LKA Test Quiz – Testing

Correct. This patient probably also has functional dyspepsia – long duration of symptoms on an almost daily basis / unremarkable EGD. Since he is H. pylori-negative and has failed treatment with a PPI, it is worth considering treatment with a TCA. Option 1 is incorrect; there is no need to re-test him for H. pylori infection. At EGD, biopsies found no chronic inflammation. As these were taken while he was off PPI therapy, this is very strong evidence that he is H. pylori-negative. While option 2 is likely to be tried in clinical practice, it is probably going to be unhelpful; there is no point in persisting with PPI therapy if it had initially been ineffective. While psychological counseling (option 3) may be helpful in specific patients, it is probably premature in this case as the patient has not yet been tried on a TCA.
Ref: The 2017 ACG and Canadian Association of Gastroenterology joint guideline. Management of Dyspepsia. Moayyedi PM et al.  Am J Gastroenterol 2017; 112: 988 – 1013
Ref: ACG practice guideline on management of H. pylori infection. Chey  W et al, Am J Gastroenterol 2017; 112: 212

Correct. 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

Correct. 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

Correct. 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 3.  The most recent ACG guideline suggests that columnar mucosa of at least 1 cm in length is necessary for a diagnosis of BE, and patients with a Z-line demonstrating <1cm of proximal displacement from the top of the gastric folds (the EGJ) should not have routine endoscopic biopsies.  The guideline also suggests against repeat endoscopic screening in patients who have had an initial negative endoscopic screening.
Ref: ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Katz PO et al. AJG 2022:117:27