DDSEP® 8 Quick Quiz

Correct answer: C

Rationale

This patient has long-standing diabetes with associated complications from prolonged hyperglycemia, with symptoms of delayed gastric emptying. The next best step would be to perform a gastric-emptying study or scintigraphy to confirm the diagnosis of diabetic gastroparesis. A dietitian consult will be necessary once gastroparesis is confirmed, since dietary modifications are the mainstay of treatment. Strict blood glucose control is necessary to prevent worsening gastrointestinal symptoms, and an evaluation by an endocrinologist is reasonable if gastroparesis is confirmed. A trial of metoclopramide may be necessary if gastroparesis symptoms are not controlled with dietary modifications, but it would not be first-line treatment in diabetic gastroparesis.

References

1. Camilleri M. Advances in diabetic gastroparesis. Rev Gastroenterol Disord. 2002;2:47-56.
2. Camilleri M, Vazquez-Roque MI. Gastric dysmotility at the organ level in gastroparesis. In: Parkman H, McCallum R. Gastroparesis: Pathophysiology, presentation, diagnosis, and treatment. New York: Springer; 2011. p. 37-46.

Correct answer: C

Rationale

This patient has long-standing diabetes with associated complications from prolonged hyperglycemia, with symptoms of delayed gastric emptying. The next best step would be to perform a gastric-emptying study or scintigraphy to confirm the diagnosis of diabetic gastroparesis. A dietitian consult will be necessary once gastroparesis is confirmed, since dietary modifications are the mainstay of treatment. Strict blood glucose control is necessary to prevent worsening gastrointestinal symptoms, and an evaluation by an endocrinologist is reasonable if gastroparesis is confirmed. A trial of metoclopramide may be necessary if gastroparesis symptoms are not controlled with dietary modifications, but it would not be first-line treatment in diabetic gastroparesis.

References

1. Camilleri M. Advances in diabetic gastroparesis. Rev Gastroenterol Disord. 2002;2:47-56.
2. Camilleri M, Vazquez-Roque MI. Gastric dysmotility at the organ level in gastroparesis. In: Parkman H, McCallum R. Gastroparesis: Pathophysiology, presentation, diagnosis, and treatment. New York: Springer; 2011. p. 37-46.

Correct answer: C

Rationale

This patient has long-standing diabetes with associated complications from prolonged hyperglycemia, with symptoms of delayed gastric emptying. The next best step would be to perform a gastric-emptying study or scintigraphy to confirm the diagnosis of diabetic gastroparesis. A dietitian consult will be necessary once gastroparesis is confirmed, since dietary modifications are the mainstay of treatment. Strict blood glucose control is necessary to prevent worsening gastrointestinal symptoms, and an evaluation by an endocrinologist is reasonable if gastroparesis is confirmed. A trial of metoclopramide may be necessary if gastroparesis symptoms are not controlled with dietary modifications, but it would not be first-line treatment in diabetic gastroparesis.

References

1. Camilleri M. Advances in diabetic gastroparesis. Rev Gastroenterol Disord. 2002;2:47-56.
2. Camilleri M, Vazquez-Roque MI. Gastric dysmotility at the organ level in gastroparesis. In: Parkman H, McCallum R. Gastroparesis: Pathophysiology, presentation, diagnosis, and treatment. New York: Springer; 2011. p. 37-46.

Correct answer: C

Rationale

This patient is presenting early post-liver transplant with severe hepatic dysfunction. This severity of enzyme elevation is concerning for an underlying hepatic artery thrombosis. The next appropriate diagnostic test for this patient is a hepatic ultrasound with Dopplers to assess hepatic artery patency. CMV infection does not typically occur within the first month post-liver transplant and would not be expected to cause this degree of elevation in the liver enzymes. Performance of liver biopsy, MRCP, or ERCP would not reveal the underlying etiology and may result in delay in diagnosis.

Reference

1. Stange BJ, Glanemann M, Nuessler NC, et al. Hepatic artery thrombosis after adult liver transplantation. Liver Transplantation 2003;9:612-20.

Correct answer: C

Rationale

This patient is presenting early post-liver transplant with severe hepatic dysfunction. This severity of enzyme elevation is concerning for an underlying hepatic artery thrombosis. The next appropriate diagnostic test for this patient is a hepatic ultrasound with Dopplers to assess hepatic artery patency. CMV infection does not typically occur within the first month post-liver transplant and would not be expected to cause this degree of elevation in the liver enzymes. Performance of liver biopsy, MRCP, or ERCP would not reveal the underlying etiology and may result in delay in diagnosis.

Reference

1. Stange BJ, Glanemann M, Nuessler NC, et al. Hepatic artery thrombosis after adult liver transplantation. Liver Transplantation 2003;9:612-20.

Correct answer: C

Rationale

This patient is presenting early post-liver transplant with severe hepatic dysfunction. This severity of enzyme elevation is concerning for an underlying hepatic artery thrombosis. The next appropriate diagnostic test for this patient is a hepatic ultrasound with Dopplers to assess hepatic artery patency. CMV infection does not typically occur within the first month post-liver transplant and would not be expected to cause this degree of elevation in the liver enzymes. Performance of liver biopsy, MRCP, or ERCP would not reveal the underlying etiology and may result in delay in diagnosis.

Reference

1. Stange BJ, Glanemann M, Nuessler NC, et al. Hepatic artery thrombosis after adult liver transplantation. Liver Transplantation 2003;9:612-20.

Correct Answer: B
 
Rationale
This patient has a neuroendocrine tumor (e.g., carcinoid). These tumors are derived from enterochromaffin-like cells and appear as nests or ribbons of endocrine cells. There are three types of carcinoids. Type 1 is the most common and has a benign course. Type 1 neuroendocrine tumors can be multifocal, well-differentiated and associated with type A chronic atrophic gastritis. Small tumors can be treated with endoscopic resection. Type 2 lesions tend to be multifocal and associated with Zollinger-Ellison syndrome (ZES) and multiple endocrine neoplasia 1 (MEN1). Up to 30% of type 2 tumors present with lymph node metastases. Type 3 gastric carcinoids are not associated with hypergastrinemia and have poor prognosis. Type 3 gastric carcinoids should be managed with surgery.
 
References
1. ASGE Standards of Practice Committee, Evans JA, Chandrasekhara V, et al. The role of endoscopy in the management of premalignant and malignant conditions of the stomach. Gastrointest Endosc. 2015;82(1):1-8.
2. Shaib YH, Rugge M, Graham DY, et al. Management of gastric polyps: an endoscopy-based approach. Clin Gastroenterol Hepatol. 2013;11(11):1374-84.
 

Correct Answer: B
 
Rationale
This patient has a neuroendocrine tumor (e.g., carcinoid). These tumors are derived from enterochromaffin-like cells and appear as nests or ribbons of endocrine cells. There are three types of carcinoids. Type 1 is the most common and has a benign course. Type 1 neuroendocrine tumors can be multifocal, well-differentiated and associated with type A chronic atrophic gastritis. Small tumors can be treated with endoscopic resection. Type 2 lesions tend to be multifocal and associated with Zollinger-Ellison syndrome (ZES) and multiple endocrine neoplasia 1 (MEN1). Up to 30% of type 2 tumors present with lymph node metastases. Type 3 gastric carcinoids are not associated with hypergastrinemia and have poor prognosis. Type 3 gastric carcinoids should be managed with surgery.
 
References
1. ASGE Standards of Practice Committee, Evans JA, Chandrasekhara V, et al. The role of endoscopy in the management of premalignant and malignant conditions of the stomach. Gastrointest Endosc. 2015;82(1):1-8.
2. Shaib YH, Rugge M, Graham DY, et al. Management of gastric polyps: an endoscopy-based approach. Clin Gastroenterol Hepatol. 2013;11(11):1374-84.
 

Correct Answer: B
 
Rationale
This patient has a neuroendocrine tumor (e.g., carcinoid). These tumors are derived from enterochromaffin-like cells and appear as nests or ribbons of endocrine cells. There are three types of carcinoids. Type 1 is the most common and has a benign course. Type 1 neuroendocrine tumors can be multifocal, well-differentiated and associated with type A chronic atrophic gastritis. Small tumors can be treated with endoscopic resection. Type 2 lesions tend to be multifocal and associated with Zollinger-Ellison syndrome (ZES) and multiple endocrine neoplasia 1 (MEN1). Up to 30% of type 2 tumors present with lymph node metastases. Type 3 gastric carcinoids are not associated with hypergastrinemia and have poor prognosis. Type 3 gastric carcinoids should be managed with surgery.
 
References
1. ASGE Standards of Practice Committee, Evans JA, Chandrasekhara V, et al. The role of endoscopy in the management of premalignant and malignant conditions of the stomach. Gastrointest Endosc. 2015;82(1):1-8.
2. Shaib YH, Rugge M, Graham DY, et al. Management of gastric polyps: an endoscopy-based approach. Clin Gastroenterol Hepatol. 2013;11(11):1374-84.
 

 Correct Answer: C
 
Rationale
In a population study of U.S. veterans infected with hepatitis C (n = 110,484), a Cox proportional hazards model was used to determine risk of developing cirrhosis and hepatocellular carcinoma for genotypes 1-4, after adjusting for age, period of service, race, gender, human immunodeficiency virus (HIV) infection, alcohol use, diabetes, body mass index, and antiviral treatment. Despite genotype 3 patients being younger, their risk of developing cirrhosis was highest with hazard ratio = 1.30 (1.22, 1.39), compared to genotype 1 (reference, HR 1.0), genotype 2 with HR = 0.68 (0.64, 0.73), and genotype 4 with HR = 0.94 (0.78, 1.14). Likewise, the risk of development of hepatocellular carcinoma was highest for genotype 3 HCV with HR = 1.80 (1.60, 2.03), compared to a genotype 2 (HR = 0.55, 0.47, 0.63), and genotype 4 (0.99, 0.68, 1.45).  
It is speculated that the hepatic steatosis that is a direct result of genotype 3 HCV may contribute to the accelerated progression to cirrhosis and HCC, but this has not been proven and was not evaluated in this Veteran Affairs study.
 
Reference
1. Kanwal F, Kramer JR, Ilyas J, et al. HCV genotype 3 is associated with an increased risk of cirrhosis and hepatocellular cancer in a national sample of U.S. veterans with HCV. Hepatology. 2014;60(1):98-105.

 Correct Answer: C
 
Rationale
In a population study of U.S. veterans infected with hepatitis C (n = 110,484), a Cox proportional hazards model was used to determine risk of developing cirrhosis and hepatocellular carcinoma for genotypes 1-4, after adjusting for age, period of service, race, gender, human immunodeficiency virus (HIV) infection, alcohol use, diabetes, body mass index, and antiviral treatment. Despite genotype 3 patients being younger, their risk of developing cirrhosis was highest with hazard ratio = 1.30 (1.22, 1.39), compared to genotype 1 (reference, HR 1.0), genotype 2 with HR = 0.68 (0.64, 0.73), and genotype 4 with HR = 0.94 (0.78, 1.14). Likewise, the risk of development of hepatocellular carcinoma was highest for genotype 3 HCV with HR = 1.80 (1.60, 2.03), compared to a genotype 2 (HR = 0.55, 0.47, 0.63), and genotype 4 (0.99, 0.68, 1.45).  
It is speculated that the hepatic steatosis that is a direct result of genotype 3 HCV may contribute to the accelerated progression to cirrhosis and HCC, but this has not been proven and was not evaluated in this Veteran Affairs study.
 
Reference
1. Kanwal F, Kramer JR, Ilyas J, et al. HCV genotype 3 is associated with an increased risk of cirrhosis and hepatocellular cancer in a national sample of U.S. veterans with HCV. Hepatology. 2014;60(1):98-105.

 Correct Answer: C
 
Rationale
In a population study of U.S. veterans infected with hepatitis C (n = 110,484), a Cox proportional hazards model was used to determine risk of developing cirrhosis and hepatocellular carcinoma for genotypes 1-4, after adjusting for age, period of service, race, gender, human immunodeficiency virus (HIV) infection, alcohol use, diabetes, body mass index, and antiviral treatment. Despite genotype 3 patients being younger, their risk of developing cirrhosis was highest with hazard ratio = 1.30 (1.22, 1.39), compared to genotype 1 (reference, HR 1.0), genotype 2 with HR = 0.68 (0.64, 0.73), and genotype 4 with HR = 0.94 (0.78, 1.14). Likewise, the risk of development of hepatocellular carcinoma was highest for genotype 3 HCV with HR = 1.80 (1.60, 2.03), compared to a genotype 2 (HR = 0.55, 0.47, 0.63), and genotype 4 (0.99, 0.68, 1.45).  
It is speculated that the hepatic steatosis that is a direct result of genotype 3 HCV may contribute to the accelerated progression to cirrhosis and HCC, but this has not been proven and was not evaluated in this Veteran Affairs study.
 
Reference
1. Kanwal F, Kramer JR, Ilyas J, et al. HCV genotype 3 is associated with an increased risk of cirrhosis and hepatocellular cancer in a national sample of U.S. veterans with HCV. Hepatology. 2014;60(1):98-105.

Q2. Correct Answer: C 
 
Rationale  
The patient presents with acute gallstone pancreatitis. In patients with gallstone pancreatitis and evidence of cholangitis, ERCP with sphincterotomy and stone extraction should be performed. The patients fever, jaundice, and right upper quadrant pain are sufficient to make the diagnosis of cholangitis. It is too early in the course of the disease to evaluate for pancreatic necrosis. Typically, triglyceride levels above 1,000 mg/dL are required to induce pancreatitis. Finally, while the patient has cholelithiasis, there is no evidence of cholecystitis. Therefore, a HIDA scan is not warranted. 
 
Reference  
1. Behrns KE, Ashley SW, Hunter JG, Carr-Locke D. Early ERCP for gallstone pancreatitis: for whom and when? J Gastrointestinal Surgery. 2008;12(4):629-33. 
 

Q2. Correct Answer: C 
 
Rationale  
The patient presents with acute gallstone pancreatitis. In patients with gallstone pancreatitis and evidence of cholangitis, ERCP with sphincterotomy and stone extraction should be performed. The patients fever, jaundice, and right upper quadrant pain are sufficient to make the diagnosis of cholangitis. It is too early in the course of the disease to evaluate for pancreatic necrosis. Typically, triglyceride levels above 1,000 mg/dL are required to induce pancreatitis. Finally, while the patient has cholelithiasis, there is no evidence of cholecystitis. Therefore, a HIDA scan is not warranted. 
 
Reference  
1. Behrns KE, Ashley SW, Hunter JG, Carr-Locke D. Early ERCP for gallstone pancreatitis: for whom and when? J Gastrointestinal Surgery. 2008;12(4):629-33. 
 

Q2. Correct Answer: C 
 
Rationale  
The patient presents with acute gallstone pancreatitis. In patients with gallstone pancreatitis and evidence of cholangitis, ERCP with sphincterotomy and stone extraction should be performed. The patients fever, jaundice, and right upper quadrant pain are sufficient to make the diagnosis of cholangitis. It is too early in the course of the disease to evaluate for pancreatic necrosis. Typically, triglyceride levels above 1,000 mg/dL are required to induce pancreatitis. Finally, while the patient has cholelithiasis, there is no evidence of cholecystitis. Therefore, a HIDA scan is not warranted. 
 
Reference  
1. Behrns KE, Ashley SW, Hunter JG, Carr-Locke D. Early ERCP for gallstone pancreatitis: for whom and when? J Gastrointestinal Surgery. 2008;12(4):629-33. 
 

Q1. Correct Answer: C 
 
Rationale  
The CagA strain of H. pylori has been found to be associated with an increased risk of gastric adenocarcinoma and MALT lymphoma. CagA-producing H. pylori infection also cause more severe mucosal inflammation and is associated with higher incidences of gastric and duodenal ulcers. A protective effect of CagA+ H. pylori against gastroesophageal reflux disease, reflux esophagitis, Barrett's esophagus, and esophageal adenocarcinoma has been suggested, as some epidemiologic studies have shown a decreased prevalence of these disorders. Although further studies are needed to verify these relationships, no studies to date have demonstrated an increased risk of esophageal carcinoma associated with H. pylori. CagA-producing H. pylori has not been associated with gastric carcinoid tumor. 
 
References  
1. Fallone CA, Barkun AN, Göttke MU, et al. Association of Helicobacter pylori genotype with gastroesophageal reflux disease and other upper gastrointestinal diseases. Am J Gastroenterol. 2000;95(3):659-69. 
2. Huang JQ, Zheng GF, Sumanac K, et al. Meta-analysis of the relationship between cagA seropositivity and gastric cancer. Gastroenterology 2003;125(6):1636-44. 
3. Islami F, Kamangar F. Helicobacter pylori and esophageal cancer risk: a meta-analysis. Cancer Prev Res. 2008;1:329-38. 

Q1. Correct Answer: C 
 
Rationale  
The CagA strain of H. pylori has been found to be associated with an increased risk of gastric adenocarcinoma and MALT lymphoma. CagA-producing H. pylori infection also cause more severe mucosal inflammation and is associated with higher incidences of gastric and duodenal ulcers. A protective effect of CagA+ H. pylori against gastroesophageal reflux disease, reflux esophagitis, Barrett's esophagus, and esophageal adenocarcinoma has been suggested, as some epidemiologic studies have shown a decreased prevalence of these disorders. Although further studies are needed to verify these relationships, no studies to date have demonstrated an increased risk of esophageal carcinoma associated with H. pylori. CagA-producing H. pylori has not been associated with gastric carcinoid tumor. 
 
References  
1. Fallone CA, Barkun AN, Göttke MU, et al. Association of Helicobacter pylori genotype with gastroesophageal reflux disease and other upper gastrointestinal diseases. Am J Gastroenterol. 2000;95(3):659-69. 
2. Huang JQ, Zheng GF, Sumanac K, et al. Meta-analysis of the relationship between cagA seropositivity and gastric cancer. Gastroenterology 2003;125(6):1636-44. 
3. Islami F, Kamangar F. Helicobacter pylori and esophageal cancer risk: a meta-analysis. Cancer Prev Res. 2008;1:329-38. 

Q1. Correct Answer: C 
 
Rationale  
The CagA strain of H. pylori has been found to be associated with an increased risk of gastric adenocarcinoma and MALT lymphoma. CagA-producing H. pylori infection also cause more severe mucosal inflammation and is associated with higher incidences of gastric and duodenal ulcers. A protective effect of CagA+ H. pylori against gastroesophageal reflux disease, reflux esophagitis, Barrett's esophagus, and esophageal adenocarcinoma has been suggested, as some epidemiologic studies have shown a decreased prevalence of these disorders. Although further studies are needed to verify these relationships, no studies to date have demonstrated an increased risk of esophageal carcinoma associated with H. pylori. CagA-producing H. pylori has not been associated with gastric carcinoid tumor. 
 
References  
1. Fallone CA, Barkun AN, Göttke MU, et al. Association of Helicobacter pylori genotype with gastroesophageal reflux disease and other upper gastrointestinal diseases. Am J Gastroenterol. 2000;95(3):659-69. 
2. Huang JQ, Zheng GF, Sumanac K, et al. Meta-analysis of the relationship between cagA seropositivity and gastric cancer. Gastroenterology 2003;125(6):1636-44. 
3. Islami F, Kamangar F. Helicobacter pylori and esophageal cancer risk: a meta-analysis. Cancer Prev Res. 2008;1:329-38. 

Correct Answer: B

Rationale 
The patient has a favorable anatomy for a surgical drainage procedure such as a lateral pancreaticojejunostomy (Peustow procedure). Surgery has been noted to provide superior pain relief over 5 years compared with endoscopy. Hospital costs and length of stay were similar between the groups. Continued medical therapy is unlikely to add further benefit on top of what she has already achieved. EUS-guided celiac plexus block will only provide temporary pain relief. There are limited long-term data on the effectiveness of total pancreatectomy with islet autotransplantation in alleviating pain.

References 
1. Cahen D.L., Gouma D.J., Laramée P., et al. Gastroenterology. 2011;141(5):1690-5. 
2. Conwell D.L., Lee L.S., Yadav D., et al. American pancreatic association practice guidelines in chronic pancreatitis. Pancreas. 2014;43:1143-62.
 

Correct Answer: B

Rationale 
The patient has a favorable anatomy for a surgical drainage procedure such as a lateral pancreaticojejunostomy (Peustow procedure). Surgery has been noted to provide superior pain relief over 5 years compared with endoscopy. Hospital costs and length of stay were similar between the groups. Continued medical therapy is unlikely to add further benefit on top of what she has already achieved. EUS-guided celiac plexus block will only provide temporary pain relief. There are limited long-term data on the effectiveness of total pancreatectomy with islet autotransplantation in alleviating pain.

References 
1. Cahen D.L., Gouma D.J., Laramée P., et al. Gastroenterology. 2011;141(5):1690-5. 
2. Conwell D.L., Lee L.S., Yadav D., et al. American pancreatic association practice guidelines in chronic pancreatitis. Pancreas. 2014;43:1143-62.
 

Correct Answer: B

Rationale 
The patient has a favorable anatomy for a surgical drainage procedure such as a lateral pancreaticojejunostomy (Peustow procedure). Surgery has been noted to provide superior pain relief over 5 years compared with endoscopy. Hospital costs and length of stay were similar between the groups. Continued medical therapy is unlikely to add further benefit on top of what she has already achieved. EUS-guided celiac plexus block will only provide temporary pain relief. There are limited long-term data on the effectiveness of total pancreatectomy with islet autotransplantation in alleviating pain.

References 
1. Cahen D.L., Gouma D.J., Laramée P., et al. Gastroenterology. 2011;141(5):1690-5. 
2. Conwell D.L., Lee L.S., Yadav D., et al. American pancreatic association practice guidelines in chronic pancreatitis. Pancreas. 2014;43:1143-62.
 

Q1. Correct answer: C

Rationale 
The initial management of dyspepsia depends on symptoms and presence of any “alarm features.” In patients without “alarm features” presenting with symptoms suggestive of hepatobiliary or pancreatic causes, the initial diagnostic tests should include liver/pancreatic blood tests and abdominal imaging. For other dyspeptic patients without alarm features, initial management would include H. pylori testing (breath, stool antigen, or antibody) and/or empiric antisecretory (PPI) therapy. However, for patients who present with “alarm features” such as dysphagia, anemia, GI bleeding, anorexia, significant weight loss, etc., an upper endoscopy should be performed to evaluate for the presence of any upper GI tract malignancy. In this patient, the presence of microcytic anemia is an alarm feature. Tricyclic antidepressants such as amitriptyline may be used as treatment for functional dyspepsia, after organic causes have been ruled out.

Reference 
1. Talley N.J., Vakil N.B., Moayyedi P. American Gastroenterological Association technical review on the evaluation of dyspepsia. Gastroenterology 2005;129:1756-80.

Q1. Correct answer: C

Rationale 
The initial management of dyspepsia depends on symptoms and presence of any “alarm features.” In patients without “alarm features” presenting with symptoms suggestive of hepatobiliary or pancreatic causes, the initial diagnostic tests should include liver/pancreatic blood tests and abdominal imaging. For other dyspeptic patients without alarm features, initial management would include H. pylori testing (breath, stool antigen, or antibody) and/or empiric antisecretory (PPI) therapy. However, for patients who present with “alarm features” such as dysphagia, anemia, GI bleeding, anorexia, significant weight loss, etc., an upper endoscopy should be performed to evaluate for the presence of any upper GI tract malignancy. In this patient, the presence of microcytic anemia is an alarm feature. Tricyclic antidepressants such as amitriptyline may be used as treatment for functional dyspepsia, after organic causes have been ruled out.

Reference 
1. Talley N.J., Vakil N.B., Moayyedi P. American Gastroenterological Association technical review on the evaluation of dyspepsia. Gastroenterology 2005;129:1756-80.

Q1. Correct answer: C

Rationale 
The initial management of dyspepsia depends on symptoms and presence of any “alarm features.” In patients without “alarm features” presenting with symptoms suggestive of hepatobiliary or pancreatic causes, the initial diagnostic tests should include liver/pancreatic blood tests and abdominal imaging. For other dyspeptic patients without alarm features, initial management would include H. pylori testing (breath, stool antigen, or antibody) and/or empiric antisecretory (PPI) therapy. However, for patients who present with “alarm features” such as dysphagia, anemia, GI bleeding, anorexia, significant weight loss, etc., an upper endoscopy should be performed to evaluate for the presence of any upper GI tract malignancy. In this patient, the presence of microcytic anemia is an alarm feature. Tricyclic antidepressants such as amitriptyline may be used as treatment for functional dyspepsia, after organic causes have been ruled out.

Reference 
1. Talley N.J., Vakil N.B., Moayyedi P. American Gastroenterological Association technical review on the evaluation of dyspepsia. Gastroenterology 2005;129:1756-80.

Answer: C
 

Rationale

The patient has ascending cholangitis. After stabilization and initiation of antibiotics, the next most appropriate step is ERCP. The patient is high risk for postsphincterotomy bleeding as he is on three antithrombotic agents. The most prudent course of action is ERCP with stent placement. ERCP and stent placement is not contraindicated in patients on antithrombotic agents. This will allow for confirmation of the diagnosis as well as therapy for the obstruction. Once the patient has recovered, he can return on an elective basis, off antithrombotic agents, for definitive management of the common bile duct stone. MRCP would allow for a diagnosis; however, it is not therapeutic, and in the setting of cholangitis, management of the obstruction is necessary. Continued medical management neither provides information regarding diagnosis nor treats the obstruction. Percutaneous biliary drain would provide appropriate drainage but, as he is at a high risk for bleeding, ERCP with stent placement is a better therapeutic option in this patient.
 

References

1. Committee, ASGE Standards of Practice, et al. Management of anti-thrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009;70(6):1060-70.

2. Boustiere C., Veitch A., Vanbiervliet G., et al. Endoscopy and antiplatelet agents. Endoscopy. 2011;43(5):445-61.

[email protected]

Answer: C
 

Rationale

The patient has ascending cholangitis. After stabilization and initiation of antibiotics, the next most appropriate step is ERCP. The patient is high risk for postsphincterotomy bleeding as he is on three antithrombotic agents. The most prudent course of action is ERCP with stent placement. ERCP and stent placement is not contraindicated in patients on antithrombotic agents. This will allow for confirmation of the diagnosis as well as therapy for the obstruction. Once the patient has recovered, he can return on an elective basis, off antithrombotic agents, for definitive management of the common bile duct stone. MRCP would allow for a diagnosis; however, it is not therapeutic, and in the setting of cholangitis, management of the obstruction is necessary. Continued medical management neither provides information regarding diagnosis nor treats the obstruction. Percutaneous biliary drain would provide appropriate drainage but, as he is at a high risk for bleeding, ERCP with stent placement is a better therapeutic option in this patient.
 

References

1. Committee, ASGE Standards of Practice, et al. Management of anti-thrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009;70(6):1060-70.

2. Boustiere C., Veitch A., Vanbiervliet G., et al. Endoscopy and antiplatelet agents. Endoscopy. 2011;43(5):445-61.

[email protected]

Answer: C
 

Rationale

The patient has ascending cholangitis. After stabilization and initiation of antibiotics, the next most appropriate step is ERCP. The patient is high risk for postsphincterotomy bleeding as he is on three antithrombotic agents. The most prudent course of action is ERCP with stent placement. ERCP and stent placement is not contraindicated in patients on antithrombotic agents. This will allow for confirmation of the diagnosis as well as therapy for the obstruction. Once the patient has recovered, he can return on an elective basis, off antithrombotic agents, for definitive management of the common bile duct stone. MRCP would allow for a diagnosis; however, it is not therapeutic, and in the setting of cholangitis, management of the obstruction is necessary. Continued medical management neither provides information regarding diagnosis nor treats the obstruction. Percutaneous biliary drain would provide appropriate drainage but, as he is at a high risk for bleeding, ERCP with stent placement is a better therapeutic option in this patient.
 

References

1. Committee, ASGE Standards of Practice, et al. Management of anti-thrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009;70(6):1060-70.

2. Boustiere C., Veitch A., Vanbiervliet G., et al. Endoscopy and antiplatelet agents. Endoscopy. 2011;43(5):445-61.

[email protected]

Answer: B

Rationale

Hypergastrinemia is normally a physiologic response to hypochlorhydria. When hypergastrinemia occurs in the setting of acidic gastric pH, it is considered inappropriate. Gastrinoma is a component of MEN-1 syndrome that results in abnormal gastrin release and acid hypersecretion. Gastric outlet obstruction may lead to stomach distention and persistent stimulation by retained food, causing increased gastrin release and acid secretion. Chronic renal failure leads to a decrease in clearance of gastrin from the circulation, resulting in hypergastrinemia. This increase in circulating gastrin results in stimulation of parietal cells to release acid into the gastric lumen. Therefore, the hypergastrinemia associated with chronic renal failure is inappropriate, given the high serum gastrin level despite low intragastric pH. Retained antrum results when a small portion of antrum is left attached to the duodenal bulb (afferent loop) during a Billroth II surgical procedure. As a result, the G cells from the retained antrum are displaced from the stomach and excluded from the inhibitory effects of gastric acid. The lack of negative feedback leads to persistently high gastrin release and resultant acid production. H. pylori pangastritis results in suppression of acid secretion, leading to a high intragastric pH. Therefore, it represents an appropriate cause for hypergastrinemia.

Reference

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.

Answer: B

Rationale

Hypergastrinemia is normally a physiologic response to hypochlorhydria. When hypergastrinemia occurs in the setting of acidic gastric pH, it is considered inappropriate. Gastrinoma is a component of MEN-1 syndrome that results in abnormal gastrin release and acid hypersecretion. Gastric outlet obstruction may lead to stomach distention and persistent stimulation by retained food, causing increased gastrin release and acid secretion. Chronic renal failure leads to a decrease in clearance of gastrin from the circulation, resulting in hypergastrinemia. This increase in circulating gastrin results in stimulation of parietal cells to release acid into the gastric lumen. Therefore, the hypergastrinemia associated with chronic renal failure is inappropriate, given the high serum gastrin level despite low intragastric pH. Retained antrum results when a small portion of antrum is left attached to the duodenal bulb (afferent loop) during a Billroth II surgical procedure. As a result, the G cells from the retained antrum are displaced from the stomach and excluded from the inhibitory effects of gastric acid. The lack of negative feedback leads to persistently high gastrin release and resultant acid production. H. pylori pangastritis results in suppression of acid secretion, leading to a high intragastric pH. Therefore, it represents an appropriate cause for hypergastrinemia.

Reference

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.

Answer: B

Rationale

Hypergastrinemia is normally a physiologic response to hypochlorhydria. When hypergastrinemia occurs in the setting of acidic gastric pH, it is considered inappropriate. Gastrinoma is a component of MEN-1 syndrome that results in abnormal gastrin release and acid hypersecretion. Gastric outlet obstruction may lead to stomach distention and persistent stimulation by retained food, causing increased gastrin release and acid secretion. Chronic renal failure leads to a decrease in clearance of gastrin from the circulation, resulting in hypergastrinemia. This increase in circulating gastrin results in stimulation of parietal cells to release acid into the gastric lumen. Therefore, the hypergastrinemia associated with chronic renal failure is inappropriate, given the high serum gastrin level despite low intragastric pH. Retained antrum results when a small portion of antrum is left attached to the duodenal bulb (afferent loop) during a Billroth II surgical procedure. As a result, the G cells from the retained antrum are displaced from the stomach and excluded from the inhibitory effects of gastric acid. The lack of negative feedback leads to persistently high gastrin release and resultant acid production. H. pylori pangastritis results in suppression of acid secretion, leading to a high intragastric pH. Therefore, it represents an appropriate cause for hypergastrinemia.

Reference

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.