DDSEP® 8 Quick Quiz

Q1: ANSWER: C

Critique

The diagnosis of H. pylori may be made using either invasive or noninvasive methods. Invasive diagnostic methods either detect organisms directly (i.e., histological identification with appropriate stains or bacterial culture) or indirectly (i.e., rapid urease testing of biopsy specimens). Noninvasive methods include serum antibody, stool antigen, and detecting the metabolites of the bacterial enzyme urease (i.e., urea breath testing). It should be noted that serology should not be used to test for eradication as the antibodies may remain elevated for years after successful eradication therapy.

Treatment of H. pylori infection has become problematic recently primarily due to increasing antibiotic resistance. The eradication rate of standard triple therapy consisting of a proton pump inhibitor combined with clarithromycin (500 mg) and amoxicillin (1 g) (or metronidazole (500 mg), all given b.i.d. for 7-14 days has now declined to unacceptable levels, averaging 70%-80% but reported as low as 55%. It is currently recommended that a noninvasive method be used (other than serology) to confirm eradication in patients in whom eradication is deemed necessary.

References

1. Malfertheiner P., Megraud F., O’Morain C.A., et al. European Helicobacter Study Group. Management of Helicobacter pylori infection – the Maastricht IV/ Florence Consensus Report. Gut 2012;61:646-64.
2. De F., Giorgio F., Hassan C., et al. Worldwide H. pylori antibiotic resistance: a systematic review. J Gastrointestin Liver Dis. 2010;19:409-14.
3. Kearney D.J., Brousal A.. Treatment of Helicobacter pylori infection in clinical practice in the United States – Results from 224 patients. Dig Dis Sci. 2000;45:265-71.

Q1: ANSWER: C

Critique

The diagnosis of H. pylori may be made using either invasive or noninvasive methods. Invasive diagnostic methods either detect organisms directly (i.e., histological identification with appropriate stains or bacterial culture) or indirectly (i.e., rapid urease testing of biopsy specimens). Noninvasive methods include serum antibody, stool antigen, and detecting the metabolites of the bacterial enzyme urease (i.e., urea breath testing). It should be noted that serology should not be used to test for eradication as the antibodies may remain elevated for years after successful eradication therapy.

Treatment of H. pylori infection has become problematic recently primarily due to increasing antibiotic resistance. The eradication rate of standard triple therapy consisting of a proton pump inhibitor combined with clarithromycin (500 mg) and amoxicillin (1 g) (or metronidazole (500 mg), all given b.i.d. for 7-14 days has now declined to unacceptable levels, averaging 70%-80% but reported as low as 55%. It is currently recommended that a noninvasive method be used (other than serology) to confirm eradication in patients in whom eradication is deemed necessary.

References

1. Malfertheiner P., Megraud F., O’Morain C.A., et al. European Helicobacter Study Group. Management of Helicobacter pylori infection – the Maastricht IV/ Florence Consensus Report. Gut 2012;61:646-64.
2. De F., Giorgio F., Hassan C., et al. Worldwide H. pylori antibiotic resistance: a systematic review. J Gastrointestin Liver Dis. 2010;19:409-14.
3. Kearney D.J., Brousal A.. Treatment of Helicobacter pylori infection in clinical practice in the United States – Results from 224 patients. Dig Dis Sci. 2000;45:265-71.

Q1: ANSWER: C

Critique

The diagnosis of H. pylori may be made using either invasive or noninvasive methods. Invasive diagnostic methods either detect organisms directly (i.e., histological identification with appropriate stains or bacterial culture) or indirectly (i.e., rapid urease testing of biopsy specimens). Noninvasive methods include serum antibody, stool antigen, and detecting the metabolites of the bacterial enzyme urease (i.e., urea breath testing). It should be noted that serology should not be used to test for eradication as the antibodies may remain elevated for years after successful eradication therapy.

Treatment of H. pylori infection has become problematic recently primarily due to increasing antibiotic resistance. The eradication rate of standard triple therapy consisting of a proton pump inhibitor combined with clarithromycin (500 mg) and amoxicillin (1 g) (or metronidazole (500 mg), all given b.i.d. for 7-14 days has now declined to unacceptable levels, averaging 70%-80% but reported as low as 55%. It is currently recommended that a noninvasive method be used (other than serology) to confirm eradication in patients in whom eradication is deemed necessary.

References

1. Malfertheiner P., Megraud F., O’Morain C.A., et al. European Helicobacter Study Group. Management of Helicobacter pylori infection – the Maastricht IV/ Florence Consensus Report. Gut 2012;61:646-64.
2. De F., Giorgio F., Hassan C., et al. Worldwide H. pylori antibiotic resistance: a systematic review. J Gastrointestin Liver Dis. 2010;19:409-14.
3. Kearney D.J., Brousal A.. Treatment of Helicobacter pylori infection in clinical practice in the United States – Results from 224 patients. Dig Dis Sci. 2000;45:265-71.

Q2: ANSWER: B

Critique

Cyclic vomiting syndrome (CVS) is characterized by typical vomiting episodes regarding onset and duration, which usually occur three or more times per year. Typically, there is absence of nausea and vomiting between episodes. CVS affects both genders; however, there does appear to be a hormonal influence in women, with 57% of women with CVS reporting an association with menses. Tricyclic antidepressants have been shown to be effective as a prophylactic agent in several small studies with amitriptyline being the most commonly studied medication. Namin and colleagues investigated 31 adult patients who fit the Rome II criteria for CVS. Twenty-seven patients were treated with amitriptyline and completed scales for anxiety, depression, and symptoms. Eighty-four percent suffered from an anxiety disorder, and 78% revealed depression. The patients were started on a low dose of amitriptyline and titrated up to a goal of 1 mg/kg per day. After an average of 16.8 months, the Visual Analog Scale revealed a significant mean improvement (P less than .05) in severity of their symptoms by 6.1. Additionally, there was 78% improvement in vomiting, 75.3% improvement in pain, and 69.3% improvement in nausea.

Choice A: Domperidone has not been found to be beneficial in CVS.

Choice C: Metoclopramide does not decrease symptom recurrence in CVS.

Choice D: Selective serotonin reuptake inhibitors have not been shown in clinical trials to decrease CVS recurrence.

Choice E: Proton pump inhibitors can help as an adjunct to suppress gastric secretion. However, they do not decrease the frequency of CVS episodes.

References

1. Namin F., et al. Clinical, psychiatric, and manometric profile of cyclic vomiting syndrome in adults and response to tricyclic therapy. Neurogastroenterol Motil. 2007;19:196-202.

Q2: ANSWER: B

Critique

Cyclic vomiting syndrome (CVS) is characterized by typical vomiting episodes regarding onset and duration, which usually occur three or more times per year. Typically, there is absence of nausea and vomiting between episodes. CVS affects both genders; however, there does appear to be a hormonal influence in women, with 57% of women with CVS reporting an association with menses. Tricyclic antidepressants have been shown to be effective as a prophylactic agent in several small studies with amitriptyline being the most commonly studied medication. Namin and colleagues investigated 31 adult patients who fit the Rome II criteria for CVS. Twenty-seven patients were treated with amitriptyline and completed scales for anxiety, depression, and symptoms. Eighty-four percent suffered from an anxiety disorder, and 78% revealed depression. The patients were started on a low dose of amitriptyline and titrated up to a goal of 1 mg/kg per day. After an average of 16.8 months, the Visual Analog Scale revealed a significant mean improvement (P less than .05) in severity of their symptoms by 6.1. Additionally, there was 78% improvement in vomiting, 75.3% improvement in pain, and 69.3% improvement in nausea.

Choice A: Domperidone has not been found to be beneficial in CVS.

Choice C: Metoclopramide does not decrease symptom recurrence in CVS.

Choice D: Selective serotonin reuptake inhibitors have not been shown in clinical trials to decrease CVS recurrence.

Choice E: Proton pump inhibitors can help as an adjunct to suppress gastric secretion. However, they do not decrease the frequency of CVS episodes.

References

1. Namin F., et al. Clinical, psychiatric, and manometric profile of cyclic vomiting syndrome in adults and response to tricyclic therapy. Neurogastroenterol Motil. 2007;19:196-202.

Q2: ANSWER: B

Critique

Cyclic vomiting syndrome (CVS) is characterized by typical vomiting episodes regarding onset and duration, which usually occur three or more times per year. Typically, there is absence of nausea and vomiting between episodes. CVS affects both genders; however, there does appear to be a hormonal influence in women, with 57% of women with CVS reporting an association with menses. Tricyclic antidepressants have been shown to be effective as a prophylactic agent in several small studies with amitriptyline being the most commonly studied medication. Namin and colleagues investigated 31 adult patients who fit the Rome II criteria for CVS. Twenty-seven patients were treated with amitriptyline and completed scales for anxiety, depression, and symptoms. Eighty-four percent suffered from an anxiety disorder, and 78% revealed depression. The patients were started on a low dose of amitriptyline and titrated up to a goal of 1 mg/kg per day. After an average of 16.8 months, the Visual Analog Scale revealed a significant mean improvement (P less than .05) in severity of their symptoms by 6.1. Additionally, there was 78% improvement in vomiting, 75.3% improvement in pain, and 69.3% improvement in nausea.

Choice A: Domperidone has not been found to be beneficial in CVS.

Choice C: Metoclopramide does not decrease symptom recurrence in CVS.

Choice D: Selective serotonin reuptake inhibitors have not been shown in clinical trials to decrease CVS recurrence.

Choice E: Proton pump inhibitors can help as an adjunct to suppress gastric secretion. However, they do not decrease the frequency of CVS episodes.

References

1. Namin F., et al. Clinical, psychiatric, and manometric profile of cyclic vomiting syndrome in adults and response to tricyclic therapy. Neurogastroenterol Motil. 2007;19:196-202.

Q1: ANSWER: E

Critique

The incidence of bacterial infections in patients with cirrhosis with and without ascites who are admitted to the hospital with an upper GI bleed is 45% and studies have shown that the use of short-term (less than 7 days) prophylactic antibiotics is associated with lower rates of bacterial infections and lower risk for bleeding and death. Nadolol, a noncardioselective beta-blocker, is not helpful in active bleeding from gastric fundic varices. Imaging studies are the second step in the management of the patient to look for splenic vein thrombosis as a cause for fundic gastric varices. In cases where isolated gastric fundic varices are due to splenic vein thrombosis the treatment would be surgical referral for splenectomy.

References

1. Chavez-Tapia N.C., Barrientos-Gutierrez T., Tellez-Avila F.I., et al. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010;Sep 8:CD002907.
2. Hou M.C., Lin H.C., Liu T.T., et al. Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: a randomized trial. Hepatology. 2004;39:746-53.
3. Rimola A., García-Tsao G., Navasa M., et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International Ascites Club. J Hepatol. 2000 Jan;32:142-53.

Q1: ANSWER: E

Critique

The incidence of bacterial infections in patients with cirrhosis with and without ascites who are admitted to the hospital with an upper GI bleed is 45% and studies have shown that the use of short-term (less than 7 days) prophylactic antibiotics is associated with lower rates of bacterial infections and lower risk for bleeding and death. Nadolol, a noncardioselective beta-blocker, is not helpful in active bleeding from gastric fundic varices. Imaging studies are the second step in the management of the patient to look for splenic vein thrombosis as a cause for fundic gastric varices. In cases where isolated gastric fundic varices are due to splenic vein thrombosis the treatment would be surgical referral for splenectomy.

References

1. Chavez-Tapia N.C., Barrientos-Gutierrez T., Tellez-Avila F.I., et al. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010;Sep 8:CD002907.
2. Hou M.C., Lin H.C., Liu T.T., et al. Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: a randomized trial. Hepatology. 2004;39:746-53.
3. Rimola A., García-Tsao G., Navasa M., et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International Ascites Club. J Hepatol. 2000 Jan;32:142-53.

Q1: ANSWER: E

Critique

The incidence of bacterial infections in patients with cirrhosis with and without ascites who are admitted to the hospital with an upper GI bleed is 45% and studies have shown that the use of short-term (less than 7 days) prophylactic antibiotics is associated with lower rates of bacterial infections and lower risk for bleeding and death. Nadolol, a noncardioselective beta-blocker, is not helpful in active bleeding from gastric fundic varices. Imaging studies are the second step in the management of the patient to look for splenic vein thrombosis as a cause for fundic gastric varices. In cases where isolated gastric fundic varices are due to splenic vein thrombosis the treatment would be surgical referral for splenectomy.

References

1. Chavez-Tapia N.C., Barrientos-Gutierrez T., Tellez-Avila F.I., et al. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010;Sep 8:CD002907.
2. Hou M.C., Lin H.C., Liu T.T., et al. Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: a randomized trial. Hepatology. 2004;39:746-53.
3. Rimola A., García-Tsao G., Navasa M., et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International Ascites Club. J Hepatol. 2000 Jan;32:142-53.

ANSWER: C

Critique

The first step in managing this patient should not be to stop the tube feedings. Enteral feedings are providing much-needed nutrition to this patient. There is no evidence that either continuous or bolus feedings are superior. Diarrhea has been shown to occur in up to 18% of patients receiving enteral nutrition. Clostridium difficile is the leading cause of health care–associated diarrhea. Antibiotic therapy is the most common risk factor associated with acquisition of C. difficile infection. Internally fed patients are more likely than non–tube fed patients to acquire C. difficile infection and, therefore, it is recommended to check for C. difficile in tube-fed patients, especially when they are receiving antibiotics. The patient has no comorbid conditions that would require elemental formula, such as short bowel syndrome or malabsorption. In addition, it is not clear that elemental formulas are superior to standard formulas in patients with malabsorption or maldigestion. Finally, standard polymeric formulas are lactose free. Other considerations in a patient on enteral feedings with diarrhea include non–C. difficile antibiotic-associated diarrhea, formula composition, sorbitol-containing medication preparations, and side effects of medications as well as hypoalbuminemia.

References

1. Loo V.G., Bourgault A.M., Poirier L., et al. Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med. 2011;365:1693-703.

2. Bliss D.Z., Johnson S., Savik K. Acquisition of Clostridium difficile and Clostridium difficile–associated diarrhea in hospitalized patients receiving tube feeding. Ann Intern Med. 1998;129:1012.

3. Macleod J.B., Lefton J., Houghton D., et al. Prospective randomized control trial of intermittent versus continuous gastric feeds for critically ill trauma patients. J Trauma. 2007;63:57.

ANSWER: C

Critique

The first step in managing this patient should not be to stop the tube feedings. Enteral feedings are providing much-needed nutrition to this patient. There is no evidence that either continuous or bolus feedings are superior. Diarrhea has been shown to occur in up to 18% of patients receiving enteral nutrition. Clostridium difficile is the leading cause of health care–associated diarrhea. Antibiotic therapy is the most common risk factor associated with acquisition of C. difficile infection. Internally fed patients are more likely than non–tube fed patients to acquire C. difficile infection and, therefore, it is recommended to check for C. difficile in tube-fed patients, especially when they are receiving antibiotics. The patient has no comorbid conditions that would require elemental formula, such as short bowel syndrome or malabsorption. In addition, it is not clear that elemental formulas are superior to standard formulas in patients with malabsorption or maldigestion. Finally, standard polymeric formulas are lactose free. Other considerations in a patient on enteral feedings with diarrhea include non–C. difficile antibiotic-associated diarrhea, formula composition, sorbitol-containing medication preparations, and side effects of medications as well as hypoalbuminemia.

References

1. Loo V.G., Bourgault A.M., Poirier L., et al. Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med. 2011;365:1693-703.

2. Bliss D.Z., Johnson S., Savik K. Acquisition of Clostridium difficile and Clostridium difficile–associated diarrhea in hospitalized patients receiving tube feeding. Ann Intern Med. 1998;129:1012.

3. Macleod J.B., Lefton J., Houghton D., et al. Prospective randomized control trial of intermittent versus continuous gastric feeds for critically ill trauma patients. J Trauma. 2007;63:57.

ANSWER: C

Critique

The first step in managing this patient should not be to stop the tube feedings. Enteral feedings are providing much-needed nutrition to this patient. There is no evidence that either continuous or bolus feedings are superior. Diarrhea has been shown to occur in up to 18% of patients receiving enteral nutrition. Clostridium difficile is the leading cause of health care–associated diarrhea. Antibiotic therapy is the most common risk factor associated with acquisition of C. difficile infection. Internally fed patients are more likely than non–tube fed patients to acquire C. difficile infection and, therefore, it is recommended to check for C. difficile in tube-fed patients, especially when they are receiving antibiotics. The patient has no comorbid conditions that would require elemental formula, such as short bowel syndrome or malabsorption. In addition, it is not clear that elemental formulas are superior to standard formulas in patients with malabsorption or maldigestion. Finally, standard polymeric formulas are lactose free. Other considerations in a patient on enteral feedings with diarrhea include non–C. difficile antibiotic-associated diarrhea, formula composition, sorbitol-containing medication preparations, and side effects of medications as well as hypoalbuminemia.

References

1. Loo V.G., Bourgault A.M., Poirier L., et al. Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med. 2011;365:1693-703.

2. Bliss D.Z., Johnson S., Savik K. Acquisition of Clostridium difficile and Clostridium difficile–associated diarrhea in hospitalized patients receiving tube feeding. Ann Intern Med. 1998;129:1012.

3. Macleod J.B., Lefton J., Houghton D., et al. Prospective randomized control trial of intermittent versus continuous gastric feeds for critically ill trauma patients. J Trauma. 2007;63:57.

ANSWER: A

Critique

Extrahepatic biliary atresia accounts for 25%-30% of children with neonatal cholestasis and it is the most commonly identified etiology. Despite the identification and ability to test for many other causes, idiopathic disease still accounts for a similar proportion of infants with cholestasis. Galactosemia, disorders of bile acid biosynthesis, and panhypopituitarism each account for 1% or slightly more of neonatal cholestasis. Autoimmune hepatitis is not a usual consideration in neonates.

Reference

Dellert S., Balistreri W., Neonatal cholestasis. In: Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, Management, 3rd ed. Walker A., Durie P., Hamilton R., Walker–Smith J., eds. Hamilton, Ontario: B. C. Decker, 2000;52:880-94.

ANSWER: A

Critique

Extrahepatic biliary atresia accounts for 25%-30% of children with neonatal cholestasis and it is the most commonly identified etiology. Despite the identification and ability to test for many other causes, idiopathic disease still accounts for a similar proportion of infants with cholestasis. Galactosemia, disorders of bile acid biosynthesis, and panhypopituitarism each account for 1% or slightly more of neonatal cholestasis. Autoimmune hepatitis is not a usual consideration in neonates.

Reference

Dellert S., Balistreri W., Neonatal cholestasis. In: Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, Management, 3rd ed. Walker A., Durie P., Hamilton R., Walker–Smith J., eds. Hamilton, Ontario: B. C. Decker, 2000;52:880-94.

ANSWER: A

Critique

Extrahepatic biliary atresia accounts for 25%-30% of children with neonatal cholestasis and it is the most commonly identified etiology. Despite the identification and ability to test for many other causes, idiopathic disease still accounts for a similar proportion of infants with cholestasis. Galactosemia, disorders of bile acid biosynthesis, and panhypopituitarism each account for 1% or slightly more of neonatal cholestasis. Autoimmune hepatitis is not a usual consideration in neonates.

Reference

Dellert S., Balistreri W., Neonatal cholestasis. In: Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, Management, 3rd ed. Walker A., Durie P., Hamilton R., Walker–Smith J., eds. Hamilton, Ontario: B. C. Decker, 2000;52:880-94.

ANSWER: D
 
Critique

This patient has vitamin B12 deficiency, which is common in the elderly. In addition, gastrectomy can produce cobalamin deficiency due to lack of gastrin and pepsin resulting in impaired release of dietary B12 from ingested proteins. Also, the lack of intrinsic factor will result in impaired absorption of B12. B12 and folate are required to metabolize homocysteine to methionine. Therefore, with deficiency of either folate or B12, there is an increase in serum homocysteine levels. B12 is also a cofactor in the synthesis of succinyl-CoA from methylmalonyl-CoA and therefore, with B12 deficiency, methylmalonic acid levels are also elevated. Hypoglycemia would not explain this constellation of symptoms. Microscopic colitis causes diarrhea but does not cause dementia or cognitive impairment, glossitis, or taste disturbances. The dominant micronutrient deficiencies with celiac disease are iron and calcium malabsorption, and while B12 deficiency is possible with extensive disease, it is not seen as commonly, and celiac would not be the most likely etiology for her B12 deficiency.
 
Reference

1. Sumner, A.E., Chin, M.M., Abrahm, J.L., et al. Elevated methylmalonic acid and total homocysteine levels show high prevalence of B12 deficiency after gastric surgery. Ann. Intern. Med. 1996;124:469.

ANSWER: D
 
Critique

This patient has vitamin B12 deficiency, which is common in the elderly. In addition, gastrectomy can produce cobalamin deficiency due to lack of gastrin and pepsin resulting in impaired release of dietary B12 from ingested proteins. Also, the lack of intrinsic factor will result in impaired absorption of B12. B12 and folate are required to metabolize homocysteine to methionine. Therefore, with deficiency of either folate or B12, there is an increase in serum homocysteine levels. B12 is also a cofactor in the synthesis of succinyl-CoA from methylmalonyl-CoA and therefore, with B12 deficiency, methylmalonic acid levels are also elevated. Hypoglycemia would not explain this constellation of symptoms. Microscopic colitis causes diarrhea but does not cause dementia or cognitive impairment, glossitis, or taste disturbances. The dominant micronutrient deficiencies with celiac disease are iron and calcium malabsorption, and while B12 deficiency is possible with extensive disease, it is not seen as commonly, and celiac would not be the most likely etiology for her B12 deficiency.
 
Reference

1. Sumner, A.E., Chin, M.M., Abrahm, J.L., et al. Elevated methylmalonic acid and total homocysteine levels show high prevalence of B12 deficiency after gastric surgery. Ann. Intern. Med. 1996;124:469.

ANSWER: D
 
Critique

This patient has vitamin B12 deficiency, which is common in the elderly. In addition, gastrectomy can produce cobalamin deficiency due to lack of gastrin and pepsin resulting in impaired release of dietary B12 from ingested proteins. Also, the lack of intrinsic factor will result in impaired absorption of B12. B12 and folate are required to metabolize homocysteine to methionine. Therefore, with deficiency of either folate or B12, there is an increase in serum homocysteine levels. B12 is also a cofactor in the synthesis of succinyl-CoA from methylmalonyl-CoA and therefore, with B12 deficiency, methylmalonic acid levels are also elevated. Hypoglycemia would not explain this constellation of symptoms. Microscopic colitis causes diarrhea but does not cause dementia or cognitive impairment, glossitis, or taste disturbances. The dominant micronutrient deficiencies with celiac disease are iron and calcium malabsorption, and while B12 deficiency is possible with extensive disease, it is not seen as commonly, and celiac would not be the most likely etiology for her B12 deficiency.
 
Reference

1. Sumner, A.E., Chin, M.M., Abrahm, J.L., et al. Elevated methylmalonic acid and total homocysteine levels show high prevalence of B12 deficiency after gastric surgery. Ann. Intern. Med. 1996;124:469.

ANSWER: D
 
Critique

Cystic fibrosis (CF) is the correct diagnosis here even in the absence of respiratory symptoms; failure to thrive with malabsorption, elevated liver chemistries, and protein malnutrition (low serum albumin) are all suggestive of CF. Additionally, profound hypoalbuminemia and anemia have been reported with the use of soy protein-based formulas in infants with CF. Although celiac disease can have a very early onset, this may obviously only follow ingestion of gluten, so it is not a diagnostic possibility in the case of this formula-fed child. Poor feeding technique is a cause of failure to thrive in early infancy, but here we have good oral intake also suggesting an absorption issue. Giardiasis may have caused this child's symptoms, as this parasitic infection may result in malabsorption, but at this early age this is a highly unlikely explanation, especially in developed countries. Milk protein allergy-induced enteropathy is also possible in this case but is less likely with heme-negative stool and elevated liver chemistries.
 
Reference

1. Messick, J. A 21st century approach to cystic fibrosis: optimizing outcomes across the disease spectrum. J. Pediatr. Gastroenterol. Nutr. 2010;51(Suppl 7):S1-7.

ANSWER: D
 
Critique

Cystic fibrosis (CF) is the correct diagnosis here even in the absence of respiratory symptoms; failure to thrive with malabsorption, elevated liver chemistries, and protein malnutrition (low serum albumin) are all suggestive of CF. Additionally, profound hypoalbuminemia and anemia have been reported with the use of soy protein-based formulas in infants with CF. Although celiac disease can have a very early onset, this may obviously only follow ingestion of gluten, so it is not a diagnostic possibility in the case of this formula-fed child. Poor feeding technique is a cause of failure to thrive in early infancy, but here we have good oral intake also suggesting an absorption issue. Giardiasis may have caused this child's symptoms, as this parasitic infection may result in malabsorption, but at this early age this is a highly unlikely explanation, especially in developed countries. Milk protein allergy-induced enteropathy is also possible in this case but is less likely with heme-negative stool and elevated liver chemistries.
 
Reference

1. Messick, J. A 21st century approach to cystic fibrosis: optimizing outcomes across the disease spectrum. J. Pediatr. Gastroenterol. Nutr. 2010;51(Suppl 7):S1-7.

ANSWER: D
 
Critique

Cystic fibrosis (CF) is the correct diagnosis here even in the absence of respiratory symptoms; failure to thrive with malabsorption, elevated liver chemistries, and protein malnutrition (low serum albumin) are all suggestive of CF. Additionally, profound hypoalbuminemia and anemia have been reported with the use of soy protein-based formulas in infants with CF. Although celiac disease can have a very early onset, this may obviously only follow ingestion of gluten, so it is not a diagnostic possibility in the case of this formula-fed child. Poor feeding technique is a cause of failure to thrive in early infancy, but here we have good oral intake also suggesting an absorption issue. Giardiasis may have caused this child's symptoms, as this parasitic infection may result in malabsorption, but at this early age this is a highly unlikely explanation, especially in developed countries. Milk protein allergy-induced enteropathy is also possible in this case but is less likely with heme-negative stool and elevated liver chemistries.
 
Reference

1. Messick, J. A 21st century approach to cystic fibrosis: optimizing outcomes across the disease spectrum. J. Pediatr. Gastroenterol. Nutr. 2010;51(Suppl 7):S1-7.

Critique

Patients with mild pancreatitis can be treated with hydration alone. Initial feeding with a low-fat diet is safe and may reduce the duration of hospitalization, compared with a clear liquid diet in patients with mild pancreatitis. Multiple studies have demonstrated that enteral feeding is safe and tolerated in acute pancreatitis. Additionally, enteral feeding may preserve gut barrier function and prevent translocation of bacteria, which are implicated in pancreatic infections. A meta-analysis of the existing literature has demonstrated improved outcome with enteral feeding, compared with parenteral feeding, with less infectious complications, reduced cost, and better glycemic control.

References

1. McClave, S.A., Change, W.K., Dhaliwal, R., et al. Nutritional support in acute pancreatitis; a systemic review of the literature. J. Parenteral Enteral Nutr. 2006;30:143–56.

2. Vu M.K., van der Veek P.P., Frolich M., et al. Does jejunal feeding activate exocrine pancreatic secretions? Eur. J. Clin. Invest. 1999;29:1053–9.

3. Petrov M.S., van Santvoort H.C., Besselink M.S., et al. Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta-analysis of randomized trials. Arch. Surg. 2008;143:1111–7.

Critique

Patients with mild pancreatitis can be treated with hydration alone. Initial feeding with a low-fat diet is safe and may reduce the duration of hospitalization, compared with a clear liquid diet in patients with mild pancreatitis. Multiple studies have demonstrated that enteral feeding is safe and tolerated in acute pancreatitis. Additionally, enteral feeding may preserve gut barrier function and prevent translocation of bacteria, which are implicated in pancreatic infections. A meta-analysis of the existing literature has demonstrated improved outcome with enteral feeding, compared with parenteral feeding, with less infectious complications, reduced cost, and better glycemic control.

References

1. McClave, S.A., Change, W.K., Dhaliwal, R., et al. Nutritional support in acute pancreatitis; a systemic review of the literature. J. Parenteral Enteral Nutr. 2006;30:143–56.

2. Vu M.K., van der Veek P.P., Frolich M., et al. Does jejunal feeding activate exocrine pancreatic secretions? Eur. J. Clin. Invest. 1999;29:1053–9.

3. Petrov M.S., van Santvoort H.C., Besselink M.S., et al. Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta-analysis of randomized trials. Arch. Surg. 2008;143:1111–7.

Critique

Patients with mild pancreatitis can be treated with hydration alone. Initial feeding with a low-fat diet is safe and may reduce the duration of hospitalization, compared with a clear liquid diet in patients with mild pancreatitis. Multiple studies have demonstrated that enteral feeding is safe and tolerated in acute pancreatitis. Additionally, enteral feeding may preserve gut barrier function and prevent translocation of bacteria, which are implicated in pancreatic infections. A meta-analysis of the existing literature has demonstrated improved outcome with enteral feeding, compared with parenteral feeding, with less infectious complications, reduced cost, and better glycemic control.

References

1. McClave, S.A., Change, W.K., Dhaliwal, R., et al. Nutritional support in acute pancreatitis; a systemic review of the literature. J. Parenteral Enteral Nutr. 2006;30:143–56.

2. Vu M.K., van der Veek P.P., Frolich M., et al. Does jejunal feeding activate exocrine pancreatic secretions? Eur. J. Clin. Invest. 1999;29:1053–9.

3. Petrov M.S., van Santvoort H.C., Besselink M.S., et al. Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta-analysis of randomized trials. Arch. Surg. 2008;143:1111–7.

Q1: ANSWER: B

Critique

This patient has developed an ulcer because of chronic NSAID use. She is older than 60 years old and is also on antiplatelet therapy. Therefore, her risk of peptic ulcer rebleeding is high and warrants lifelong secondary prophylaxis with a proton pump inhibitor (Choice B). Therefore, stopping all prophylactic measures would be inappropriate (Choice A). Repeat endoscopy to assess for gastric ulcer healing may be warranted, especially in the setting of risk factors for malignancy, but duodenal ulcers do not require endoscopic follow-up (Choice C). There is no role to empirically treat H. pylori in the context of having negative test results (Choice E).

References

1. Bhatt, D.L., et al. ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. Am. J. Gastroenterol. 2008;103:2890-907.

2. Abraham, N., et al. ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines: A Focused Update of the ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. J. Am. Coll. Cardiol. 2010;56:2051-66.

Q1: ANSWER: B

Critique

This patient has developed an ulcer because of chronic NSAID use. She is older than 60 years old and is also on antiplatelet therapy. Therefore, her risk of peptic ulcer rebleeding is high and warrants lifelong secondary prophylaxis with a proton pump inhibitor (Choice B). Therefore, stopping all prophylactic measures would be inappropriate (Choice A). Repeat endoscopy to assess for gastric ulcer healing may be warranted, especially in the setting of risk factors for malignancy, but duodenal ulcers do not require endoscopic follow-up (Choice C). There is no role to empirically treat H. pylori in the context of having negative test results (Choice E).

References

1. Bhatt, D.L., et al. ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. Am. J. Gastroenterol. 2008;103:2890-907.

2. Abraham, N., et al. ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines: A Focused Update of the ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. J. Am. Coll. Cardiol. 2010;56:2051-66.

Q1: ANSWER: B

Critique

This patient has developed an ulcer because of chronic NSAID use. She is older than 60 years old and is also on antiplatelet therapy. Therefore, her risk of peptic ulcer rebleeding is high and warrants lifelong secondary prophylaxis with a proton pump inhibitor (Choice B). Therefore, stopping all prophylactic measures would be inappropriate (Choice A). Repeat endoscopy to assess for gastric ulcer healing may be warranted, especially in the setting of risk factors for malignancy, but duodenal ulcers do not require endoscopic follow-up (Choice C). There is no role to empirically treat H. pylori in the context of having negative test results (Choice E).

References

1. Bhatt, D.L., et al. ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. Am. J. Gastroenterol. 2008;103:2890-907.

2. Abraham, N., et al. ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines: A Focused Update of the ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use. J. Am. Coll. Cardiol. 2010;56:2051-66.

Q2: ANSWER: A

Critique

This pregnant patient has features compatible with Listeria monocytogenes infection. In any pregnant patient presenting with fever, Listeria needs to be considered after ruling out common conditions such as a urinary tract infection given the high morbidity associated with this condition. Blood cultures are used to make the diagnosis of Listeria, while stool and vaginal cultures are not helpful. While CSF cultures can be used in cases of Listeria meningitis, the yield of blood cultures is higher. Urine cultures are unlikely to add additional information in this patient’s case given the negative urine dipstick.

Reference

1. Jackson, K.A., Iwamoto, M., Swerdlow, D. Pregnancy-associated listeriosis. Epidemiol. Infect. 2010;138:1503-9.

Q2: ANSWER: A

Critique

This pregnant patient has features compatible with Listeria monocytogenes infection. In any pregnant patient presenting with fever, Listeria needs to be considered after ruling out common conditions such as a urinary tract infection given the high morbidity associated with this condition. Blood cultures are used to make the diagnosis of Listeria, while stool and vaginal cultures are not helpful. While CSF cultures can be used in cases of Listeria meningitis, the yield of blood cultures is higher. Urine cultures are unlikely to add additional information in this patient’s case given the negative urine dipstick.

Reference

1. Jackson, K.A., Iwamoto, M., Swerdlow, D. Pregnancy-associated listeriosis. Epidemiol. Infect. 2010;138:1503-9.

Q2: ANSWER: A

Critique

This pregnant patient has features compatible with Listeria monocytogenes infection. In any pregnant patient presenting with fever, Listeria needs to be considered after ruling out common conditions such as a urinary tract infection given the high morbidity associated with this condition. Blood cultures are used to make the diagnosis of Listeria, while stool and vaginal cultures are not helpful. While CSF cultures can be used in cases of Listeria meningitis, the yield of blood cultures is higher. Urine cultures are unlikely to add additional information in this patient’s case given the negative urine dipstick.

Reference

1. Jackson, K.A., Iwamoto, M., Swerdlow, D. Pregnancy-associated listeriosis. Epidemiol. Infect. 2010;138:1503-9.