DDSEP® 8 Quick Quiz

Rationale

The patient clinically has rumination syndrome or an adaptation to the belch reflex, with effortless regurgitation, with voluntary re-swallowing of the regurgitated material. Recurrent small bowel obstruction is less likely as the pattern of regurgitation is with almost every meal, within minutes and does not follow the typical pattern of a bowel obstruction. Idiopathic gastroparesis is less likely as the pattern of regurgitation is not consistent with gastroparesis, in addition she is not diabetic.

She has no psychiatric history and there are no findings suggestive of bulimia.
 

Reference

1. Marrero F.J., Shay S.S. Regurgitation and rumination. In: Richter, J.E. Castell, D.O., eds. The Esophagus, 5th ed. West Sussex, England: Wiley-Blackwell; 2012.

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Rationale

The patient clinically has rumination syndrome or an adaptation to the belch reflex, with effortless regurgitation, with voluntary re-swallowing of the regurgitated material. Recurrent small bowel obstruction is less likely as the pattern of regurgitation is with almost every meal, within minutes and does not follow the typical pattern of a bowel obstruction. Idiopathic gastroparesis is less likely as the pattern of regurgitation is not consistent with gastroparesis, in addition she is not diabetic.

She has no psychiatric history and there are no findings suggestive of bulimia.
 

Reference

1. Marrero F.J., Shay S.S. Regurgitation and rumination. In: Richter, J.E. Castell, D.O., eds. The Esophagus, 5th ed. West Sussex, England: Wiley-Blackwell; 2012.

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Rationale

The patient clinically has rumination syndrome or an adaptation to the belch reflex, with effortless regurgitation, with voluntary re-swallowing of the regurgitated material. Recurrent small bowel obstruction is less likely as the pattern of regurgitation is with almost every meal, within minutes and does not follow the typical pattern of a bowel obstruction. Idiopathic gastroparesis is less likely as the pattern of regurgitation is not consistent with gastroparesis, in addition she is not diabetic.

She has no psychiatric history and there are no findings suggestive of bulimia.
 

Reference

1. Marrero F.J., Shay S.S. Regurgitation and rumination. In: Richter, J.E. Castell, D.O., eds. The Esophagus, 5th ed. West Sussex, England: Wiley-Blackwell; 2012.

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Rationale

This patient’s symptoms are most concerning for Whipple’s disease in light of the diarrhea, weight loss, arthralgias, and CNS symptoms. This diagnosis requires identification of periodic acid-Schiff staining macrophages in the duodenal lamina propria. Further PCR analysis can also be used to identify RNA of the causative pathogen, Tropheryma whipplei. Congo Red staining is indicated if amyloidosis is suspected. Sudan staining is used to test stool for fat. Birefringence is used to detect crystals, most typically in synovial fluid. Immunohistochemistry has many applications and is commonly employed to evaluate for Helicobacter pylori.

Reference

1. Moos V., Schneider T. Changing paradigms in Whipple’s disease and infection with Tropheryma whipplei. Eur J Clin Microbiol Infect Dis. 2011;30(10):1151-8.

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Rationale

This patient’s symptoms are most concerning for Whipple’s disease in light of the diarrhea, weight loss, arthralgias, and CNS symptoms. This diagnosis requires identification of periodic acid-Schiff staining macrophages in the duodenal lamina propria. Further PCR analysis can also be used to identify RNA of the causative pathogen, Tropheryma whipplei. Congo Red staining is indicated if amyloidosis is suspected. Sudan staining is used to test stool for fat. Birefringence is used to detect crystals, most typically in synovial fluid. Immunohistochemistry has many applications and is commonly employed to evaluate for Helicobacter pylori.

Reference

1. Moos V., Schneider T. Changing paradigms in Whipple’s disease and infection with Tropheryma whipplei. Eur J Clin Microbiol Infect Dis. 2011;30(10):1151-8.

[email protected]

Rationale

This patient’s symptoms are most concerning for Whipple’s disease in light of the diarrhea, weight loss, arthralgias, and CNS symptoms. This diagnosis requires identification of periodic acid-Schiff staining macrophages in the duodenal lamina propria. Further PCR analysis can also be used to identify RNA of the causative pathogen, Tropheryma whipplei. Congo Red staining is indicated if amyloidosis is suspected. Sudan staining is used to test stool for fat. Birefringence is used to detect crystals, most typically in synovial fluid. Immunohistochemistry has many applications and is commonly employed to evaluate for Helicobacter pylori.

Reference

1. Moos V., Schneider T. Changing paradigms in Whipple’s disease and infection with Tropheryma whipplei. Eur J Clin Microbiol Infect Dis. 2011;30(10):1151-8.

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Correct Answer: B 
 
Rationale  
This patient has large varices, which should be treated. In patients with cirrhosis and medium/large varices that have never bled, nonselective beta-blockers reduce the risk of first variceal hemorrhage by 50%. In high-quality randomized-controlled trials, endoscopic variceal ligation (EVL) is as effective as nonselective beta-blockers in preventing first variceal hemorrhage. Therefore, either of these therapies should be used for the prevention of first variceal bleeding. In this case, propranolol is not the best choice in the setting of diabetes, asthma as well as a blood pressure and pulse that are low already. Endoscopic variceal band ligation would be preferred in this patient. It is also more effective than sclerotherapy and is associated with fewer side effects. TIPS would be effective, but more invasive and not first-line for treatment of nonbleeding varices and comes with increased risk of hepatic encephalopathy and potentially mortality. The combination of nadolol and endoscopic variceal band ligation may have more side effects without a further reduction in the risk of first variceal hemorrhage beyond either therapy alone. 
 
References  
1. Gluud L.L., Klingenberg S., Nikolova D., Gluud C. Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials. Am J Gastroenterol. 2007;102(12):2842-8.  
2. Gluud L.L., Krag A. Banding ligation versus betablockers for primary prevention in oesophageal varices in adults. Cochrane Database Syst Rev. 2012;8:CD004544. doi: 10.1002/14651858. CD004544. 
3. Villanueva C., Piqueras M., Aracil C., et al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol. 2006;45(4):560-7.

Correct Answer: B 
 
Rationale  
This patient has large varices, which should be treated. In patients with cirrhosis and medium/large varices that have never bled, nonselective beta-blockers reduce the risk of first variceal hemorrhage by 50%. In high-quality randomized-controlled trials, endoscopic variceal ligation (EVL) is as effective as nonselective beta-blockers in preventing first variceal hemorrhage. Therefore, either of these therapies should be used for the prevention of first variceal bleeding. In this case, propranolol is not the best choice in the setting of diabetes, asthma as well as a blood pressure and pulse that are low already. Endoscopic variceal band ligation would be preferred in this patient. It is also more effective than sclerotherapy and is associated with fewer side effects. TIPS would be effective, but more invasive and not first-line for treatment of nonbleeding varices and comes with increased risk of hepatic encephalopathy and potentially mortality. The combination of nadolol and endoscopic variceal band ligation may have more side effects without a further reduction in the risk of first variceal hemorrhage beyond either therapy alone. 
 
References  
1. Gluud L.L., Klingenberg S., Nikolova D., Gluud C. Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials. Am J Gastroenterol. 2007;102(12):2842-8.  
2. Gluud L.L., Krag A. Banding ligation versus betablockers for primary prevention in oesophageal varices in adults. Cochrane Database Syst Rev. 2012;8:CD004544. doi: 10.1002/14651858. CD004544. 
3. Villanueva C., Piqueras M., Aracil C., et al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol. 2006;45(4):560-7.

Correct Answer: B 
 
Rationale  
This patient has large varices, which should be treated. In patients with cirrhosis and medium/large varices that have never bled, nonselective beta-blockers reduce the risk of first variceal hemorrhage by 50%. In high-quality randomized-controlled trials, endoscopic variceal ligation (EVL) is as effective as nonselective beta-blockers in preventing first variceal hemorrhage. Therefore, either of these therapies should be used for the prevention of first variceal bleeding. In this case, propranolol is not the best choice in the setting of diabetes, asthma as well as a blood pressure and pulse that are low already. Endoscopic variceal band ligation would be preferred in this patient. It is also more effective than sclerotherapy and is associated with fewer side effects. TIPS would be effective, but more invasive and not first-line for treatment of nonbleeding varices and comes with increased risk of hepatic encephalopathy and potentially mortality. The combination of nadolol and endoscopic variceal band ligation may have more side effects without a further reduction in the risk of first variceal hemorrhage beyond either therapy alone. 
 
References  
1. Gluud L.L., Klingenberg S., Nikolova D., Gluud C. Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials. Am J Gastroenterol. 2007;102(12):2842-8.  
2. Gluud L.L., Krag A. Banding ligation versus betablockers for primary prevention in oesophageal varices in adults. Cochrane Database Syst Rev. 2012;8:CD004544. doi: 10.1002/14651858. CD004544. 
3. Villanueva C., Piqueras M., Aracil C., et al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol. 2006;45(4):560-7.

Correct Answer: A 
 
Rationale 
This patient has an idiopathic, nonNSAID, non-H. pylori-associated ulcer and should be on daily PPI indefinitely. These patients have a high rate of recurrent bleeding (42%) and mortality when followed prospectively without being on antisecretory therapy. Although no randomized trials have assessed the benefit of medical cotherapy in this population, antiulcer therapy seems to reduce recurrent idiopathic ulcers. 
 
References 
1. Wong G.L.H., Wong V.W.S., Chan Y., et al. High incidence of mortality and recurrent bleeding in patients with Helicobacter pylori-negative idiopathic bleeding ulcers. Gastroenterology. 2009;137:525-31. 
2. Laine L., Jensen D.M. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345-60.

Correct Answer: A 
 
Rationale 
This patient has an idiopathic, nonNSAID, non-H. pylori-associated ulcer and should be on daily PPI indefinitely. These patients have a high rate of recurrent bleeding (42%) and mortality when followed prospectively without being on antisecretory therapy. Although no randomized trials have assessed the benefit of medical cotherapy in this population, antiulcer therapy seems to reduce recurrent idiopathic ulcers. 
 
References 
1. Wong G.L.H., Wong V.W.S., Chan Y., et al. High incidence of mortality and recurrent bleeding in patients with Helicobacter pylori-negative idiopathic bleeding ulcers. Gastroenterology. 2009;137:525-31. 
2. Laine L., Jensen D.M. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345-60.

Correct Answer: A 
 
Rationale 
This patient has an idiopathic, nonNSAID, non-H. pylori-associated ulcer and should be on daily PPI indefinitely. These patients have a high rate of recurrent bleeding (42%) and mortality when followed prospectively without being on antisecretory therapy. Although no randomized trials have assessed the benefit of medical cotherapy in this population, antiulcer therapy seems to reduce recurrent idiopathic ulcers. 
 
References 
1. Wong G.L.H., Wong V.W.S., Chan Y., et al. High incidence of mortality and recurrent bleeding in patients with Helicobacter pylori-negative idiopathic bleeding ulcers. Gastroenterology. 2009;137:525-31. 
2. Laine L., Jensen D.M. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345-60.

Q2. Correct Answer: D 
 
Rationale  
This patient is on nadolol, a nonselective beta-blocker, for the primary prophylaxis of large esophageal varices. The dose of nonselective beta-blockers should be increased in a stepwise manner until the maximum tolerated dose or until a resting heart rate of 50-55/min is met. Since this patient is already at target heart rate, there is no indication to increase the dose. Repeat endoscopy is not indicated to assess change in size of varices once initiated on nonselective beta-blockers and at target heart rate. The choice between beta-blockers or endoscopic variceal ligation depends on local resources and expertise, patient preference and characteristics, side effects, and contraindications. Carvedilol, a nonselective beta-blocker with vasodilatory properties, is a promising alternative therapy that deserves further evaluation. However, given that nadolol has achieved target heart rate and patient is tolerating it, there is no indication to change management. 
 
Reference  
1. Garcia-Tsao G., Sanyal A.J., Grace N.D., Carey W.. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.  
2. Tripathi D., Ferguson J.W., Kochar N., et al. Randomized controlled trial of carvedilol versus variceal band ligation for the prevention of the first variceal bleed. Hepatology. 2009;50(3):825-33. 
 
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Q2. Correct Answer: D 
 
Rationale  
This patient is on nadolol, a nonselective beta-blocker, for the primary prophylaxis of large esophageal varices. The dose of nonselective beta-blockers should be increased in a stepwise manner until the maximum tolerated dose or until a resting heart rate of 50-55/min is met. Since this patient is already at target heart rate, there is no indication to increase the dose. Repeat endoscopy is not indicated to assess change in size of varices once initiated on nonselective beta-blockers and at target heart rate. The choice between beta-blockers or endoscopic variceal ligation depends on local resources and expertise, patient preference and characteristics, side effects, and contraindications. Carvedilol, a nonselective beta-blocker with vasodilatory properties, is a promising alternative therapy that deserves further evaluation. However, given that nadolol has achieved target heart rate and patient is tolerating it, there is no indication to change management. 
 
Reference  
1. Garcia-Tsao G., Sanyal A.J., Grace N.D., Carey W.. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.  
2. Tripathi D., Ferguson J.W., Kochar N., et al. Randomized controlled trial of carvedilol versus variceal band ligation for the prevention of the first variceal bleed. Hepatology. 2009;50(3):825-33. 
 
[email protected]

Q2. Correct Answer: D 
 
Rationale  
This patient is on nadolol, a nonselective beta-blocker, for the primary prophylaxis of large esophageal varices. The dose of nonselective beta-blockers should be increased in a stepwise manner until the maximum tolerated dose or until a resting heart rate of 50-55/min is met. Since this patient is already at target heart rate, there is no indication to increase the dose. Repeat endoscopy is not indicated to assess change in size of varices once initiated on nonselective beta-blockers and at target heart rate. The choice between beta-blockers or endoscopic variceal ligation depends on local resources and expertise, patient preference and characteristics, side effects, and contraindications. Carvedilol, a nonselective beta-blocker with vasodilatory properties, is a promising alternative therapy that deserves further evaluation. However, given that nadolol has achieved target heart rate and patient is tolerating it, there is no indication to change management. 
 
Reference  
1. Garcia-Tsao G., Sanyal A.J., Grace N.D., Carey W.. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.  
2. Tripathi D., Ferguson J.W., Kochar N., et al. Randomized controlled trial of carvedilol versus variceal band ligation for the prevention of the first variceal bleed. Hepatology. 2009;50(3):825-33. 
 
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Q1. Correct Answer: D 
 
Rationale  
There is a risk of perineal trauma with vaginal delivery, and therefore, patients with active perianal Crohn's disease should undergo cesarean delivery to avoid exacerbation of disease. Patients without a history of perianal disease or those with inactive perianal disease have a low rate of relapse, and cesarean delivery is not warranted. Aside from patients with active perineal disease, the mode of delivery should be left to the discretion of the obstetrician. None of the other choices above, including ileal pouch-anal anastomosis, justify the decision to perform cesarean section.

Q1. Correct Answer: D 
 
Rationale  
There is a risk of perineal trauma with vaginal delivery, and therefore, patients with active perianal Crohn's disease should undergo cesarean delivery to avoid exacerbation of disease. Patients without a history of perianal disease or those with inactive perianal disease have a low rate of relapse, and cesarean delivery is not warranted. Aside from patients with active perineal disease, the mode of delivery should be left to the discretion of the obstetrician. None of the other choices above, including ileal pouch-anal anastomosis, justify the decision to perform cesarean section.

Q1. Correct Answer: D 
 
Rationale  
There is a risk of perineal trauma with vaginal delivery, and therefore, patients with active perianal Crohn's disease should undergo cesarean delivery to avoid exacerbation of disease. Patients without a history of perianal disease or those with inactive perianal disease have a low rate of relapse, and cesarean delivery is not warranted. Aside from patients with active perineal disease, the mode of delivery should be left to the discretion of the obstetrician. None of the other choices above, including ileal pouch-anal anastomosis, justify the decision to perform cesarean section.

Rationale  
For patients who have small varices with either red wale signs or the presence of severe liver disease (Child Pugh class C), the risk of first hemorrhage is as high as for patients with large varices. Because these small varices are difficult to ligate, therapy with a nonselective beta-blocker such as nadolol is recommended. Nonselective beta-adrenergic blockers (propranolol, nadolol) reduce portal pressure by reducing portal venous inflow through both a beta-1 (reduction in cardiac output) and a beta-2 (splanchnic vasoconstriction). A decrease in HVPG greater than 20% in patients treated with nonselective beta-blockers has been associated with a lower rate of first variceal hemorrhage, ascites, and death. Clinical targets include a heart rate below 60 bpm or a 25% reduction from baseline heart rate. Metoprolol is a selective beta-blocker and is not effective in reducing portal pressure. Nitrates alone are not effective in preventing first variceal hemorrhage and are associated with increased long-term mortality in patients over the age of 50. Diltiazem is a calcium channel blocker, which has not been shown to be effective in the treatment of esophageal varices. Observation is not an appropriate option given the high risk of bleeding for these varices, which should be addressed. 
  
References  
1. Garcia-Tsao G., Sanyal A.J., Grace N.D., et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.  
2. de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV Consensus Workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2005;43:167-76. 
 
[email protected]  
 

Rationale  
For patients who have small varices with either red wale signs or the presence of severe liver disease (Child Pugh class C), the risk of first hemorrhage is as high as for patients with large varices. Because these small varices are difficult to ligate, therapy with a nonselective beta-blocker such as nadolol is recommended. Nonselective beta-adrenergic blockers (propranolol, nadolol) reduce portal pressure by reducing portal venous inflow through both a beta-1 (reduction in cardiac output) and a beta-2 (splanchnic vasoconstriction). A decrease in HVPG greater than 20% in patients treated with nonselective beta-blockers has been associated with a lower rate of first variceal hemorrhage, ascites, and death. Clinical targets include a heart rate below 60 bpm or a 25% reduction from baseline heart rate. Metoprolol is a selective beta-blocker and is not effective in reducing portal pressure. Nitrates alone are not effective in preventing first variceal hemorrhage and are associated with increased long-term mortality in patients over the age of 50. Diltiazem is a calcium channel blocker, which has not been shown to be effective in the treatment of esophageal varices. Observation is not an appropriate option given the high risk of bleeding for these varices, which should be addressed. 
  
References  
1. Garcia-Tsao G., Sanyal A.J., Grace N.D., et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.  
2. de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV Consensus Workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2005;43:167-76. 
 
[email protected]  
 

Rationale  
For patients who have small varices with either red wale signs or the presence of severe liver disease (Child Pugh class C), the risk of first hemorrhage is as high as for patients with large varices. Because these small varices are difficult to ligate, therapy with a nonselective beta-blocker such as nadolol is recommended. Nonselective beta-adrenergic blockers (propranolol, nadolol) reduce portal pressure by reducing portal venous inflow through both a beta-1 (reduction in cardiac output) and a beta-2 (splanchnic vasoconstriction). A decrease in HVPG greater than 20% in patients treated with nonselective beta-blockers has been associated with a lower rate of first variceal hemorrhage, ascites, and death. Clinical targets include a heart rate below 60 bpm or a 25% reduction from baseline heart rate. Metoprolol is a selective beta-blocker and is not effective in reducing portal pressure. Nitrates alone are not effective in preventing first variceal hemorrhage and are associated with increased long-term mortality in patients over the age of 50. Diltiazem is a calcium channel blocker, which has not been shown to be effective in the treatment of esophageal varices. Observation is not an appropriate option given the high risk of bleeding for these varices, which should be addressed. 
  
References  
1. Garcia-Tsao G., Sanyal A.J., Grace N.D., et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.  
2. de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV Consensus Workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2005;43:167-76. 
 
[email protected]  
 

References  
1. Garcia-Tsao G., Sanyal A.J., Grace N.D., et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.  
2. de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV Consensus Workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2005;43:167-76. 
 
[email protected]

References  
1. Garcia-Tsao G., Sanyal A.J., Grace N.D., et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.  
2. de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV Consensus Workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2005;43:167-76. 
 
[email protected]

References  
1. Garcia-Tsao G., Sanyal A.J., Grace N.D., et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46(3):922-38.  
2. de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV Consensus Workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2005;43:167-76. 
 
[email protected]

Q2. Correct Answer: A

Rationale
Anti-TNF therapy is relatively safe and well-tolerated. However, there are a few important issues to consider prior to initiation of therapy. There is a risk of reactivation of both Mycobacterium tuberculosis and hepatitis B. In this patient’s case, her PPD positivity is likely a false positive from remote BCG vaccination. An interferon gamma release assay (e.g. QuantiFERON®) can be checked to confirm this; even if that is positive, in the absence of active tuberculosis (TB), she can be treated for latent TB for several weeks prior to initiation of anti-TNF therapy. Her hepatitis B serologies do not suggest chronic infection but rather prior infection with resolution. In this case, anti-TNF therapy is not precluded; rather, the AGA recommends considering concurrent antiviral prophylaxis while on anti-TNF therapy. Anti-TNF agents are not known to significantly increase the risk of progressive multifocal leukoencephalopathy like the nonselective anti-integrin natalizumab, so JC virus antibody positivity does not preclude their use. There is a slight increased risk of melanoma in those on anti-TNF therapy; non-melanoma skin cancers are of greater concern in those on thiopurine therapy. Finally, anti-TNF therapy should be avoided in those with demyelinating diseases or those at high risk for such diseases.

References
1. Reddy K.R., Beavers K.L., Hammond S.P., et al. American Gastroenterological Association Institute Guideline on the prevention and treatment of Hepatitis B virus reactivation during immunosuppressive drug therapy. Gastroenterology. 2014;148[1]:215-9.
2. Long M.D., Martin C.F., Pipkin C.A., et al. Risk of melanoma and nonmelanoma skin cancer among patients with inflammatory bowel disease. Gastroenterology. 2012;143[2]:390-9.
3. Ariyaratnam J., Subramanian V. Association between thiopurine use and nonmelanoma skin cancers in patients with inflammatory bowel disease: A meta-analysis. Am J Gastroenterol. 2014;109:163-9.

Q2. Correct Answer: A

Rationale
Anti-TNF therapy is relatively safe and well-tolerated. However, there are a few important issues to consider prior to initiation of therapy. There is a risk of reactivation of both Mycobacterium tuberculosis and hepatitis B. In this patient’s case, her PPD positivity is likely a false positive from remote BCG vaccination. An interferon gamma release assay (e.g. QuantiFERON®) can be checked to confirm this; even if that is positive, in the absence of active tuberculosis (TB), she can be treated for latent TB for several weeks prior to initiation of anti-TNF therapy. Her hepatitis B serologies do not suggest chronic infection but rather prior infection with resolution. In this case, anti-TNF therapy is not precluded; rather, the AGA recommends considering concurrent antiviral prophylaxis while on anti-TNF therapy. Anti-TNF agents are not known to significantly increase the risk of progressive multifocal leukoencephalopathy like the nonselective anti-integrin natalizumab, so JC virus antibody positivity does not preclude their use. There is a slight increased risk of melanoma in those on anti-TNF therapy; non-melanoma skin cancers are of greater concern in those on thiopurine therapy. Finally, anti-TNF therapy should be avoided in those with demyelinating diseases or those at high risk for such diseases.

References
1. Reddy K.R., Beavers K.L., Hammond S.P., et al. American Gastroenterological Association Institute Guideline on the prevention and treatment of Hepatitis B virus reactivation during immunosuppressive drug therapy. Gastroenterology. 2014;148[1]:215-9.
2. Long M.D., Martin C.F., Pipkin C.A., et al. Risk of melanoma and nonmelanoma skin cancer among patients with inflammatory bowel disease. Gastroenterology. 2012;143[2]:390-9.
3. Ariyaratnam J., Subramanian V. Association between thiopurine use and nonmelanoma skin cancers in patients with inflammatory bowel disease: A meta-analysis. Am J Gastroenterol. 2014;109:163-9.

Q2. Correct Answer: A

Rationale
Anti-TNF therapy is relatively safe and well-tolerated. However, there are a few important issues to consider prior to initiation of therapy. There is a risk of reactivation of both Mycobacterium tuberculosis and hepatitis B. In this patient’s case, her PPD positivity is likely a false positive from remote BCG vaccination. An interferon gamma release assay (e.g. QuantiFERON®) can be checked to confirm this; even if that is positive, in the absence of active tuberculosis (TB), she can be treated for latent TB for several weeks prior to initiation of anti-TNF therapy. Her hepatitis B serologies do not suggest chronic infection but rather prior infection with resolution. In this case, anti-TNF therapy is not precluded; rather, the AGA recommends considering concurrent antiviral prophylaxis while on anti-TNF therapy. Anti-TNF agents are not known to significantly increase the risk of progressive multifocal leukoencephalopathy like the nonselective anti-integrin natalizumab, so JC virus antibody positivity does not preclude their use. There is a slight increased risk of melanoma in those on anti-TNF therapy; non-melanoma skin cancers are of greater concern in those on thiopurine therapy. Finally, anti-TNF therapy should be avoided in those with demyelinating diseases or those at high risk for such diseases.

References
1. Reddy K.R., Beavers K.L., Hammond S.P., et al. American Gastroenterological Association Institute Guideline on the prevention and treatment of Hepatitis B virus reactivation during immunosuppressive drug therapy. Gastroenterology. 2014;148[1]:215-9.
2. Long M.D., Martin C.F., Pipkin C.A., et al. Risk of melanoma and nonmelanoma skin cancer among patients with inflammatory bowel disease. Gastroenterology. 2012;143[2]:390-9.
3. Ariyaratnam J., Subramanian V. Association between thiopurine use and nonmelanoma skin cancers in patients with inflammatory bowel disease: A meta-analysis. Am J Gastroenterol. 2014;109:163-9.

Q1. Correct Answer: A

Rationale
This patient has an idiopathic, non-NSAID, non-H. pylori-associated ulcer and should be on daily PPI indefinitely. These patients have a high rate of recurrent bleeding (42%) and mortality when followed prospectively without being on antisecretory therapy. Although no randomized trials have assessed the benefit of medical cotherapy in this population, antiulcer therapy seems to reduce recurrent idiopathic ulcers.

References
1. Wong G.L.H., Wong V.W.S. Chan Y., et al. High incidence of mortality and recurrent bleeding in patients with Helicobacter pylori-negative idiopathic bleeding ulcers. Gastroenterology. 2009;137:525-31.
2. Laine L. Jensen D.M. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107[3]:345-60.

Q1. Correct Answer: A

Rationale
This patient has an idiopathic, non-NSAID, non-H. pylori-associated ulcer and should be on daily PPI indefinitely. These patients have a high rate of recurrent bleeding (42%) and mortality when followed prospectively without being on antisecretory therapy. Although no randomized trials have assessed the benefit of medical cotherapy in this population, antiulcer therapy seems to reduce recurrent idiopathic ulcers.

References
1. Wong G.L.H., Wong V.W.S. Chan Y., et al. High incidence of mortality and recurrent bleeding in patients with Helicobacter pylori-negative idiopathic bleeding ulcers. Gastroenterology. 2009;137:525-31.
2. Laine L. Jensen D.M. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107[3]:345-60.

Q1. Correct Answer: A

Rationale
This patient has an idiopathic, non-NSAID, non-H. pylori-associated ulcer and should be on daily PPI indefinitely. These patients have a high rate of recurrent bleeding (42%) and mortality when followed prospectively without being on antisecretory therapy. Although no randomized trials have assessed the benefit of medical cotherapy in this population, antiulcer therapy seems to reduce recurrent idiopathic ulcers.

References
1. Wong G.L.H., Wong V.W.S. Chan Y., et al. High incidence of mortality and recurrent bleeding in patients with Helicobacter pylori-negative idiopathic bleeding ulcers. Gastroenterology. 2009;137:525-31.
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