TABLE IV-114 Risk Factors for Active Tuberculosis Among Persons Who Have Been Infected With Tubercle Bacilli 20 page

A. Antinuclear antibodies in a homogeneous pattern

B. Anti-liver/kidney microsomal antibodies

C. Antimitochondrial antibodies

D. Hypergammaglobulinemia

E. Rheumatoid factor

VIII-52. In chronic hepatitis B virus (HBV) infection, the presence of hepatitis B e antigen (HBeAg) signifies which of the following?

A. Development of liver fibrosis leading to cirrhosis.

B. Dominant viral population is less virulent and less transmissible.

C. Increased likelihood of an acute flare in the next 1–2 weeks.

D. Ongoing viral replication.

E. Resolving infection.

VIII-53. A 32-year-old woman is admitted to the hospital with fever, abdominal pain, and jaundice. She drinks approximately 6 beers daily and has recently increased her alcohol intake to more than 12 beers daily. She has no other substance abuse history and has no history of alcoholic liver disease or pancreatitis. She is not taking any medications. On physical examination, she appears ill and disheveled with a fruity odor to her breath. Her vital signs are as follows: heart rate 122 beats/min, blood pressure 95/56 mmHg, respiratory rate 22 breaths/min, temperature 101.2°F, and oxygen saturation 98% on room air. She has scleral icterus, and spider angiomata are present on the trunk. The liver edge is palpable 10 cm below the right costal margin. It is smooth and tender to palpation. The spleen is not palpable. No ascites or lower extremity edema is present. Laboratory studies demonstrate an AST of 431 U/L, A LT of 198 U/L, bilirubin of 8.6 mg/dL, alkaline phosphatase of 201 U/L, amylase of 88 U/L, and lipase of 50 U/L. Total protein is 6.2 g/dL, and albumin is 2.8 g/dL. The prothrombin time is 28.9 seconds. What is the best approach to treatment of this patient?

A. Administer IV fluids, thiamine, and folate, and observe for improvement in laboratory tests and
clinical condition.

B. Administer IV fluids, thiamine, folate, and imipenem while awaiting blood culture results.

C. Administer prednisone 40 mg daily for 4 weeks before beginning a taper.

D. Consult surgery for management of acute cholecystitis.

E. Perform an abdominal CT with IV contrast to assess for necrotizing pancreatitis.

VIII-54. A 48-year-old woman presents complaining of fatigue and itching. She has been tired for the past 6 months and has recently developed diffuse itching. It is worse in the evening hours, but it is intermittent. She does not note it to be worse following hot baths or showers. Her past medical history is significant only for hypothyroidism for which she takes levothyroxine 125 μg daily. On physical examination, she has mild jaundice and scleral icterus. The liver is enlarged to 15 cm on palpation and is palpable 5 cm below the right costal margin. Xanthomas are seen on both elbows. Hyperpigmentation is noticeable on the trunk and arms where the patient has excoriations. Laboratory studies demonstrate the following: WBC 8900/μL, hemoglobin 13.3 g/dL, hematocrit 41.6%, and platelets 160,000/μL. The creatinine is 1.2 mg/dL. The AST is 52 U/L, A LT is 62 U/L, alkaline phosphatase is 216 U/L, total bilirubin is 3.2 mg/dL, and direct bilirubin is 2.9 mg/dL. The total protein is 8.2 g/dL, and albumin is 3.9 U/L. The thyroid-stimulating hormone is 4.5 U/mL. Antimitochondrial antibodies are positive. P-ANCA and C-ANCA are negative. What is the most likely cause of the patient’s symptoms?

A. Lymphoma

B. Polycythemia vera

C. Primary biliary cirrhosis

D. Primary sclerosis cholangitis

E. Uncontrolled hypothyroidism

VIII-55. A 63-year-old man presents to the emergency department complaining of hematemesis. The vomiting began abruptly and was not preceded by any abdominal pain or other symptoms. He describes the vomiting as about 500 mL of bright red blood. He has not had melena or bright red blood per rectum. He has known alcoholic cirrhosis and continues to drink at least 12 beers daily. He does not seek regular medical care, and he has not previously had an endoscopy to screen for varices. When he is initially evaluated in the emergency department, he is noted to be tachycardic with a heart rate of 125 beats/min and a blood pressure of 76/40. After 1 L of IV saline, his blood pressure increases to 92/56. He has an additional 300 mL of hematemesis upon arriving in the emergency department. The initial hematocrit is 32%. All of the following should be a part of the initial management of this patient EXCEPT:

A. Administration of octreotide 100 μg/h by continuous IV infusion

B. Administration of propranolol 10 mg four times daily

C. Emergent GI consult for upper endoscopy

D. Ongoing volume resuscitation with saline and packed red blood cells as needed to maintain
adequate blood pressure

E. Placement of large-bore IV access in the antecubital fossae or large central vein

VIII-56. A 42-year-old man with cirrhosis related to hepatitis C and alcohol abuse has ascites requiring frequent large-volume paracentesis. All of the following therapies would be indicated for this patient EXCEPT:

A. Fluid restriction to less than 2 L daily

B. Furosemide 40 mg daily

C. Sodium restriction to less than 2 g daily

D. Spironolactone 100 mg daily

E. Transjugular intrahepatic portosystemic shunt if medical therapy fails

VIII-57. Which of the following statements about cardiac cirrhosis is TRUE?

A. AST and ALT levels may mimic the very high levels seen in acute viral hepatitis.

B. Budd-Chiari syndrome cannot be distinguished clinically from cardiac cirrhosis.

C. Echocardiography is the gold standard for diagnosing constrictive pericarditis as a cause of
cirrhosis.

D. Prolonged passive congestion from right-sided heart failure results first in congestion and
necrosis of portal triads, resulting in subsequent fibrosis.

E. Venoocclusive disease can be confused with cardiac cirrhosis and is a major cause of morbidity
and mortality in patients undergoing liver transplantation.

VIII-58. You are asked to consult on a 62-year-old white female with pruritus for 4 months. She has noted progressive fatigue and a 5-lb weight loss. She has intermittent nausea but no vomiting and denies changes in her bowel habits. There is no history of prior alcohol use, blood transfusions, or illicit drug use. The patient is widowed and had two heterosexual partners in her lifetime. Her past medical history is significant only for hypothyroidism, for which she takes levothyroxine. Her family history is unremarkable. On examination she is mildly icteric. She has spider angiomata on her torso. You palpate a nodular liver edge 2 cm below the right costal margin. The remainder of the examination is unremarkable. A right upper quadrant ultrasound confirms your suspicion of cirrhosis. You order a complete blood count and a comprehensive metabolic panel. What is the most appropriate next test?

A. 24-hour urine copper

B. Antimitochondrial antibodies (AMA)

C. Endoscopic retrograde cholangiopancreatography (ERCP)

D. Hepatitis B serologies

E. Serum ferritin

VIII-59. A 58-year-old man is evaluated for a new diagnosis of cirrhosis. The patient has a medical history of diabetes mellitus, hypertriglyceridemia, and hypertension. He takes pioglitazone, rosuvastatin, lisinopril, and atenolol. He is a lifetime nonsmoker and has never used IV drugs. He drinks about one glass of wine weekly. For about 4–8 years in his 20s, he admits to binge drinking as much as 12–18 beers on the weekends, but has not drunk more than two glasses of wine weekly for many years. He has never had a blood transfusion and has been in a monogamous sexual relationship for 30 years. He has no family history of liver disease. He works as a machinist in a factory making airplane engines. He denies chemical exposures. His physical examination is notable for a body mass index of 45.9 kg/m². He has stigmata of chronic liver disease including spider angiomata and caput medusa. Moderate ascites is present. Workup has shown no evidence of viral hepatitis, hemochromatosis, Wilson’s disease, autoimmune hepatitis, or α₁ antitrypsin deficiency. He undergoes

liver biopsy, which shows fibrosis in a perivenular and perisinusoidal distribution. Which of the following statements is TRUE regarding the cause of the patient’s cirrhosis?

A. As opposed to individuals with metabolic syndrome alone, these individuals do not show
significant insulin resistance.

B. The aspartate aminotransferase is commonly elevated to more than twice the alanine
aminotransferase level.

C. The lack of steatohepatitis on liver biopsy rules out nonalcoholic fatty liver disease as a cause
of the patient’s cirrhosis.

D. The prevalence of the milder form of this disorder is between 10 and 20% in the United States
and Europe, with as much as 10–15% of affected individuals developing cirrhosis in some series.

E. Treatment with ursodeoxycholic acid and HMG-CoA reductase inhibitors has been demonstrated
to improve outcomes in this disorder.

VIII-60. Which of the following statements regarding liver transplantation is TRUE?

A. Individuals with cholangiocarcinoma should be referred early for consideration of liver
transplantation.

B. Living donor transplantation is only performed in children.

C. Reinfection with hepatitis B typically occurs in 35% or more of patients with liver
transplantation.

D. The 5-year survival rate for orthotopic liver transplantation is about 50%.

E. The most common indication for liver transplantation is chronic hepatitis B infection.

VIII-61. A 55-year-old male with cirrhosis is seen in the clinic for follow-up of a recent hospitalization for spontaneous bacterial peritonitis. He is doing well and finishing his course of antibiotics. He is taking propranolol and lactulose. Besides complications of end-stage liver disease, he has well-controlled diabetes mellitus and had a basal cell carcinoma resected 5 years ago. The cirrhosis is thought to be due to alcohol abuse, and his last drink of alcohol was 2 weeks ago. He and his wife ask if he is a liver transplant candidate. He can be counseled in which of the following ways?

A. Because he had a skin cancer he is not a transplant candidate.

B. Because he has diabetes mellitus he is not a transplant candidate.

C. He is appropriate for liver transplantation and should be referred immediately.

D. He is not a transplant candidate as he has a history of alcohol dependence.

E. He is not a transplant candidate now, but may be after a sustained period of proven abstinence
from alcohol.

VIII-62. A 44-year-old woman is evaluated for complaints of abdominal pain. She describes the pain as a postprandial burning pain. It is worse with spicy or fatty foods and is relieved with antacids. She is diagnosed with a gastric ulcer and is treated appropriately for Helicobacter pylori. During the course of her evaluation for her abdominal pain, the patient had a right upper quadrant ultrasound that demonstrated the presence of gallstones. Following treatment of H. pylori, her symptoms have resolved. She is requesting your opinion regarding whether treatment is required for the finding of gallstone disease. Upon review of the ultrasound report, there were numerous stones in the gallbladder, including in the neck of the gallbladder. The largest stone measures 2.8 cm. What is your advice to the patient regarding the risk of complications and the need for definitive treatment?

A. Given the size and number of stones, prophylactic cholecystectomy is recommended.

B. No treatment is necessary unless the patient develops symptoms of biliary colic frequently and
severely enough to interfere with the patient’s life.

C. The only reason to proceed with cholecystectomy is the development of gallstone pancreatitis or
cholangitis.

D. The risk of developing acute cholecystitis is about 5–10% per year.

E. Ursodeoxycholic acid should be given at a dose of 10–15 mg/kg daily for a minimum of 6
months to dissolve the stones.

VIII-63. A 62-year-old man has been hospitalized in intensive care for the past 3 weeks following an automobile accident resulting in multiple long-bone fractures and acute respiratory distress syndrome. He has been slowly improving, but remains on mechanical ventilation. He is now febrile and hypotensive, requiring vasopressors. He is being treated empirically with cefepime and vancomycin. Multiple blood cultures are negative. He has no new infiltrates or increasing secretions on chest radiograph. His laboratory studies demonstrated a rise in his liver function tests, bilirubin, and alkaline phosphatase. Amylase and lipase are normal. A right upper quadrant ultrasound shows sludge in the gallbladder, but no stones. The bile duct is not dilated. What is the next best step in the evaluation and treatment of this patient?

A. Discontinue cefepime.

B. Initiate treatment with clindamycin.

C. Initiate treatment with metronidazole.

D. Perform hepatobiliary scintigraphy.

E. Refer for exploratory laparotomy.

VIII-64. All of the following are associated with an increased risk for cholelithiasis EXCEPT:

A. Chronic hemolytic anemia

B. Female sex

C. High-protein diet

D. Obesity

E. Pregnancy

VIII-65. A 41-year-old female presents to your clinic with a week of jaundice. She notes pruritus, icterus, and dark urine. She denies fever, abdominal pain, or weight loss. The examination is unremarkable except for yellow discoloration of the skin. Total bilirubin is 6.0 mg/dL, and direct bilirubin is 5.1 mg/dL. AST is 84 U/L, and ALT is 92 U/L. Alkaline phosphatase is 662 U/L. CT scan of the abdomen is unremarkable. Right upper quadrant ultrasound shows a normal gallbladder but does not visualize the common bile duct. What is the most appropriate next management step?

A. Antibiotics and observation

B. Endoscopic retrograde cholangiopancreatography (ERCP)

C. Hepatitis serologies

D. HIDA scan

E. Serologies for antimitochondrial antibodies

VIII-66. A 27-year-old woman is admitted to the hospital with acute-onset severe right upper quadrant pain that radiates to the back. The pain is constant and not relieved with eating or bowel movements. Her labs show a marked elevation in amylase and lipase, and acute pancreatitis is diagnosed. Which of the following is the best first test to demonstrate the etiology of her pancreatitis?

A. Right upper quadrant ultrasound

B. Serum alcohol level

C. Serum triglyceride level

D. Technetium HIDA scan

E. Urine drug screen

VIII-67. A 58-year-old man with severe alcoholism is admitted to the hospital with acute pancreatitis. His symptoms have been present for 3 days and he has continued to drink heavily. He now has persistent vomiting and feels dizzy upon standing. On examination he has severe epigastric and right upper quadrant tenderness and decreased bowel sounds, and appears uncomfortable. A faint blue discoloration is present around the umbilicus. What is the significance of this finding?

A. A CT of the abdomen is likely to show severe necrotizing pancreatitis.

B. Abdominal plain film is likely to show pancreatic calcification.

C. Concomitant appendicitis should be ruled out.

D. He likely has a pancreatico-aortic fistula.

E. Pancreatic pseudocyst is likely present.

VIII-68. A 36-year-old man is admitted to the hospital with acute pancreatitis. In order to determine the severity of disease and risk of mortality, the BISAP (Bedside Index of Severity in Acute Pancreatitis) is calculated. All of the following variables are used to calculate this score EXCEPT:

A. Age greater than 60 years

B. BUN greater than 35

C. Impaired mental status

D. Pleural effusion

E. White blood cell count greater than 15,000 leukocytes/μL

VIII-69. A 54-year-old man is admitted to the intensive care unit with severe pancreatitis. His BMI is 30 or above and he has a prior history of diabetes mellitus. A CT of the abdomen is obtained and shows severe necrotizing pancreatitis. He is presently afebrile. Which of the following medications has been shown to be effective in the treatment of acute necrotizing pancreatitis?

A. Calcitonin

B. Cimetidine

C. Glucagon

D. Imipenem

E. None of the above

VIII-70. Which of the following statements is true regarding enteral feeding in acute pancreatitis?

A. A patient with persistent evidence of pancreatic necrosis on CT 2 weeks after acute presentation
should be maintained on bowel rest.

B. All patients with elevations of amylase and lipase and CT evidence of pancreatitis should be
fasted until amylase and lipase normalize.

C. Enteral feeding with a nasojejunal tube has been demonstrated to have fewer infectious
complications than total parenteral nutrition in the management of patients with acute pancreatitis.

D. Patients requiring surgical removal of infected pancreatic pseudocysts should be treated with
total parental nutrition.

E. Total parenteral nutrition has been shown to maintain integrity of the intestinal tract in acute
pancreatitis.

VIII-71. A 47-year-old woman presents to the emergency department with severe mid-abdominal pain radiating to her back. The pain began acutely and is sharp. She denies cramping or flatulence. She has had two episodes of emesis of bilious material since the pain began, but this has not lessened the pain. She currently rates the pain as a 10 out of 10 and feels the pain is worse in the supine position. For the past few months, she has had intermittent episodes of right upper and mid-epigastric pain that occurs after eating but subsides over a few hours. This is associated with a feeling of excess gas. She denies any history of alcohol abuse. She has no medical history of hypertension or hyperlipidemia. On physical examination, she is writhing in distress and slightly diaphoretic. Vital signs are as follows: heart rate 127 beats/min, blood pressure 92/50 mmHg, respiratory rate 20 breaths/min, temperature 37.9°C, and 88% oxygen saturation on room air. Her body mass index is 29 kg/m². The cardiovascular examination reveals a regular tachycardia. The chest examination shows dullness to percussion at bilateral bases with a few scattered crackles. On abdominal examination, bowel sounds are hypoactive. There is no rash or bruising evident on inspection of the abdomen. There is voluntary guarding on palpation. The pain with palpation is greatest in the periumbilical and epigastric areas without rebound tenderness. There is no evidence of jaundice, and the liver span is about 10 cm to percussion. Amylase level is 750 IU/L, and lipase level is 1129 IU/L. Other laboratory values include aspartate aminotransferase (AST) 168 U/L, alanine aminotransferase (ALT) 196 U/L, total bilirubin 2.3 mg/dL, alkaline phosphatase level 268 U/L, lactate dehydrogenase (LDH) 300 U/L, and creatinine 1.9 mg/dL. The hematocrit is 43%, and white blood cell (WBC) count is 11,500/μL with 89% neutrophils. An arterial blood gas shows a pH of 7.32, PCO₂ of 32 mmHg, and a PO₂ of 56 mmHg. An ultrasound confirms a dilated common bile duct with evidence of pancreatitis manifested as an edematous and enlarged pancreas. A CT scan shows no evidence of necrosis. After 3 L of normal saline, her blood pressure comes up to 110/60 mmHg with a heart rate of 105 beats/min. Which of the following statements best describes the pathophysiology of this disease?

A. Intrapancreatic activation of digestive enzymes with autodigestion and acinar cell injury

B. Chemoattraction of neutrophils with subsequent infiltration and inflammation

C. Distant organ involvement and systemic inflammatory response syndrome related to release of
activated pancreatic enzymes and cytokines

D. All of the above

VIII-72. A 25-year-old female with cystic fibrosis is diagnosed with chronic pancreatitis. She is at risk for all of the following complications EXCEPT:

A. Vitamin B₁₂ deficiency

B. Vitamin A deficiency

C. Pancreatic carcinoma

D. Niacin deficiency

E. Steatorrhea

VIII-73. A 64-year-old man seeks evaluation from his primary care physician because of chronic diarrhea. He reports that he has two or three large loose bowel movements daily. He describes them as markedly foul smelling, and they often leave an oily ring in the toilet. He also notes that the bowel movements often follow heavy meals, but if he fasts or eats low-fat foods, the stools are more formed. Over the past 6 months, he has lost about 18 kg. In this setting, he reports intermittent episodes of abdominal pain that can be quite severe. He describes the pain as sharp and in a mid-epigastric location. He has not sought evaluation of the pain previously, but when it occurs he will limit his oral intake and treat the pain with nonsteroidal anti-inflammatory drugs. He notes the pain has not lasted for more than 48 hours and is not associated with meals. His past medical history is remarkable for peripheral vascular disease and tobacco use. He currently smokes one pack of cigarettes daily. In addition, he drinks 2–6 beers daily. He has stopped all alcohol intake for up to a week at a time in the past without withdrawal symptoms. His current medications are aspirin 81 mg daily and albuterol metered dose inhaler (MDI) on an as-needed basis. On physical examination, the patient is thin but appears well. His body mass index is 18.2 kg/m². Vital signs are normal. Cardiac and pulmonary examinations are normal. The abdominal examination shows mild epigastric tenderness without rebound or guarding. The liver span is 12 cm to percussion and palpable 2 cm below the right costal margin. There is no splenomegaly or ascites present. There are decreased pulses in the lower extremities bilaterally. An abdominal radiograph demonstrates calcifications in the epigastric area, and CT scan confirms that these calcifications are located within the body of the pancreas. No pancreatic ductal dilatation is noted. Amylase level is 32 U/L, and lipase level is 22 U/L. What is the next most appropriate step in diagnosing and managing this patient’s primary complaint?

A. Advise the patient to stop all alcohol use and prescribe pancreatic enzymes.

B. Advise the patient to stop all alcohol use and prescribe narcotic analgesia and pancreatic
enzymes.

C. Perform angiography to assess for ischemic bowel disease.

D. Prescribe prokinetic agents to improve gastric emptying.

E. Refer the patient for endoscopic retrograde cholangiopancreatography (ERCP) for
sphincterotomy.

ANSWERS

VIII-1. The answer is E. (Chap. 292) Endoscopy, also known as esophagogastroduodenoscopy (EGD), is the best test for the evaluation of the proximal gastrointestinal tract. Because of high-quality images, disorders of color such as Barrett’s metaplasia, and mucosal irregularities are easily demonstrated. The sensitivity of endoscopy is superior to that of barium radiography for mucosal lesions. Because the endoscope has an instrumentation channel, biopsy specimens are easily obtained and dilation of

strictures can also be performed. The only advantage that barium radiography confers is the absence of the requirement for sedation, which, in some populations at risk for conscious sedation, is an important consideration.

VIII-2. The answer is E. (Chap. 292) Intermittent solid food dysphagia is a classic symptom in Schatzki’s ring in which a distal esophageal ring occurs at the squamocolumnar mucosal junction. The origin of these rings is unknown, and smaller rings with a lumen of greater than 13 mm are common in the general population (up to 15%). When the lumen is less than 13 mm, dysphagia may occur. Schatzki’s rings typically occur in persons older than 40 years and often cause “steakhouse syndrome” from meat getting stuck at the ring. The rings are easily treated with dilation. Plummer-Vinson syndrome also includes esophageal rings, but typically the rings occur in the proximal esophagus, are associated with iron-deficiency anemia, and occur in middle-aged women. Achalasia involves both solid and liquid dysphagia often with regurgitation. Adenocarcinoma often includes solid and liquid dysphagia at later stages. Most esophageal diverticulae are asymptomatic.

VIII-3. The answer is B. (Chap. 292) Aside from the discomfort and local complications of gastroesophageal reflux disease (GERD), a number of other non-GI–related sites may have a complication related to it. Syndromes with a well-established association with GERD include chronic cough, laryngitis, asthma, and dental erosions. Other diseases have implicated GERD as potentially contributory, but the role of GERD is less well established. These include pharyngitis, pulmonary fibrosis, chronic sinusitis, cardiac arrhythmias, sleep apnea, and recurrent aspiration pneumonia.

VIII-4. The answer is A. (Chap. 292) This patient has symptoms of esophagitis. In patients with HIV, various infections can cause this disease, including herpes simplex virus (HSV), cytomegalovirus (CMV), varicella-zoster virus (VZV), Candida, and HIV itself. The lack of thrush does not rule out Candida as a cause of esophagitis, and EGD is necessary for diagnosis. CMV classically causes serpiginous ulcers in the distal esophagus that may coalesce to form giant ulcers. Brushings alone are insufficient for diagnosis, and biopsies must be performed. Biopsies reveal intranuclear and intracytoplasmic inclusions with enlarged nuclei in large fibroblasts and endothelial cells. Given her notable swallowing symptoms, IV ganciclovir is the treatment of choice. Valganciclovir is an effective oral preparation. Foscarnet is useful in treating ganciclovir-resistant CMV. Herpes simplex virus manifests as vesicles and punched-out lesions in the esophagus, with the characteristic finding on biopsy of ballooning degeneration with ground-glass changes in the nuclei. It can be treated with acyclovir or foscarnet in resistant cases. Candida esophagitis has the appearance of yellow nodular plaques with surrounding erythema. Treatment usually requires fluconazole therapy. Finally, HIV alone can cause esophagitis that can be quite resistant to therapy. On EGD these ulcers appear deep and linear. Treatment with thalidomide or oral glucocorticoids is employed, and highly active antiretroviral therapy should be considered.

VIII-5. The answer is D. (Chap. 293) The patient has a duodenal ulcer, which is almost universally due to H. pylori infection, although in a minority of cases NSAID use may either facilitate development or be the only identified cause. The patient was taking acetaminophen and not a traditional NSAID, making H. pylori–associated peptic ulcer disease the most likely cause of the findings. H. pylori infection is closely correlated with advancing age, low socioeconomic status, and low education levels. After initial infection, antral gastritis is very common, and in a portion of cases, duodenal or gastric ulcers form. Associated with these conditions is the development of gastric cancer or MALT lymphoma.

Duodenal ulcers are rarely cancerous, although this is a not an uncommon finding in gastric cancers. After discovery of the ulcer, first-line therapy is eradication of H. pylori in addition to acid suppression.

VIII-6. The answer is D. (Chap. 293) Noninvasive testing for H. pylori infection is recommended in patients with suggestive symptoms and no other indication for endoscopy, e.g., GI bleeding, atypical symptoms. Several tests have good sensitivity and specificity, including plasma serology for H. pylori, ¹⁴C or ¹³C-urea breath test, and the fecal H. pylori antigen test. Sensitivity and specificity are greater than 80% and greater than 90%, respectively, for serology, while the urea breath test and fecal antigen testing are greater than 90% for both. Serology is not useful for early follow-up after therapy completion, as antibody titers will take several weeks to months to fall. The urea breath test, which relies on the presence of urease secreted by H. pylori to digest the swallowed radioactive urea and liberate ¹⁴C or ¹³C as part of ammonia, is simple and rapid. It is useful for early follow-up, as it requires living bacteria to secrete urease and produce a positive test. The limitations to the test include the requirement for ingestion of radioactive materials, albeit low dose, and false-negative results with recent use of PPI, antibiotics, or bismuth compounds. Stool antigen testing is cheap and convenient, but is not established for proof of eradication.

VIII-7. The answer is A. (Chap. 293) H. pylori should be eradicated in patients with documented peptic ulcer disease no matter the number of episodes, severity, presence of confounding factors (e.g., NSAID ingestion), or symptomatic status. Documented eradication of H. pylori is associated with substantially lower recurrence rates and symptom improvement. Treating patients with GERD who require long-term acid reduction therapy and the role of H. pylori eradication to prevent gastric cancer are controversial. Fourteen-day regimens are most effective. Shorter duration of therapy with current agents available has high recurrence rates. Dual-therapy regimens are not recommended because of eradication rates of less than 80%. A number of combinations are available (Table VIII-7). Triple-therapy regimens (one antacid plus two antibiotics) for 14 days have an eradication rate of 85–90%. Antibiotic resistance is the most common cause of failure to eradicate in compliant patients. Unfortunately, there is no currently available test for H. pylori sensitivity to direct therapy. Quadruple therapy should be reserved for patients with failure to eradicate after an effective initial course.

Date: 2016-04-22; view: 821