2 separate bouts of pancreatitis. He complains of ongoing chronic pain and requests assistance. His current regimen is oxycodone/acetaminophen (5/325) tablets of about 6 per day. What is the next best step in treatment? 1. Switch to methadone at a similar morphine equivalent dosage. 2. Add Tylenol 650 mg tablets, 4 per day. 3. Refer to pain management 4. Offer celiac plexus blockade 5. Counsel patient on alcohol and tobacco cessation. 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