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.  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 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 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. Botulinum toxin injection is considered first-line therapy only for patients with achalasia who are unfit for definitive therapies (pneumatic dilation, Heller myotomy, or POEM).  Oral pharmacologic therapy for achalasia (calcium channel blockers, nitrates, sildenafil) is used only for patients who are not candidates for definitive therapies and have failed botulinum toxin injection.  The ACG achalasia guideline specifically recommends against stent placement in achalasia.  Patients with type II achalasia  generally have a good response to any of the 3 definitive therapies, any one of which would be a reasonable choice for the initial treatment of this patient.
Ref: ACG Clinical Guideline: Diagnosis and  Management of Achalasia. Vaezi MF et al. Am J Gastroenterol 2020;115:1393