DDSEP® 8 Quick Quiz

Q2. Correct answer: C  
 
Rationale  
Vitamin B12 absorption requires intrinsic factor to bind B12 to facilitate absorption in the terminal ileum. Any interruption of terminal ileal absorptive capacity can thus lead to vitamin B12 deficiency (e.g. Crohn's disease, ileal resection). Intrinsic factor is produced by parietal cells, so any condition that leads to decreased parietal cell mass or function can lead to vitamin B12 deficiency (e.g. atrophic gastritis). In order for intrinsic factor to bind vitamin B12, B12 must first be released from binding with the R-protein, which occurs via pancreatic protease breakdown of the R-protein. Patients with chronic pancreatitis are not able to break down the R-protein as efficiently, and thus can develop vitamin B12 deficiency.  
 
References  
1. Green R. Vitamin B12 deficiency from the perspective of a practicing hematologist. Blood. 2017;129(19):2603-11.

2. Gueant GL, at al. Malabsorption of vitamin B12 in pancreatic insufficiency of the adult and of the child. Pancreas 1990 Sep;5(5):559-67. 
 
[email protected]

Q2. Correct answer: C  
 
Rationale  
Vitamin B12 absorption requires intrinsic factor to bind B12 to facilitate absorption in the terminal ileum. Any interruption of terminal ileal absorptive capacity can thus lead to vitamin B12 deficiency (e.g. Crohn's disease, ileal resection). Intrinsic factor is produced by parietal cells, so any condition that leads to decreased parietal cell mass or function can lead to vitamin B12 deficiency (e.g. atrophic gastritis). In order for intrinsic factor to bind vitamin B12, B12 must first be released from binding with the R-protein, which occurs via pancreatic protease breakdown of the R-protein. Patients with chronic pancreatitis are not able to break down the R-protein as efficiently, and thus can develop vitamin B12 deficiency.  
 
References  
1. Green R. Vitamin B12 deficiency from the perspective of a practicing hematologist. Blood. 2017;129(19):2603-11.

2. Gueant GL, at al. Malabsorption of vitamin B12 in pancreatic insufficiency of the adult and of the child. Pancreas 1990 Sep;5(5):559-67. 
 
[email protected]

Q2. Correct answer: C  
 
Rationale  
Vitamin B12 absorption requires intrinsic factor to bind B12 to facilitate absorption in the terminal ileum. Any interruption of terminal ileal absorptive capacity can thus lead to vitamin B12 deficiency (e.g. Crohn's disease, ileal resection). Intrinsic factor is produced by parietal cells, so any condition that leads to decreased parietal cell mass or function can lead to vitamin B12 deficiency (e.g. atrophic gastritis). In order for intrinsic factor to bind vitamin B12, B12 must first be released from binding with the R-protein, which occurs via pancreatic protease breakdown of the R-protein. Patients with chronic pancreatitis are not able to break down the R-protein as efficiently, and thus can develop vitamin B12 deficiency.  
 
References  
1. Green R. Vitamin B12 deficiency from the perspective of a practicing hematologist. Blood. 2017;129(19):2603-11.

2. Gueant GL, at al. Malabsorption of vitamin B12 in pancreatic insufficiency of the adult and of the child. Pancreas 1990 Sep;5(5):559-67. 
 
[email protected]

Q1. Correct Answer: B  
 
Rationale  
In patients 70 years or older with a history of gastrointestinal bleeding and on chronic NSAIDs, the use of a PPI can reduce the risk of recurrent bleeding. In the setting of an acute bleeding episode, aspirin should resume within 7 days of adequate hemostasis. However, there are no advantages of enteric coated or buffered aspirin in reducing the risk of recurrent bleeding. 
  
References  
1. Kelly JP, Kaufmann DW, et al. Risk of aspirin-associated major upper-gastrointestinal bleeding with enteric-coated or buffered product. Lancet 1996;348:1413-6.  
2. Laine L, Jensen D. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107:345-60.

Q1. Correct Answer: B  
 
Rationale  
In patients 70 years or older with a history of gastrointestinal bleeding and on chronic NSAIDs, the use of a PPI can reduce the risk of recurrent bleeding. In the setting of an acute bleeding episode, aspirin should resume within 7 days of adequate hemostasis. However, there are no advantages of enteric coated or buffered aspirin in reducing the risk of recurrent bleeding. 
  
References  
1. Kelly JP, Kaufmann DW, et al. Risk of aspirin-associated major upper-gastrointestinal bleeding with enteric-coated or buffered product. Lancet 1996;348:1413-6.  
2. Laine L, Jensen D. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107:345-60.

Q1. Correct Answer: B  
 
Rationale  
In patients 70 years or older with a history of gastrointestinal bleeding and on chronic NSAIDs, the use of a PPI can reduce the risk of recurrent bleeding. In the setting of an acute bleeding episode, aspirin should resume within 7 days of adequate hemostasis. However, there are no advantages of enteric coated or buffered aspirin in reducing the risk of recurrent bleeding. 
  
References  
1. Kelly JP, Kaufmann DW, et al. Risk of aspirin-associated major upper-gastrointestinal bleeding with enteric-coated or buffered product. Lancet 1996;348:1413-6.  
2. Laine L, Jensen D. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107:345-60.

Q2. Correct Answer: A  
 
Rationale:  
In a patient with chronic pancreatitis and a pancreatic mass, the most likely etiology is adenocarcinoma. This patient has radiologically resectable pancreas cancer. There is no evidence of lymphadenopathy or vascular invasion. Performing an ERCP with stent placement to relieve biliary obstruction has not been shown to be of benefit in patients with a resectable pancreatic mass. In fact, surgical outcomes are worse if a stent is placed in the bile duct. Surgical consultation should be obtained and the patient should undergo pancreaticoduodenectomy. EUS is sometimes done, but most cases of resectable disease should go straight to surgery.  
 
Reference  
Ghaneh P, et al. Biology and management of pancreatic cancer. Gut 2007;56(8)1134-52. 
 
[email protected]

Q2. Correct Answer: A  
 
Rationale:  
In a patient with chronic pancreatitis and a pancreatic mass, the most likely etiology is adenocarcinoma. This patient has radiologically resectable pancreas cancer. There is no evidence of lymphadenopathy or vascular invasion. Performing an ERCP with stent placement to relieve biliary obstruction has not been shown to be of benefit in patients with a resectable pancreatic mass. In fact, surgical outcomes are worse if a stent is placed in the bile duct. Surgical consultation should be obtained and the patient should undergo pancreaticoduodenectomy. EUS is sometimes done, but most cases of resectable disease should go straight to surgery.  
 
Reference  
Ghaneh P, et al. Biology and management of pancreatic cancer. Gut 2007;56(8)1134-52. 
 
[email protected]

Q2. Correct Answer: A  
 
Rationale:  
In a patient with chronic pancreatitis and a pancreatic mass, the most likely etiology is adenocarcinoma. This patient has radiologically resectable pancreas cancer. There is no evidence of lymphadenopathy or vascular invasion. Performing an ERCP with stent placement to relieve biliary obstruction has not been shown to be of benefit in patients with a resectable pancreatic mass. In fact, surgical outcomes are worse if a stent is placed in the bile duct. Surgical consultation should be obtained and the patient should undergo pancreaticoduodenectomy. EUS is sometimes done, but most cases of resectable disease should go straight to surgery.  
 
Reference  
Ghaneh P, et al. Biology and management of pancreatic cancer. Gut 2007;56(8)1134-52. 
 
[email protected]

Q1. Correct Answer: B  
 
Rationale:  
Risk factors for gallstone formation include increased age, female gender, pregnancy, dyslipidemia, diabetes, obesity and rapid weight loss - especially after gastric bypass surgery. Medications such as hormone replacement therapies/ oral contraceptive agents, fibrates, somatostatin analogues also increase gallstone risk. Currently, there is evidence suggesting potential benefit of prophylactic cholecystectomy during Roux-en-Y gastric bypass, given the potential risk of gallstone formation with rapid weight loss following surgery. However, there is also data from randomized controlled trials that the use of ursodeoxycholic acid following surgery may help reduce risk of gallstone formation for this group of patients.  
 
Reference: 
Stokes et al. Ursodeoxycholic acid and diets higher in fat prevent gallbladder Stones during weight loss: A meta-analysis of randomized controlled trials. 2014. Clin Gastroenterol Hepatol. 2014;12:1090-100. 

Q1. Correct Answer: B  
 
Rationale:  
Risk factors for gallstone formation include increased age, female gender, pregnancy, dyslipidemia, diabetes, obesity and rapid weight loss - especially after gastric bypass surgery. Medications such as hormone replacement therapies/ oral contraceptive agents, fibrates, somatostatin analogues also increase gallstone risk. Currently, there is evidence suggesting potential benefit of prophylactic cholecystectomy during Roux-en-Y gastric bypass, given the potential risk of gallstone formation with rapid weight loss following surgery. However, there is also data from randomized controlled trials that the use of ursodeoxycholic acid following surgery may help reduce risk of gallstone formation for this group of patients.  
 
Reference: 
Stokes et al. Ursodeoxycholic acid and diets higher in fat prevent gallbladder Stones during weight loss: A meta-analysis of randomized controlled trials. 2014. Clin Gastroenterol Hepatol. 2014;12:1090-100. 

Q1. Correct Answer: B  
 
Rationale:  
Risk factors for gallstone formation include increased age, female gender, pregnancy, dyslipidemia, diabetes, obesity and rapid weight loss - especially after gastric bypass surgery. Medications such as hormone replacement therapies/ oral contraceptive agents, fibrates, somatostatin analogues also increase gallstone risk. Currently, there is evidence suggesting potential benefit of prophylactic cholecystectomy during Roux-en-Y gastric bypass, given the potential risk of gallstone formation with rapid weight loss following surgery. However, there is also data from randomized controlled trials that the use of ursodeoxycholic acid following surgery may help reduce risk of gallstone formation for this group of patients.  
 
Reference: 
Stokes et al. Ursodeoxycholic acid and diets higher in fat prevent gallbladder Stones during weight loss: A meta-analysis of randomized controlled trials. 2014. Clin Gastroenterol Hepatol. 2014;12:1090-100. 

Q2. Correct answer: E  
 
Rationale:  
Radiographic evaluation is commonly employed in the diagnosis and management of patients with lower GI bleeding. CT scans, tagged red blood cell scintigraphy, and angiography all have roles in the care of these patients. Though tagged red blood cell scintigraphy is the most sensitive modality at detecting active bleeding, requiring rates from 0.05-0.1 cc/min, it is relatively poor at localizing the bleeding, accurately predicting the location in only 60%-70% of cases. CT scans have the advantage of being quickly performed and are widely available. If extravasation is seen, its location is also accurately determined. It is not as sensitive as red blood cell scintigraphy, however, and requires bleeding rates of 0.3-0.5 cc/min to be positive. Angiography has the advantage of being both diagnostic and potentially therapeutic. It is best performed in sicker patients with hypotension and high transfusion demands as it is higher yield in these situations. Angiography is the least sensitive of these modalities, requiring bleeding rates between 0.5 and 1 cc/min to be positive.  

Reference:  
1. Strate LL, Naumann CR. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clin Gastroenterol Hepatol. 2010 Apr;8(4):333-43. 

[email protected]

Q2. Correct answer: E  
 
Rationale:  
Radiographic evaluation is commonly employed in the diagnosis and management of patients with lower GI bleeding. CT scans, tagged red blood cell scintigraphy, and angiography all have roles in the care of these patients. Though tagged red blood cell scintigraphy is the most sensitive modality at detecting active bleeding, requiring rates from 0.05-0.1 cc/min, it is relatively poor at localizing the bleeding, accurately predicting the location in only 60%-70% of cases. CT scans have the advantage of being quickly performed and are widely available. If extravasation is seen, its location is also accurately determined. It is not as sensitive as red blood cell scintigraphy, however, and requires bleeding rates of 0.3-0.5 cc/min to be positive. Angiography has the advantage of being both diagnostic and potentially therapeutic. It is best performed in sicker patients with hypotension and high transfusion demands as it is higher yield in these situations. Angiography is the least sensitive of these modalities, requiring bleeding rates between 0.5 and 1 cc/min to be positive.  

Reference:  
1. Strate LL, Naumann CR. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clin Gastroenterol Hepatol. 2010 Apr;8(4):333-43. 

[email protected]

Q2. Correct answer: E  
 
Rationale:  
Radiographic evaluation is commonly employed in the diagnosis and management of patients with lower GI bleeding. CT scans, tagged red blood cell scintigraphy, and angiography all have roles in the care of these patients. Though tagged red blood cell scintigraphy is the most sensitive modality at detecting active bleeding, requiring rates from 0.05-0.1 cc/min, it is relatively poor at localizing the bleeding, accurately predicting the location in only 60%-70% of cases. CT scans have the advantage of being quickly performed and are widely available. If extravasation is seen, its location is also accurately determined. It is not as sensitive as red blood cell scintigraphy, however, and requires bleeding rates of 0.3-0.5 cc/min to be positive. Angiography has the advantage of being both diagnostic and potentially therapeutic. It is best performed in sicker patients with hypotension and high transfusion demands as it is higher yield in these situations. Angiography is the least sensitive of these modalities, requiring bleeding rates between 0.5 and 1 cc/min to be positive.  

Reference:  
1. Strate LL, Naumann CR. The role of colonoscopy and radiological procedures in the management of acute lower intestinal bleeding. Clin Gastroenterol Hepatol. 2010 Apr;8(4):333-43. 

[email protected]

Q1. Correct answer: C 
 
Rationale: 
The two standard treatment regimens for AIH include corticosteroids (prednisone or prednisolone) alone, or corticosteroids combined with azathioprine. The combination regimen allows for a lower dose of steroids and fewer side effects with the same therapeutic efficacy. This patient appears to have developed azathioprine-induced pancreatitis, which is a rare complication more often seen in patients with Crohn's disease treated with azathioprine. In patients who are intolerant of azathioprine, mycophenolate mofetil and calcineurin inhibitors have been used with success.  
There are data supporting the use of budesonide in place of prednisone, but this regimen is not as effective in patients with cirrhosis or advanced fibrosis, so it is reserved for patients with lesser degrees of liver fibrosis. The TNF-alpha inhibitors are not used to treat AIH, nor is the IL-1 inhibitor anakinra. 
 
References: 
1. Czaja AJ. Diagnosis and management of autoimmune hepatitis: Current status and future directions. Gut Liver. 2016;10:177-203. 
2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Autoimmune Hepatitis. J Hepatol. 2015:63:971-1004. 
3. Manns MP, et al. Diagnosis and management of autoimmune hepatitis. Hepatology. 2010;51:1-31.

Q1. Correct answer: C 
 
Rationale: 
The two standard treatment regimens for AIH include corticosteroids (prednisone or prednisolone) alone, or corticosteroids combined with azathioprine. The combination regimen allows for a lower dose of steroids and fewer side effects with the same therapeutic efficacy. This patient appears to have developed azathioprine-induced pancreatitis, which is a rare complication more often seen in patients with Crohn's disease treated with azathioprine. In patients who are intolerant of azathioprine, mycophenolate mofetil and calcineurin inhibitors have been used with success.  
There are data supporting the use of budesonide in place of prednisone, but this regimen is not as effective in patients with cirrhosis or advanced fibrosis, so it is reserved for patients with lesser degrees of liver fibrosis. The TNF-alpha inhibitors are not used to treat AIH, nor is the IL-1 inhibitor anakinra. 
 
References: 
1. Czaja AJ. Diagnosis and management of autoimmune hepatitis: Current status and future directions. Gut Liver. 2016;10:177-203. 
2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Autoimmune Hepatitis. J Hepatol. 2015:63:971-1004. 
3. Manns MP, et al. Diagnosis and management of autoimmune hepatitis. Hepatology. 2010;51:1-31.

Q1. Correct answer: C 
 
Rationale: 
The two standard treatment regimens for AIH include corticosteroids (prednisone or prednisolone) alone, or corticosteroids combined with azathioprine. The combination regimen allows for a lower dose of steroids and fewer side effects with the same therapeutic efficacy. This patient appears to have developed azathioprine-induced pancreatitis, which is a rare complication more often seen in patients with Crohn's disease treated with azathioprine. In patients who are intolerant of azathioprine, mycophenolate mofetil and calcineurin inhibitors have been used with success.  
There are data supporting the use of budesonide in place of prednisone, but this regimen is not as effective in patients with cirrhosis or advanced fibrosis, so it is reserved for patients with lesser degrees of liver fibrosis. The TNF-alpha inhibitors are not used to treat AIH, nor is the IL-1 inhibitor anakinra. 
 
References: 
1. Czaja AJ. Diagnosis and management of autoimmune hepatitis: Current status and future directions. Gut Liver. 2016;10:177-203. 
2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Autoimmune Hepatitis. J Hepatol. 2015:63:971-1004. 
3. Manns MP, et al. Diagnosis and management of autoimmune hepatitis. Hepatology. 2010;51:1-31.

Q2. Correct answer: C  
 
Rationale  
Oral iron, and not infusions, are associated with peptic ulcer disease. Sumatriptan alone, or tamoxifen, are not known to cause ulcers.  
 
Reference: 
Miyake K., Kusunoki M., Shinji Y., et al. Bisphosphonate increases risk of gastroduodenal ulcer in rheumatoid arthritis patients on long-term nonsteroidal anti-inflammatory drug therapy. J Gastroenterol. 2009;44(2):113. 
 
[email protected]

Q2. Correct answer: C  
 
Rationale  
Oral iron, and not infusions, are associated with peptic ulcer disease. Sumatriptan alone, or tamoxifen, are not known to cause ulcers.  
 
Reference: 
Miyake K., Kusunoki M., Shinji Y., et al. Bisphosphonate increases risk of gastroduodenal ulcer in rheumatoid arthritis patients on long-term nonsteroidal anti-inflammatory drug therapy. J Gastroenterol. 2009;44(2):113. 
 
[email protected]

Q2. Correct answer: C  
 
Rationale  
Oral iron, and not infusions, are associated with peptic ulcer disease. Sumatriptan alone, or tamoxifen, are not known to cause ulcers.  
 
Reference: 
Miyake K., Kusunoki M., Shinji Y., et al. Bisphosphonate increases risk of gastroduodenal ulcer in rheumatoid arthritis patients on long-term nonsteroidal anti-inflammatory drug therapy. J Gastroenterol. 2009;44(2):113. 
 
[email protected]

Q1. Correct answer: D  
 
Rationale  
Achalasia and pseudoachalasia are on the differential. Given the advanced age, progressive course, and significant weight loss, an endoscopy with careful attention to GEJ should be performed to rule out malignancy causing a pseudoachalasia presentation (answer D). Manometry should be done after the endoscopy to confirm and subtype the achalasia. If achalasia is confirmed and malignancy is ruled out, myotomy either with a modified Heller approach or peroral endoscopic myotomy would be appropriate in a surgically fit patient (answer A) and botulinum toxin may be considered in a poor surgical candidate. Medications such as calcium channel blockers and nitrates (answer C) are not definitive treatment options for achalasia and not warranted in malignancy. Additional information is needed on the diagnosis and prognosis prior to committing to a G tube (answer E).  
 
Reference : 
Zaninotto G., Bennett C., Boeckxstaens G., et al. The 2018 ISDE achalasia guidelines. Dis Esophagus. 2018 Sep 1;31(9).

Q1. Correct answer: D  
 
Rationale  
Achalasia and pseudoachalasia are on the differential. Given the advanced age, progressive course, and significant weight loss, an endoscopy with careful attention to GEJ should be performed to rule out malignancy causing a pseudoachalasia presentation (answer D). Manometry should be done after the endoscopy to confirm and subtype the achalasia. If achalasia is confirmed and malignancy is ruled out, myotomy either with a modified Heller approach or peroral endoscopic myotomy would be appropriate in a surgically fit patient (answer A) and botulinum toxin may be considered in a poor surgical candidate. Medications such as calcium channel blockers and nitrates (answer C) are not definitive treatment options for achalasia and not warranted in malignancy. Additional information is needed on the diagnosis and prognosis prior to committing to a G tube (answer E).  
 
Reference : 
Zaninotto G., Bennett C., Boeckxstaens G., et al. The 2018 ISDE achalasia guidelines. Dis Esophagus. 2018 Sep 1;31(9).

Q1. Correct answer: D  
 
Rationale  
Achalasia and pseudoachalasia are on the differential. Given the advanced age, progressive course, and significant weight loss, an endoscopy with careful attention to GEJ should be performed to rule out malignancy causing a pseudoachalasia presentation (answer D). Manometry should be done after the endoscopy to confirm and subtype the achalasia. If achalasia is confirmed and malignancy is ruled out, myotomy either with a modified Heller approach or peroral endoscopic myotomy would be appropriate in a surgically fit patient (answer A) and botulinum toxin may be considered in a poor surgical candidate. Medications such as calcium channel blockers and nitrates (answer C) are not definitive treatment options for achalasia and not warranted in malignancy. Additional information is needed on the diagnosis and prognosis prior to committing to a G tube (answer E).  
 
Reference : 
Zaninotto G., Bennett C., Boeckxstaens G., et al. The 2018 ISDE achalasia guidelines. Dis Esophagus. 2018 Sep 1;31(9).

Q2. Correct Answer: C  

Rationale 
This patient has a main duct IPMN, which has a high potential for malignant transformation and should be resected if possible. Resection is also indicated for branch-duct IPMN's, which are symptomatic (e.g. pancreatitis), associated with obstructive jaundice or main duct involvement, have a solid component within the cyst, or have concerning features on EUS-FNA.  
 
Reference  
1. Elta GH, et al, ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts. Am J Gastroenterol. 2018;113:464-79. 
 
[email protected]

Q2. Correct Answer: C  

Rationale 
This patient has a main duct IPMN, which has a high potential for malignant transformation and should be resected if possible. Resection is also indicated for branch-duct IPMN's, which are symptomatic (e.g. pancreatitis), associated with obstructive jaundice or main duct involvement, have a solid component within the cyst, or have concerning features on EUS-FNA.  
 
Reference  
1. Elta GH, et al, ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts. Am J Gastroenterol. 2018;113:464-79. 
 
[email protected]

Q2. Correct Answer: C  

Rationale 
This patient has a main duct IPMN, which has a high potential for malignant transformation and should be resected if possible. Resection is also indicated for branch-duct IPMN's, which are symptomatic (e.g. pancreatitis), associated with obstructive jaundice or main duct involvement, have a solid component within the cyst, or have concerning features on EUS-FNA.  
 
Reference  
1. Elta GH, et al, ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts. Am J Gastroenterol. 2018;113:464-79. 
 
[email protected]

Q1. Correct Answer: D 

Rationale  
The severe reflux may be due to the hiatal hernia and worsened by the obesity. This patient has medically complicated obesity and thus bariatric surgery is an option. A gastric bypass in this situation offers the best anti-reflux procedure for this patient. A fundoplication in the setting of obesity has a higher rate of recurrence of symptoms (Answers A, B). While a gastric sleeve is an option for the obesity, a gastric sleeve (Answer E) may cause de novo reflux or worsen pre-existing symptoms. Magnetic sphincter augmentation (Answer C) has demonstrated promising results in patients with a BMI less than 35 and hiatal hernia less than 3 cm. Data are not available for patients with higher BMIs.  
 
References  
1. Abdelrahman T, Latif A, Chan DS, et al. Outcomes after laparoscopic anti-reflux surgery related to obesity: A systematic review and meta-analysis. Int J Surg. 2018 Mar;51:76-82.  
2. Stenard F, Iannelli A. Laparoscopic sleeve gastrectomy and gastroesophageal reflux. World J Gastroenterol. 2015 Sep 28;21(36):10348-57. 
 

Q1. Correct Answer: D 

Rationale  
The severe reflux may be due to the hiatal hernia and worsened by the obesity. This patient has medically complicated obesity and thus bariatric surgery is an option. A gastric bypass in this situation offers the best anti-reflux procedure for this patient. A fundoplication in the setting of obesity has a higher rate of recurrence of symptoms (Answers A, B). While a gastric sleeve is an option for the obesity, a gastric sleeve (Answer E) may cause de novo reflux or worsen pre-existing symptoms. Magnetic sphincter augmentation (Answer C) has demonstrated promising results in patients with a BMI less than 35 and hiatal hernia less than 3 cm. Data are not available for patients with higher BMIs.  
 
References  
1. Abdelrahman T, Latif A, Chan DS, et al. Outcomes after laparoscopic anti-reflux surgery related to obesity: A systematic review and meta-analysis. Int J Surg. 2018 Mar;51:76-82.  
2. Stenard F, Iannelli A. Laparoscopic sleeve gastrectomy and gastroesophageal reflux. World J Gastroenterol. 2015 Sep 28;21(36):10348-57. 
 

Q1. Correct Answer: D 

Rationale  
The severe reflux may be due to the hiatal hernia and worsened by the obesity. This patient has medically complicated obesity and thus bariatric surgery is an option. A gastric bypass in this situation offers the best anti-reflux procedure for this patient. A fundoplication in the setting of obesity has a higher rate of recurrence of symptoms (Answers A, B). While a gastric sleeve is an option for the obesity, a gastric sleeve (Answer E) may cause de novo reflux or worsen pre-existing symptoms. Magnetic sphincter augmentation (Answer C) has demonstrated promising results in patients with a BMI less than 35 and hiatal hernia less than 3 cm. Data are not available for patients with higher BMIs.  
 
References  
1. Abdelrahman T, Latif A, Chan DS, et al. Outcomes after laparoscopic anti-reflux surgery related to obesity: A systematic review and meta-analysis. Int J Surg. 2018 Mar;51:76-82.  
2. Stenard F, Iannelli A. Laparoscopic sleeve gastrectomy and gastroesophageal reflux. World J Gastroenterol. 2015 Sep 28;21(36):10348-57.