LKA Test Quiz – Testing

Incorrect. The correct answer is 4. For a patient with suspected benign gastric outlet obstruction, ruling out H pylori infection as a reversible cause of peptic ulcer disease as well as NSAID and tobacco avoidance are all first step recommendations.
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 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 2. When a 4 hour gastric emptying scan is performed, it needs to be off any opioids which the patient may be prescribed for pain complaints.  The patient is not considered refractory until there is documentation that the patient has failed a “gastroparesis diet” which consists of a low-fat, small molecule diet for at least four weeks.  Video capsule studies are not appropriate to measure motility but rather mucosal and luminal deformities and abnormalities.  Appropriate testing for gastroparesis includes a 4 hour gastric emptying scan  (not a 2 hour one).
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.  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. 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.