LKA Test Quiz – Testing

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.

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. 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

Incorrect. The correct answer is 4. The patient has failed first-line treatment with a clarithromycin-based regimen. She should NEVER receive clarithromycin again for treatment of H. pylori infection. Therefore, options 1 and 2 are incorrect. (In addition, option 1 is also incorrect because of the suggested 28-day course; treatment need never be for longer than 14 days.) Option 3 is not a good choice since so little is known about the efficacy of levofloxacin-based treatments in the U.S., and since levofloxacin has been associated with unacceptable safety risks (i.e., tendonitis, tendon rupture). It should generally be avoided first- and second-line. Option 4 is the best choice; bismuth-based quadruple therapy (with tetracycline rather than doxycycline) is usually a reliable treatment either first- or second-line. It is, however, complicated for patients to take because of the large number of tablets.
Ref: Chey et al, Am J Gastroenterol 2017; 112: 212 – ACG practice guideline on management of H. pylori infection

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.