LKA Test Quiz – Testing

Incorrect. The correct answer is 3. Although the patient has a history of cardiovascular disease, he is not in shock and has no evidence of profuse / active bleeding. His baseline hemoglobin of 9 is probably adequate and does not indicate an immediate need for transfusion. Therefore, options 2 and 4 are incorrect. He appears to be fairly stable. There is no obvious need for an urgent EGD, so option 1 is not correct. EGD should be performed within 24 hours of presentation, so scheduling it for the following morning seems appropriate. That makes option 3 the best choice. IV PPI treatment can be started; oral PPI treatment is inappropriate in this situation as the patient will presumably be having EGD at some time. As an aside, this 70-year-old man should have been on oral PPI treatment at home given his age, his cardiovascular comorbidity and his (appropriate) use of low-dose aspirin.
Ref:Laine et al,  Updated ACG guideline on upper GI and ulcer bleeding. Am J Gastroenterol 2021; 116: 899 – 917
Ref:Mullady et al, AGA Clinical Practice Update on endoscopic treatment of non-variceal upper GI bleeding. Gastroenterology 2020; 159: 1120 – 1128

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 patient is on chronic antibiotics for over a year and is at high risk for Clostridium difficile (C. difficile) colonization and infection. The stability of gastrointestinal symptoms on antibiotics makes sudden worsening of diarrhea unlikely to be due to small intestinal bacterial overgrowth (SIBO) and more likely from C. difficile. Patients with inflammatory bowel disease are more frequently colonized with C. difficile which is a more serious and life-threatening condition to consider than SIBO.  If the stools are C. difficile negative, then a flare of Crohn’s disease and/or SIBO become more of a consideration.
Ref: Quigley AMM. Et al. AGA Clinical Practice Guidelines on Small Intestinal Bacterial Overgrowth: Expert Review. Gastro;2020; 159:1526-1532

Incorrect. The correct answer is 4. Duodenal stent placement is the correct answer as this intervention is most in-line with the patient’s goals of care as it is most likely to allow for rapid advancement of oral diet and recovery/discharge from the hospital among the choices here. Gastrojejunostomy and pancreaticojejunostomy are invasive surgeries and given the presence of metastatic disease pancreaticojejunostomy is also not likely indicated regardless of goals of care. Percutaneous gastrostomy tube placement is reasonable for venting purposes but would not be ideal for feeding in the setting of duodenal obstruction and is not in-line with the patient’s stated goal of being able to eat.
Ref: ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction . Jue  TL et al, GIE 2021 volume 93, pages 309-322

Incorrect. The correct answer is 3. The patient probably has functional dyspepsia – long duration of symptoms / normal EGD. Biopsies should have been taken at EGD. Unfortunately, for some reason, they were not. The diagnosis of H. pylori infection should not be based only on a positive serological test. While serology has good negative predictive value (i.e., a “negative” result is probably a true negative), its positive predictive value in this country is unacceptably low. Therefore, a positive serological test should be confirmed with a test of active infection – either a urea breath test or a fecal antigen test. On that basis, option 1 is incorrect; treatment should not be initiated at this stage but should be based on a test of active infection. (As an aside, this triple combination should NOT be used for H. pylori infection unless it is known that the patient‘s H. pylori strain is clarithromycin-sensitive.) Option 2 is also incorrect; this patient may have H. pylori infection. That needs to be confirmed with a test of active infection. If she is H. pylori-positive, she should be offered treatment. It would be premature to conclude that treatment for H. pylori infection is unnecessary. Empiric treatment with a PPI might help her symptoms (assuming she had not tried this before, which seems unlikely). However, determination of H. pylori status takes precedence – and empiric use of a PPI would interfere with the ability to do that with a urea breath test or fecal antigen test.
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