LKA Practice Exam #3 This quiz covers questions 31-45 in the LKA Primer Page 1 of 15 31. A 62 year-old female with a history of recurrent acute pancreatitis and recent CT imaging showing parenchymal calcifications within the pancreas presents with progressive weight loss. Her hemoglobin A1c recently increased from 5.7% to 7.2%. She started taking pancreatic enzymes with some benefit, but she continues to lose weight. What is the next best step in management? 1. Increase pancreatic enzyme replacement dose 2. Refer for ERCP for stone removal 3. Counsel patient on dietary modification including a low fat, low carbohydrate diet 4. Obtain CT pancreas protocol 5. Refer for Total Pancreatectomy with Islet Auto Transplantation Page 2 of 15 32. A 65 year-old female presents to your clinic after a bout of pancreatitis. Etiology for it remains idiopathic, but there was a 3.2 cm cyst in the pancreatic head, which was presumed to be a pseudocyst. The cyst causes some focal dilation of the main pancreatic duct up to 5 mm. What is the next best step in management? 1. Obtain MRI in 6 months 2. Refer for surgical evaluation 3. Laparoscopic cholecystectomy 4. Refer for EUS with fine needle aspiration 5. Refer for ERCP for pancreatogram Page 3 of 15 33. A 42 year-old female presents with a 4.5 cm unilocular pancreatic tail cyst found on CT scan as part of an evaluation for non-specific epigastric pain. An EUS was performed and the cyst fluid CEA was 550 ng/ml. Cytology showed fragments of ovarian type stroma of the cyst wall. What is the next best step in management? 1. Refer for surgical evaluation 2. Repeat MRI in 6 months 3. Repeat MRI in 2 years 4. Refer for cyst ablation 5. Repeat EUS in 6 months Page 4 of 15 34. A 33 year-old with a history of inflammatory Crohn’s ileocolitis is starting on infliximab for severe disease. He has a significant decrease in symptoms within 8 weeks of initiation and by week 28 is in clinical remission. He has a history of basal cell skin cancers so declined to be on concomitant thiopurine and was still interested in fathering children so was not placed on methotrexate. He remains on infliximab monotherapy. He had done well on maintenance infusions every 8 weeks for 2 years. You are seeing him back in clinic now with complaints of diarrhea, abdominal pain and fatigue. Colonoscopy reveals active disease in the terminal ileum and right colon. What should you do now? 1. Increase his dose to 10 mg/kg now 2. Decrease the interval to every 6 weeks now 3. Check a trough level of infliximab 4. Add azathioprine now Page 5 of 15 35. A 40 year-old with a history of ulcerative colitis on adalimumab every other week in combination with azathioprine wants to join your practice as a patient. He has 4-5 loose stools per day with some urgency and cramping. There is visible blood in 50% of his stools. Fecal calprotectin is 800 ug/mg (normal < 50), flex sig shows moderately active disease. A trough drug level is 9 mcg/mL and antibody level > 150 U/mL (normal 0 U/mL). What should you do now? 1. Escalate to weekly adalimumab 2. Increase dose of azathioprine 3. Change therapy to another biologic 4. Give a course of steroids to control active disease and continue every other week adalimumab Page 6 of 15 36. 32 year-old with a history of severe ileal Crohn’s disease who was started on infliximab and azathioprine as combination therapy 2 years ago now presents to establish care in your practice. He is starting to have breakthrough symptoms of diarrhea and pain at 4 weeks into his every 6- week infusion regimen. CTE reveals 10 cm of active ileitis. Trough drug level of infliximab is 20 mcg/ml ( high levels; < 5 mcg/ml would be considered a low level) with an antibody level of 0. What would you prescribe next? 1. Increase infliximab to 10 mg/kg every 4 weeks 2. Ustekinumab with azathioprine 3. Ustekinumab as monotherapy 4. Vedolizumab with azathioprine Page 7 of 15 37. A 27 year-old woman has just been diagnosed with Crohns ileocolitis complicated by a perianal fistula. She complains of discomfort and drainage requiring a pad which she changes twice a day. An MRI of the abdomen shows 10 cm of active ileal disease, colonoscopy shows involvement of the right colon and rectum and an MRI of the pelvis reveals a trans-sphincteric fistula without branching. There is no accompanying abscess. What do you start her on as initial therapy? 1. Prednisone, antibiotics and mesalamine 2. Adalimumb as monotherapy 3. Adalimumab along with antibiotics 4. Budesonide and mesalamine Page 8 of 15 38. A 72 year-old man with a history of hypertension, type 2 diabetes, hypercholesterolemia and obesity presents with a 3 month history of worsening diarrhea, rectal bleeding and worsening knee pain. His last colonoscopy was 3 years ago for colorectal cancer screening with an adequate prep which revealed a single 4 mm tubular adenoma. He has 4-6 bm per 24 hours with urgency, tenesmus, and at least one nocturnal bowel movement. At least 50% are associated with blood. He is bothered by his symptoms but still able to go golfing and care for his grandson twice a week. His primary provider ordered stool studies which were negative for infection but he was given a course of metronidazole empirically which did not help. He has not had any significant weight loss. He tried cutting out lactose which did not help. Hemoglobin is slightly decreased at 12.2 g/dL, MCV is normal but platelets 350,000. CRP is normal. A fecal calprotectin is > 1000 mcg/mg. Colonoscopy reveals a pan colitis that is circumferential and continuous from anus to cecum. You score it a Mayo 2. Biopsies are consistent with crypt architectural distortion, goblet cell depletion, and a lymphocytic infiltration, no dysplasia is noted. What do you do next? 1. Recommend surgery 2. Start high dose mesalamine and prednisone 3. Hospitalize for initiation of infliximab 4. Start high dose prednisone and a thiopurine for steroid sparing 5. Start high dose mesalamine and budesonide Page 9 of 15 39. An 80 year-old with a long standing history of Crohn’s of the small bowel presents with complaints of worsening bloating, nausea and occasional emesis. His primary provider advised him to start eating more fiber as his cholesterol was too high. He has otherwise been well with every 8 week infusions of vedolizumab for the past 3 years. He has not lost any weight and has 1-2 formed stools per day. He continues to work 35 hours a week at his accounting firm and plays tennis on weekends. On physical exam, his BMI is 30 and his abdomen is soft, nontender, nondistended but slightly tympanic. There is no mass or organomegaly. On CT enterography, there is a 5 cm stricture of the terminal ileum with smooth contours, no mural edema or hyperenhancement, no lymphadenopathy and some dilation of the prestenotic bowel to 4 cm. What do you recommend next? 1. Change vedolizumab to ustekinumab 2. Attempt endoscopic dilation of the stricture 3. 8 week course of tapering steroids 4. Surgical consultation for resection Page 10 of 15 40.A 22 year-old is admitted from the Emergency Department with a history of worsening ulcerative colitis. He was diagnosed a few months ago and has been on 2.4 g mesalamine. He presents with 10-12 bloody bowel movements per 24 hours, with low grade fever, arthralgias and crampy pain. Labs in the ED reveal a hemoglobin of 9.9 g/dL, CRP 4 (normal < 0.8), WBC 10, and normal liver enzymes but albumin decreased at 3.2 grams. CT shows diffuse colitis but no evidence for dilation or small bowel inflammation. His stool pathogen panel is negative. He is started on IVF and IV steroids and is now on the hospital floor. What do you discuss about next treatments? 1. Metronidazole 500 mg po tid 2. Infliximab at 10 mg/kg IV or cyclosporine IV at 2 mg/kg 3. 4.8 g oral mesalamine 4. Metronidazole 500 mg IV tid 5. Infliximab at 5 mg/kg or cyclosporine IV at 2 mg/kg Page 11 of 15 41. 24 year-old with a history of ulcerative colitis presents to your office to establish care. He was diagnosed 6 months ago with a history of rectal bleeding and diarrhea. He was started on 2.4 g of mesalamine daily and states that he had a minimal change in symptoms. He was offered steroids over the phone but declined as he was concerned about side effects. He was recently given 4.8 g of mesalamine daily instead. He currently is having 8-10 stools per day, with urgency and tenesmus, over 50% of stools have visible blood. He is having nocturnal bowel movements every few days. He is unable to make it through a full day of work. C diff is negative and flex sig with biopsies shows Mayo 3 disease without CMV on biopsy. What do you offer him next? 1. Additional mesalamine via enema 2. Adalimumab subcutaneous induction therapy 3. Either infliximab at standard dosing or vedolizumab 4. Oral delayed release budesonide 5. Vedolizumab with continued high dose mesalamine Page 12 of 15 42. 19 year-old with a history of Crohn’s disease of the small intestine doing well in remission on an injectable biologic is going back to college upon it’s re-opening after closing down for Covid. He is thinking of stopping his meds because he is immunosuppressed and worried about getting sick. He did get 2 vaccinations and a booster. What do you recommend? 1. Stop the biologic as he is at greater risk for getting Covid 2. Continue the biologic as he is at no greater risk for getting Covid 3. Stop the biologic for now and reassess in 3 months after he has been at school 4. Change him to mesalamine Page 13 of 15 43. A 30 year school teacher with a history of ulcerative colitis controlled on combination therapy of azathioprine and an injectable biologic. She develops symptomatic Covid infection. What do you counsel her about her medications? 1. Stop the injectable therapy until symptoms resolve 2. Stop the azathioprine until symptoms resolve 3. Stop both biologic and azathioprine until symptoms resolve 4. Continue both therapies Page 14 of 15 44. A 27 year-old woman with Crohn’s ileitis currently well on injectable anti-TNF ( adalimimab) as monotherapy comes to the office to discuss wanting to get pregnant. She has not had any surgeries and no extra-intestinal manifestations of disease. She has 1-2 formed stools per day and denies any abdominal pain, nausea, vomiting, rectal bleeding or weight loss. She eats a regular diet without any restrictions. Her physical exam is normal, including a perianal exam. Labs reveal a hemoglobin of 14 g/dL, MCV 90, platelets and WBC normal. CRP is normal as are liver chemistries. A CT enterography is performed that does not indicate any active disease in the small intestine or colon. What is your next step? 1. start budesonide as prophylaxis against a flare 2. start a prenatal vitamin 3. check a drug adalimimab level 4. colonoscopy Page 15 of 15 45. A 28 year-old woman with a history of well controlled ulcerative colitis on vedolizumab every 8 weeks has just delivered a healthy baby via C section done for prolonged labor. Her last vedolizumab infusion was 7 weeks prior to delivery. She is ready to be discharged and does not have any evidence of infection at the incision site nor complaints consistent with early mastitis. What do you counsel her about her next infusion? 1. She should get it as soon as she is able to schedule 2. She should continue to hold it for 3-4 weeks until she is off any venous thromboemolism (VTE) prophylaxis 3. She should be transitioned to another biologic as she wants to nurse 4. She should be started on delayed release budesonide to prophylax against disease and delay an infusion until her wound has completely healed View ResultsYou will be shown your score and the correct answers with explanation at the end of the quiz. If you'd like to have your quiz results emailed to you, please enter your name and email below.Email Address *First Name *Start QuizSkip and continue Return to LKA Product Portal
