DDSEP® 8 Quick Quiz

Q1: ANSWER: D

Critique

The patient has had complicated recurrent Crohn’s disease and two resections. If this were his first resection of a short-segment ileal stricture, then choice (a) would be a reasonable alternative to starting medication at this time. This is based on the endoscopic scoring system of Rutgeerts in which endoscopic findings in the neoterminal ileum at 6-12 months postoperatively are somewhat predictive of clinical recurrence over the next 5 years. Short-term antibiotic therapy with ciprofloxacin has not been shown to be a good long-term solution to prevention of postoperative recurrence. Both azathioprine and 6-mercaptopurine have a modest effect on the prevention of postoperative recurrence of Crohn’s disease. Azathioprine at 1 mg/kg per day would be less than an optimal dose for this purpose. The D’Haens study used 1.5-2 mg/kg of azathioprine in combination with 3 months of metronidazole. At 1 year the endoscopic recurrence rate (i2-i4 lesions) was greater in the placebo group at 69% compared with 44% in the azathioprine-treated group. Infliximab has been shown in a small randomized trial to be very effective in preventing postoperative recurrence of Crohn’s disease. In a 24-subject randomized trial, 91% of the infliximab treated patients were free of endoscopic recurrence, compared to 9% of patients receiving placebo. In this patient, who is at a high risk for recurrence with recurrent inflammation, multiple surgeries, and continued smoking, anti-TNF therapy should be initiated within 4 weeks after surgery. Mesalamine has minimal postoperative preventative effects and would not be appropriate monotherapy to use in this high-risk patient.

References

1. D’Haens, G.R., Vermeire, S., Van Assche G., et al. Therapy of metronidazole with azathioprine to prevent postoperative recurrence of Crohn’s disease: a controlled randomized trial. Gastroenterology 2008;135:1123-9.

2. Regueiro, M., Schraut, W., Baidoo, L., et al. Infliximab prevents Crohn’s disease recurrence after ileal resection. Gastroenterology 2009;136:441-50.e1;quiz 716. Epub 2008 Oct 31.

3. Rutgeerts P, Geboes K, Vantrappen G, Beyls J, Kerremans R, Hiele M. Predictability of the postoperative course of Crohn’s disease. Gastroenterology 1990;99:956-63.

4. Schwartz M, Regueiro M. Prevention and treatment of postoperative Crohn’s disease recurrence: an update for a new decade. Curr. Gastroenterol. Rep. 2011;13:95-100.

Q1: ANSWER: D

Critique

The patient has had complicated recurrent Crohn’s disease and two resections. If this were his first resection of a short-segment ileal stricture, then choice (a) would be a reasonable alternative to starting medication at this time. This is based on the endoscopic scoring system of Rutgeerts in which endoscopic findings in the neoterminal ileum at 6-12 months postoperatively are somewhat predictive of clinical recurrence over the next 5 years. Short-term antibiotic therapy with ciprofloxacin has not been shown to be a good long-term solution to prevention of postoperative recurrence. Both azathioprine and 6-mercaptopurine have a modest effect on the prevention of postoperative recurrence of Crohn’s disease. Azathioprine at 1 mg/kg per day would be less than an optimal dose for this purpose. The D’Haens study used 1.5-2 mg/kg of azathioprine in combination with 3 months of metronidazole. At 1 year the endoscopic recurrence rate (i2-i4 lesions) was greater in the placebo group at 69% compared with 44% in the azathioprine-treated group. Infliximab has been shown in a small randomized trial to be very effective in preventing postoperative recurrence of Crohn’s disease. In a 24-subject randomized trial, 91% of the infliximab treated patients were free of endoscopic recurrence, compared to 9% of patients receiving placebo. In this patient, who is at a high risk for recurrence with recurrent inflammation, multiple surgeries, and continued smoking, anti-TNF therapy should be initiated within 4 weeks after surgery. Mesalamine has minimal postoperative preventative effects and would not be appropriate monotherapy to use in this high-risk patient.

References

1. D’Haens, G.R., Vermeire, S., Van Assche G., et al. Therapy of metronidazole with azathioprine to prevent postoperative recurrence of Crohn’s disease: a controlled randomized trial. Gastroenterology 2008;135:1123-9.

2. Regueiro, M., Schraut, W., Baidoo, L., et al. Infliximab prevents Crohn’s disease recurrence after ileal resection. Gastroenterology 2009;136:441-50.e1;quiz 716. Epub 2008 Oct 31.

3. Rutgeerts P, Geboes K, Vantrappen G, Beyls J, Kerremans R, Hiele M. Predictability of the postoperative course of Crohn’s disease. Gastroenterology 1990;99:956-63.

4. Schwartz M, Regueiro M. Prevention and treatment of postoperative Crohn’s disease recurrence: an update for a new decade. Curr. Gastroenterol. Rep. 2011;13:95-100.

Q1: ANSWER: D

Critique

The patient has had complicated recurrent Crohn’s disease and two resections. If this were his first resection of a short-segment ileal stricture, then choice (a) would be a reasonable alternative to starting medication at this time. This is based on the endoscopic scoring system of Rutgeerts in which endoscopic findings in the neoterminal ileum at 6-12 months postoperatively are somewhat predictive of clinical recurrence over the next 5 years. Short-term antibiotic therapy with ciprofloxacin has not been shown to be a good long-term solution to prevention of postoperative recurrence. Both azathioprine and 6-mercaptopurine have a modest effect on the prevention of postoperative recurrence of Crohn’s disease. Azathioprine at 1 mg/kg per day would be less than an optimal dose for this purpose. The D’Haens study used 1.5-2 mg/kg of azathioprine in combination with 3 months of metronidazole. At 1 year the endoscopic recurrence rate (i2-i4 lesions) was greater in the placebo group at 69% compared with 44% in the azathioprine-treated group. Infliximab has been shown in a small randomized trial to be very effective in preventing postoperative recurrence of Crohn’s disease. In a 24-subject randomized trial, 91% of the infliximab treated patients were free of endoscopic recurrence, compared to 9% of patients receiving placebo. In this patient, who is at a high risk for recurrence with recurrent inflammation, multiple surgeries, and continued smoking, anti-TNF therapy should be initiated within 4 weeks after surgery. Mesalamine has minimal postoperative preventative effects and would not be appropriate monotherapy to use in this high-risk patient.

References

1. D’Haens, G.R., Vermeire, S., Van Assche G., et al. Therapy of metronidazole with azathioprine to prevent postoperative recurrence of Crohn’s disease: a controlled randomized trial. Gastroenterology 2008;135:1123-9.

2. Regueiro, M., Schraut, W., Baidoo, L., et al. Infliximab prevents Crohn’s disease recurrence after ileal resection. Gastroenterology 2009;136:441-50.e1;quiz 716. Epub 2008 Oct 31.

3. Rutgeerts P, Geboes K, Vantrappen G, Beyls J, Kerremans R, Hiele M. Predictability of the postoperative course of Crohn’s disease. Gastroenterology 1990;99:956-63.

4. Schwartz M, Regueiro M. Prevention and treatment of postoperative Crohn’s disease recurrence: an update for a new decade. Curr. Gastroenterol. Rep. 2011;13:95-100.

ANSWER: C
 
Critique

Sulfasalazine can cause reversible azoospermia and infertility. About 80% of patients taking sulfasalazine have semen abnormalities and 72% have oligospermia. Only one case of azoospermia has been reported in patients taking pure mesalamines. The sperm abnormalities are thought to be caused by the sulfapyridine moiety in the sulfasalazine molecule. Therefore, a switch from sulfasalazine to Asacol® or any other pure mesalamine is indicated.

Sulfasalazine inhibits dihydrofolate reductase and can cause folate deficiency. As a result, it should always be given along with oral folic acid supplementation. There is no clear evidence that 6-mercaptopurine affects male fertility. Holding both medications in a patient with UC would put him at increased risk of recurrence and should not be recommended. Withdrawal of an immunomodulatory agent such as 6-mercaptopurine or azathioprine in patients who are in remission can lead to rapid relapse in up to one-third of patients in 1 year and two-thirds within 5 years. Since 6-mercaptopurine is maintaining remission, there is no need for a switch to infliximab. An in vitro fertilization specialist might be required if there is no conception despite sulfasalazine withdrawal.
 
References

1. Nielsen O.H., Munck L.K. Drug insight: aminosalicylates for the treatment of IBD. Nat. Clin. Pract. Gastroenterol. Hepatol. 2007;4:160-70.
2. Cassinotti A., Actis G.C., Duca P., et al. Maintenance treatment with azathioprine in ulcerative colitis: outcome and predictive factors after drug withdrawal. Am. J. Gastroenterol. 2009;104:2760-7.

ANSWER: C
 
Critique

Sulfasalazine can cause reversible azoospermia and infertility. About 80% of patients taking sulfasalazine have semen abnormalities and 72% have oligospermia. Only one case of azoospermia has been reported in patients taking pure mesalamines. The sperm abnormalities are thought to be caused by the sulfapyridine moiety in the sulfasalazine molecule. Therefore, a switch from sulfasalazine to Asacol® or any other pure mesalamine is indicated.

Sulfasalazine inhibits dihydrofolate reductase and can cause folate deficiency. As a result, it should always be given along with oral folic acid supplementation. There is no clear evidence that 6-mercaptopurine affects male fertility. Holding both medications in a patient with UC would put him at increased risk of recurrence and should not be recommended. Withdrawal of an immunomodulatory agent such as 6-mercaptopurine or azathioprine in patients who are in remission can lead to rapid relapse in up to one-third of patients in 1 year and two-thirds within 5 years. Since 6-mercaptopurine is maintaining remission, there is no need for a switch to infliximab. An in vitro fertilization specialist might be required if there is no conception despite sulfasalazine withdrawal.
 
References

1. Nielsen O.H., Munck L.K. Drug insight: aminosalicylates for the treatment of IBD. Nat. Clin. Pract. Gastroenterol. Hepatol. 2007;4:160-70.
2. Cassinotti A., Actis G.C., Duca P., et al. Maintenance treatment with azathioprine in ulcerative colitis: outcome and predictive factors after drug withdrawal. Am. J. Gastroenterol. 2009;104:2760-7.

ANSWER: C
 
Critique

Sulfasalazine can cause reversible azoospermia and infertility. About 80% of patients taking sulfasalazine have semen abnormalities and 72% have oligospermia. Only one case of azoospermia has been reported in patients taking pure mesalamines. The sperm abnormalities are thought to be caused by the sulfapyridine moiety in the sulfasalazine molecule. Therefore, a switch from sulfasalazine to Asacol® or any other pure mesalamine is indicated.

Sulfasalazine inhibits dihydrofolate reductase and can cause folate deficiency. As a result, it should always be given along with oral folic acid supplementation. There is no clear evidence that 6-mercaptopurine affects male fertility. Holding both medications in a patient with UC would put him at increased risk of recurrence and should not be recommended. Withdrawal of an immunomodulatory agent such as 6-mercaptopurine or azathioprine in patients who are in remission can lead to rapid relapse in up to one-third of patients in 1 year and two-thirds within 5 years. Since 6-mercaptopurine is maintaining remission, there is no need for a switch to infliximab. An in vitro fertilization specialist might be required if there is no conception despite sulfasalazine withdrawal.
 
References

1. Nielsen O.H., Munck L.K. Drug insight: aminosalicylates for the treatment of IBD. Nat. Clin. Pract. Gastroenterol. Hepatol. 2007;4:160-70.
2. Cassinotti A., Actis G.C., Duca P., et al. Maintenance treatment with azathioprine in ulcerative colitis: outcome and predictive factors after drug withdrawal. Am. J. Gastroenterol. 2009;104:2760-7.

ANSWER: C
 
Critique

A recent Olmstead County, Minn., study was undertaken to understand the epidemiology of community-acquired C. difficile infections. In the cohort of 385 proven C. difficile infections, 41% were community acquired. Compared to cases acquired in the hospital, community C. difficile infections were observed in younger (B) females (A) who had lower comorbidity scores and fewer chronic illnesses (D). Also, these outpatient cases were less likely to have recent antibiotic exposure (E) and fortunately had less severe clinical courses. A large population-based study and several others have confirmed that the use of gastric acid-suppressive agents such as PPIs (C) increases the risk of C. difficile-associated disease (adjusted risk ratio 2.9, 95% CI: 2.4-3.4).
 
References

1. Khanna S., Pardi D.S., Aronson S.L., et al. The epidemiology of community-acquired Clostridium difficile infection: a population-based study. Am. J. Gastroenterol. 2012;107:89-95.
2. Dial S., Delaney J.A., Barkun A.N., Suissa S. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA 2005;294:2989.

ANSWER: C
 
Critique

A recent Olmstead County, Minn., study was undertaken to understand the epidemiology of community-acquired C. difficile infections. In the cohort of 385 proven C. difficile infections, 41% were community acquired. Compared to cases acquired in the hospital, community C. difficile infections were observed in younger (B) females (A) who had lower comorbidity scores and fewer chronic illnesses (D). Also, these outpatient cases were less likely to have recent antibiotic exposure (E) and fortunately had less severe clinical courses. A large population-based study and several others have confirmed that the use of gastric acid-suppressive agents such as PPIs (C) increases the risk of C. difficile-associated disease (adjusted risk ratio 2.9, 95% CI: 2.4-3.4).
 
References

1. Khanna S., Pardi D.S., Aronson S.L., et al. The epidemiology of community-acquired Clostridium difficile infection: a population-based study. Am. J. Gastroenterol. 2012;107:89-95.
2. Dial S., Delaney J.A., Barkun A.N., Suissa S. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA 2005;294:2989.

ANSWER: C
 
Critique

A recent Olmstead County, Minn., study was undertaken to understand the epidemiology of community-acquired C. difficile infections. In the cohort of 385 proven C. difficile infections, 41% were community acquired. Compared to cases acquired in the hospital, community C. difficile infections were observed in younger (B) females (A) who had lower comorbidity scores and fewer chronic illnesses (D). Also, these outpatient cases were less likely to have recent antibiotic exposure (E) and fortunately had less severe clinical courses. A large population-based study and several others have confirmed that the use of gastric acid-suppressive agents such as PPIs (C) increases the risk of C. difficile-associated disease (adjusted risk ratio 2.9, 95% CI: 2.4-3.4).
 
References

1. Khanna S., Pardi D.S., Aronson S.L., et al. The epidemiology of community-acquired Clostridium difficile infection: a population-based study. Am. J. Gastroenterol. 2012;107:89-95.
2. Dial S., Delaney J.A., Barkun A.N., Suissa S. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA 2005;294:2989.

ANSWER: A

Critique

While small bowel biopsies are the gold standard test for the exclusion of celiac disease, HLA typing for DQ2 and DQ8 (A) is very useful as an exclusionary test for celiac disease, as the diagnosis is quite unlikely in their absence. DQ2 and DQ8 haplotyping also are useful when small intestinal biopsies are equivocal. Antigliadin antibodies (B & C) do not have particularly high negative predictive values, and have little value here. Also, gluten challenge testing (E) would be of limited utility in excluding the presence of celiac disease.

Reference
1. Liu E., Rewers M., Eisenbarth G.S. Genetic testing: who should do the testing and what is the role of genetic testing in the setting of celiac disease? Gastroenterology 2005;128(4 Suppl 1):S33-7.

ANSWER: A

Critique

While small bowel biopsies are the gold standard test for the exclusion of celiac disease, HLA typing for DQ2 and DQ8 (A) is very useful as an exclusionary test for celiac disease, as the diagnosis is quite unlikely in their absence. DQ2 and DQ8 haplotyping also are useful when small intestinal biopsies are equivocal. Antigliadin antibodies (B & C) do not have particularly high negative predictive values, and have little value here. Also, gluten challenge testing (E) would be of limited utility in excluding the presence of celiac disease.

Reference
1. Liu E., Rewers M., Eisenbarth G.S. Genetic testing: who should do the testing and what is the role of genetic testing in the setting of celiac disease? Gastroenterology 2005;128(4 Suppl 1):S33-7.

ANSWER: A

Critique

While small bowel biopsies are the gold standard test for the exclusion of celiac disease, HLA typing for DQ2 and DQ8 (A) is very useful as an exclusionary test for celiac disease, as the diagnosis is quite unlikely in their absence. DQ2 and DQ8 haplotyping also are useful when small intestinal biopsies are equivocal. Antigliadin antibodies (B & C) do not have particularly high negative predictive values, and have little value here. Also, gluten challenge testing (E) would be of limited utility in excluding the presence of celiac disease.

Reference
1. Liu E., Rewers M., Eisenbarth G.S. Genetic testing: who should do the testing and what is the role of genetic testing in the setting of celiac disease? Gastroenterology 2005;128(4 Suppl 1):S33-7.

ANSWER: C

Critique

The patient in this clinical presentation has symptoms most consistent with cyclic vomiting syndrome (CVS) and has undergone additional testing to exclude luminal pathology. His gastric emptying study is consistent with rapid gastric emptying, which can be seen in 60% of patients with CVS. There is increasing recognition of hyperemesis in the setting of cannabis use, and this may be contributing to this patient’s symptoms. However, prior to recommending that patients stop using cannabis, appropriate treatment for CVS should be instituted. There are several reports that suggest long-term tricyclic antidepressant (TCA) therapy significantly reduces the frequency and duration of CVS episodes, ED visits, and hospitalizations. Although psychiatric disorders are associated with nonresponse to TCA therapy, an appropriate trial of a TCA is warranted prior to referral to psychiatry in the absence of a clear psychological diagnosis. The clinical picture does not suggest small intestinal bacterial overgrowth.

Reference
1. Hejazi R.A., Reddymasu S.C., Namin F., Lavenbarg T., Foran P., McCallum R.W. Efficacy of tricyclic antidepressant therapy in adults with cyclic vomiting syndrome: a two-year follow-up study. J. Clin. Gastroenterol. 2010;44:18-21.

ANSWER: C

Critique

The patient in this clinical presentation has symptoms most consistent with cyclic vomiting syndrome (CVS) and has undergone additional testing to exclude luminal pathology. His gastric emptying study is consistent with rapid gastric emptying, which can be seen in 60% of patients with CVS. There is increasing recognition of hyperemesis in the setting of cannabis use, and this may be contributing to this patient’s symptoms. However, prior to recommending that patients stop using cannabis, appropriate treatment for CVS should be instituted. There are several reports that suggest long-term tricyclic antidepressant (TCA) therapy significantly reduces the frequency and duration of CVS episodes, ED visits, and hospitalizations. Although psychiatric disorders are associated with nonresponse to TCA therapy, an appropriate trial of a TCA is warranted prior to referral to psychiatry in the absence of a clear psychological diagnosis. The clinical picture does not suggest small intestinal bacterial overgrowth.

Reference
1. Hejazi R.A., Reddymasu S.C., Namin F., Lavenbarg T., Foran P., McCallum R.W. Efficacy of tricyclic antidepressant therapy in adults with cyclic vomiting syndrome: a two-year follow-up study. J. Clin. Gastroenterol. 2010;44:18-21.

ANSWER: C

Critique

The patient in this clinical presentation has symptoms most consistent with cyclic vomiting syndrome (CVS) and has undergone additional testing to exclude luminal pathology. His gastric emptying study is consistent with rapid gastric emptying, which can be seen in 60% of patients with CVS. There is increasing recognition of hyperemesis in the setting of cannabis use, and this may be contributing to this patient’s symptoms. However, prior to recommending that patients stop using cannabis, appropriate treatment for CVS should be instituted. There are several reports that suggest long-term tricyclic antidepressant (TCA) therapy significantly reduces the frequency and duration of CVS episodes, ED visits, and hospitalizations. Although psychiatric disorders are associated with nonresponse to TCA therapy, an appropriate trial of a TCA is warranted prior to referral to psychiatry in the absence of a clear psychological diagnosis. The clinical picture does not suggest small intestinal bacterial overgrowth.

Reference
1. Hejazi R.A., Reddymasu S.C., Namin F., Lavenbarg T., Foran P., McCallum R.W. Efficacy of tricyclic antidepressant therapy in adults with cyclic vomiting syndrome: a two-year follow-up study. J. Clin. Gastroenterol. 2010;44:18-21.

ANSWER: B

Critique

This patient has evidence of an acute colonic pseudo-obstruction (known as Ogilvie’s syndrome). This is seen most commonly after non-GI related surgeries such as cardiac or orthopedic surgeries. The exact etiology is uncertain but increased inhibitory sympathetic and/or decreased stimulatory, parasympathetic innervations of the distal colon have been incriminated. The most appropriate first step in management of this patient is a thorough clinical evaluation to ensure there is no evidence of peritonitis to suggest a perforation complication. The next step is to exclude an obstruction and the CT had no clear evidence of obstruction. One could consider a water soluble enema to exclude obstruction but should avoid the use of barium in the event of a perforation. The next steps include restricting all possible culprit medications such as opiates and anticholinergics, encouraging ambulation (although often clinical circumstances limit ambulation), and correcting any potential electrolyte abnormalities.

Placement of a nasogastric tube to low intermittent suction, keeping the patient NPO (nothing by mouth), and placing a rectal tube to gravity are practical measure that can facilitate decompression. If the patient cannot ambulate, some clinicians also advocate rotating the patient into the right lateral decubitus position for several hours, alternating with the supine position, to facilitate gas evacuation. Such conservative measures are appropriate if there is no evidence of clinical toxicity or progression of the condition. Cecal diameters may be monitored on plain abdominal x-rays. If there is no clinical response to the above measures, then further treatments may be considered. Use of an acetylcholinesterase inhibitor has been shown to be beneficial in a placebo-controlled trial. If use of an acetylcholinesterase inhibitor is unsuccessful, colonic decompression can be considered though this typically provides only transient benefit. Finally, an emergent cecostomy can be considered if colonic decompression is unsuccessful.

References

1. De Giorgio R., Cogliandro R.F., Barbara G., Corinaldesi  R., Stanghellini V. Chronic intestinal pseudo-obstruction: clinical features, diagnosis, and therapy. Gastroenterol. Clin. North Am. 2011;40:787-807.

2. Ponec R.J., Saunders M.D., KImmey M.B.  Neostigmine for the treatment of acute colonic pseudo-obstruction. N. Engl. J. Med. 1999;341:137-41.

ANSWER: B

Critique

This patient has evidence of an acute colonic pseudo-obstruction (known as Ogilvie’s syndrome). This is seen most commonly after non-GI related surgeries such as cardiac or orthopedic surgeries. The exact etiology is uncertain but increased inhibitory sympathetic and/or decreased stimulatory, parasympathetic innervations of the distal colon have been incriminated. The most appropriate first step in management of this patient is a thorough clinical evaluation to ensure there is no evidence of peritonitis to suggest a perforation complication. The next step is to exclude an obstruction and the CT had no clear evidence of obstruction. One could consider a water soluble enema to exclude obstruction but should avoid the use of barium in the event of a perforation. The next steps include restricting all possible culprit medications such as opiates and anticholinergics, encouraging ambulation (although often clinical circumstances limit ambulation), and correcting any potential electrolyte abnormalities.

Placement of a nasogastric tube to low intermittent suction, keeping the patient NPO (nothing by mouth), and placing a rectal tube to gravity are practical measure that can facilitate decompression. If the patient cannot ambulate, some clinicians also advocate rotating the patient into the right lateral decubitus position for several hours, alternating with the supine position, to facilitate gas evacuation. Such conservative measures are appropriate if there is no evidence of clinical toxicity or progression of the condition. Cecal diameters may be monitored on plain abdominal x-rays. If there is no clinical response to the above measures, then further treatments may be considered. Use of an acetylcholinesterase inhibitor has been shown to be beneficial in a placebo-controlled trial. If use of an acetylcholinesterase inhibitor is unsuccessful, colonic decompression can be considered though this typically provides only transient benefit. Finally, an emergent cecostomy can be considered if colonic decompression is unsuccessful.

References

1. De Giorgio R., Cogliandro R.F., Barbara G., Corinaldesi  R., Stanghellini V. Chronic intestinal pseudo-obstruction: clinical features, diagnosis, and therapy. Gastroenterol. Clin. North Am. 2011;40:787-807.

2. Ponec R.J., Saunders M.D., KImmey M.B.  Neostigmine for the treatment of acute colonic pseudo-obstruction. N. Engl. J. Med. 1999;341:137-41.

ANSWER: B

Critique

This patient has evidence of an acute colonic pseudo-obstruction (known as Ogilvie’s syndrome). This is seen most commonly after non-GI related surgeries such as cardiac or orthopedic surgeries. The exact etiology is uncertain but increased inhibitory sympathetic and/or decreased stimulatory, parasympathetic innervations of the distal colon have been incriminated. The most appropriate first step in management of this patient is a thorough clinical evaluation to ensure there is no evidence of peritonitis to suggest a perforation complication. The next step is to exclude an obstruction and the CT had no clear evidence of obstruction. One could consider a water soluble enema to exclude obstruction but should avoid the use of barium in the event of a perforation. The next steps include restricting all possible culprit medications such as opiates and anticholinergics, encouraging ambulation (although often clinical circumstances limit ambulation), and correcting any potential electrolyte abnormalities.

Placement of a nasogastric tube to low intermittent suction, keeping the patient NPO (nothing by mouth), and placing a rectal tube to gravity are practical measure that can facilitate decompression. If the patient cannot ambulate, some clinicians also advocate rotating the patient into the right lateral decubitus position for several hours, alternating with the supine position, to facilitate gas evacuation. Such conservative measures are appropriate if there is no evidence of clinical toxicity or progression of the condition. Cecal diameters may be monitored on plain abdominal x-rays. If there is no clinical response to the above measures, then further treatments may be considered. Use of an acetylcholinesterase inhibitor has been shown to be beneficial in a placebo-controlled trial. If use of an acetylcholinesterase inhibitor is unsuccessful, colonic decompression can be considered though this typically provides only transient benefit. Finally, an emergent cecostomy can be considered if colonic decompression is unsuccessful.

References

1. De Giorgio R., Cogliandro R.F., Barbara G., Corinaldesi  R., Stanghellini V. Chronic intestinal pseudo-obstruction: clinical features, diagnosis, and therapy. Gastroenterol. Clin. North Am. 2011;40:787-807.

2. Ponec R.J., Saunders M.D., KImmey M.B.  Neostigmine for the treatment of acute colonic pseudo-obstruction. N. Engl. J. Med. 1999;341:137-41.

ANSWER: D

Critique

The patient is most likely to have Zollinger-Ellison syndrome (ZES), a condition caused by a gastrinoma. In 25% of cases, ZES is associated with multiple endocrine neoplasia type 1 (MEN-1). Clinical features of MEN-1 include gastrinoma or other islet cell tumor, hyperparathyroidism, and anterior pituitary tumors. ZES should be especially considered in a patient with multiple, refractory, or recurrent peptic ulcer disease, especially if accompanied by diarrhea or hypercalcemia. Diarrhea is often a predominant symptom and is caused by the large volume of acid that inactivates pancreatic lipase and damages the absorptive mucosa of the proximal gut. Tests to diagnose ZES include serum gastrin radioimmunoassay, secretin stimulation test, somatostatin receptor scintigraphy, and endoscopic ultrasound. Almost all gastrinomas contain somatostatin receptors on the gastrin cells and somatostatin scintigraphy using [111In-DPTA-Dphe1]-octreotide is considered the initial localization study of choice. It has 71% sensitivity and 86% specificity for primary tumors and 92% sensitivity for detection of metastatic disease.

References

1. Murugesan S.V., Varro A., Pritchard D.M. Review article: Strategies to determine whether hypergastrinaemia is due to Zollinger-Ellison syndrome rather than a more common benign cause. Aliment Pharmacol. Ther. 2009;29:1055-68.

2. Jensen R.T., Niederle B., Mitry E., et al. Frascati Consensus Conference; European Neuroendocrine Tumor Society. Gastrinoma (duodenal and pancreatic). Neuroendocrinology 2006;84:173-82.

3. Hung, P.D., Schubert, M.L., Mihas, A.A. Zollinger-Ellison Syndrome. Current Treatment Options in Gastroenterology 2003;6:163-70.

4. Gibril F., Reynolds J.C., Doppman J.L., et al. Somatostatin receptor scintigraphy: Its sensitivity compared with that of other imaging methods in detecting primary and metastatic gastrinomas - A prospective study. Ann. Intern. Med. 1996;125:26-34.

5. Hung, P.D., Schubert, M.L., Mihas, A.A. Zollinger-Ellison Syndrome. Current Treatment Options in Gastroenterology 2003;6:163-70. 

ANSWER: D

Critique

The patient is most likely to have Zollinger-Ellison syndrome (ZES), a condition caused by a gastrinoma. In 25% of cases, ZES is associated with multiple endocrine neoplasia type 1 (MEN-1). Clinical features of MEN-1 include gastrinoma or other islet cell tumor, hyperparathyroidism, and anterior pituitary tumors. ZES should be especially considered in a patient with multiple, refractory, or recurrent peptic ulcer disease, especially if accompanied by diarrhea or hypercalcemia. Diarrhea is often a predominant symptom and is caused by the large volume of acid that inactivates pancreatic lipase and damages the absorptive mucosa of the proximal gut. Tests to diagnose ZES include serum gastrin radioimmunoassay, secretin stimulation test, somatostatin receptor scintigraphy, and endoscopic ultrasound. Almost all gastrinomas contain somatostatin receptors on the gastrin cells and somatostatin scintigraphy using [111In-DPTA-Dphe1]-octreotide is considered the initial localization study of choice. It has 71% sensitivity and 86% specificity for primary tumors and 92% sensitivity for detection of metastatic disease.

References

1. Murugesan S.V., Varro A., Pritchard D.M. Review article: Strategies to determine whether hypergastrinaemia is due to Zollinger-Ellison syndrome rather than a more common benign cause. Aliment Pharmacol. Ther. 2009;29:1055-68.

2. Jensen R.T., Niederle B., Mitry E., et al. Frascati Consensus Conference; European Neuroendocrine Tumor Society. Gastrinoma (duodenal and pancreatic). Neuroendocrinology 2006;84:173-82.

3. Hung, P.D., Schubert, M.L., Mihas, A.A. Zollinger-Ellison Syndrome. Current Treatment Options in Gastroenterology 2003;6:163-70.

4. Gibril F., Reynolds J.C., Doppman J.L., et al. Somatostatin receptor scintigraphy: Its sensitivity compared with that of other imaging methods in detecting primary and metastatic gastrinomas - A prospective study. Ann. Intern. Med. 1996;125:26-34.

5. Hung, P.D., Schubert, M.L., Mihas, A.A. Zollinger-Ellison Syndrome. Current Treatment Options in Gastroenterology 2003;6:163-70. 

ANSWER: D

Critique

The patient is most likely to have Zollinger-Ellison syndrome (ZES), a condition caused by a gastrinoma. In 25% of cases, ZES is associated with multiple endocrine neoplasia type 1 (MEN-1). Clinical features of MEN-1 include gastrinoma or other islet cell tumor, hyperparathyroidism, and anterior pituitary tumors. ZES should be especially considered in a patient with multiple, refractory, or recurrent peptic ulcer disease, especially if accompanied by diarrhea or hypercalcemia. Diarrhea is often a predominant symptom and is caused by the large volume of acid that inactivates pancreatic lipase and damages the absorptive mucosa of the proximal gut. Tests to diagnose ZES include serum gastrin radioimmunoassay, secretin stimulation test, somatostatin receptor scintigraphy, and endoscopic ultrasound. Almost all gastrinomas contain somatostatin receptors on the gastrin cells and somatostatin scintigraphy using [111In-DPTA-Dphe1]-octreotide is considered the initial localization study of choice. It has 71% sensitivity and 86% specificity for primary tumors and 92% sensitivity for detection of metastatic disease.

References

1. Murugesan S.V., Varro A., Pritchard D.M. Review article: Strategies to determine whether hypergastrinaemia is due to Zollinger-Ellison syndrome rather than a more common benign cause. Aliment Pharmacol. Ther. 2009;29:1055-68.

2. Jensen R.T., Niederle B., Mitry E., et al. Frascati Consensus Conference; European Neuroendocrine Tumor Society. Gastrinoma (duodenal and pancreatic). Neuroendocrinology 2006;84:173-82.

3. Hung, P.D., Schubert, M.L., Mihas, A.A. Zollinger-Ellison Syndrome. Current Treatment Options in Gastroenterology 2003;6:163-70.

4. Gibril F., Reynolds J.C., Doppman J.L., et al. Somatostatin receptor scintigraphy: Its sensitivity compared with that of other imaging methods in detecting primary and metastatic gastrinomas - A prospective study. Ann. Intern. Med. 1996;125:26-34.

5. Hung, P.D., Schubert, M.L., Mihas, A.A. Zollinger-Ellison Syndrome. Current Treatment Options in Gastroenterology 2003;6:163-70. 

ANSWER: D

Critique

Cough is considered to be one of the atypical manifestations of reflux disease. The mechanisms include regurgitation with tracheal aspiration of gastric content, but also triggering of reflex bronchial reactivity with small amounts of acid in the distal esophagus in predisposed individuals. However, environmental allergens, postnasal drip, and airway disorders can also trigger chronic cough. Upper endoscopy with esophageal biopsies may demonstrate reflux esophagitis, but this does not establish whether cough is triggered by reflux events. A solid bolus barium swallow is useful in the evaluation of esophageal dysphagia. Impedance planimetry assesses biomechanical properties of the esophageal wall, and does not help assess the role of reflux in chronic cough. Esophageal high-resolution manometry will demonstrate esophageal motor patterns, but does not determine causality of chronic cough. Wireless pH testing off PPI therapy has the potential to determine whether cough events correlate with acidic reflux events. Some investigators have combined this with a cough monitor that can precisely time cough events, allowing for more accurate assessments of the association between cough and reflux events.

ANSWER: D

Critique

Cough is considered to be one of the atypical manifestations of reflux disease. The mechanisms include regurgitation with tracheal aspiration of gastric content, but also triggering of reflex bronchial reactivity with small amounts of acid in the distal esophagus in predisposed individuals. However, environmental allergens, postnasal drip, and airway disorders can also trigger chronic cough. Upper endoscopy with esophageal biopsies may demonstrate reflux esophagitis, but this does not establish whether cough is triggered by reflux events. A solid bolus barium swallow is useful in the evaluation of esophageal dysphagia. Impedance planimetry assesses biomechanical properties of the esophageal wall, and does not help assess the role of reflux in chronic cough. Esophageal high-resolution manometry will demonstrate esophageal motor patterns, but does not determine causality of chronic cough. Wireless pH testing off PPI therapy has the potential to determine whether cough events correlate with acidic reflux events. Some investigators have combined this with a cough monitor that can precisely time cough events, allowing for more accurate assessments of the association between cough and reflux events.

ANSWER: D

Critique

Cough is considered to be one of the atypical manifestations of reflux disease. The mechanisms include regurgitation with tracheal aspiration of gastric content, but also triggering of reflex bronchial reactivity with small amounts of acid in the distal esophagus in predisposed individuals. However, environmental allergens, postnasal drip, and airway disorders can also trigger chronic cough. Upper endoscopy with esophageal biopsies may demonstrate reflux esophagitis, but this does not establish whether cough is triggered by reflux events. A solid bolus barium swallow is useful in the evaluation of esophageal dysphagia. Impedance planimetry assesses biomechanical properties of the esophageal wall, and does not help assess the role of reflux in chronic cough. Esophageal high-resolution manometry will demonstrate esophageal motor patterns, but does not determine causality of chronic cough. Wireless pH testing off PPI therapy has the potential to determine whether cough events correlate with acidic reflux events. Some investigators have combined this with a cough monitor that can precisely time cough events, allowing for more accurate assessments of the association between cough and reflux events.

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 because of increasing antibiotic resistance. The eradication rate of standard triple therapy consisting of a PPI 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 to be 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.

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 because of increasing antibiotic resistance. The eradication rate of standard triple therapy consisting of a PPI 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 to be 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.

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 because of increasing antibiotic resistance. The eradication rate of standard triple therapy consisting of a PPI 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 to be 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.

ANSWER: D

Critique

The presentation is one of intermittent solid food dysphagia in the setting of frequent heartburn in a young white male. The differential diagnosis includes reflux esophagitis and peptic stricture, as well as eosinophilic esophagitis. Sometimes, the two conditions overlap. Empiric proton pump inhibitor therapy is of value in clarifying the diagnosis of gastroesophageal reflux disease in patients with typical symptoms of heartburn and regurgitation. This is because the likelihood of gastroesophageal reflux disease is very high in patients with typical reflux symptoms. However, in this setting eosinophilic esophagitis needs to be excluded. So the optimal approach is to initiate proton pump inhibitor therapy, and then inspect and biopsy the esophagus. Treatments specific for eosinophilic esophagitis (topical fluticasone, montelukast) will only be indicated if the diagnosis of eosinophilic esophagitis is confirmed.

Prednisone is not utilized often orally for the management of eosinophilic esophagitis. Baclofen, a GABA-B receptor agonist, has been demonstrated to reduce the frequency of transient lower esophageal sphincter relaxations and improve residual symptoms in patients on PPI therapy.

ANSWER: D

Critique

The presentation is one of intermittent solid food dysphagia in the setting of frequent heartburn in a young white male. The differential diagnosis includes reflux esophagitis and peptic stricture, as well as eosinophilic esophagitis. Sometimes, the two conditions overlap. Empiric proton pump inhibitor therapy is of value in clarifying the diagnosis of gastroesophageal reflux disease in patients with typical symptoms of heartburn and regurgitation. This is because the likelihood of gastroesophageal reflux disease is very high in patients with typical reflux symptoms. However, in this setting eosinophilic esophagitis needs to be excluded. So the optimal approach is to initiate proton pump inhibitor therapy, and then inspect and biopsy the esophagus. Treatments specific for eosinophilic esophagitis (topical fluticasone, montelukast) will only be indicated if the diagnosis of eosinophilic esophagitis is confirmed.

Prednisone is not utilized often orally for the management of eosinophilic esophagitis. Baclofen, a GABA-B receptor agonist, has been demonstrated to reduce the frequency of transient lower esophageal sphincter relaxations and improve residual symptoms in patients on PPI therapy.

ANSWER: D

Critique

The presentation is one of intermittent solid food dysphagia in the setting of frequent heartburn in a young white male. The differential diagnosis includes reflux esophagitis and peptic stricture, as well as eosinophilic esophagitis. Sometimes, the two conditions overlap. Empiric proton pump inhibitor therapy is of value in clarifying the diagnosis of gastroesophageal reflux disease in patients with typical symptoms of heartburn and regurgitation. This is because the likelihood of gastroesophageal reflux disease is very high in patients with typical reflux symptoms. However, in this setting eosinophilic esophagitis needs to be excluded. So the optimal approach is to initiate proton pump inhibitor therapy, and then inspect and biopsy the esophagus. Treatments specific for eosinophilic esophagitis (topical fluticasone, montelukast) will only be indicated if the diagnosis of eosinophilic esophagitis is confirmed.

Prednisone is not utilized often orally for the management of eosinophilic esophagitis. Baclofen, a GABA-B receptor agonist, has been demonstrated to reduce the frequency of transient lower esophageal sphincter relaxations and improve residual symptoms in patients on PPI therapy.