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GERD Quiz


GERD Quiz

تناغماً مع أجواء الهضمية المخيمة حالياً على حكيم!

(والمؤمنون والمؤمنات بعضهم أولياء بعض يأمرون بالمعروف وينهون عن المنكر ويقيمون الصلاة ويؤتون الزكاة ويطيعون الله و رسوله أولئك سيرحمهم الله إن الله عزيز حكيم)

Al Durra's picture
by
بعد التخرج


1) A 27-year-old woman presents with a 1-month history of daily burning retrosternal chest pain after meals.

Which of the following could be contributing to her acid reflux?

a). Stress

b). Starting sertraline

c). Starting fexofenadine

d). Weight gain

e). Low-fat diet

2) A 37-year-old man presents with typical symptoms of GERD and recent difficulty swallowing.

What is true regarding the next step in the workup of this patient?

a). He needs no further workup.

b). He should undergo endoscopy because it is preferable to barium radiography to diagnosis esophageal stricture.

c). He should undergo barium radiography because it is preferable to endoscopy to diagnose esophageal stricture.

d). He should undergo barium radiography or upper endoscopy as they are equivalent in diagnosing esophageal stricture.

e). He should have H. pylori serum testing.

3) A 45-year-old woman has symptoms of GERD that have not responded to 4 weeks each of over-the-counter antacids or a daily histamine-2 receptor blocker. She reports good adherence to dietary modifications.

The next step in her management is:

a). No further changes, as the symptoms of GERD rarely have significant impact on quality of life.

b). No further changes, as she has not had an adequate trial of H2RAs yet.

c). Once-daily PPI therapy.

d). Twice-daily H2RA blocker.

e). Referral to gastroenterologist for endoscopy.

4) A 26-year-old woman is in the emergency department with fever, cough, and shortness of breath, and is diagnosed with community-acquired pneumonia. Which of the following medications, started in the past 2 weeks, could have contributed to her developing this illness?

a). Lansoprazole

b). Metoclopramide

c). Oral contraceptive pill

d). Isotretinoin

e). Sertraline

5) A 67-year-old man will be discharged from the hospital today after suffering an inferior wall MI. He takes omeprazole for GERD. Which of the following medications will the omeprazole interfere with?

a). Metoprolol

b). Lisinopril

c). Atorvastatin

d). Aspirin

e). Clopidogrel

6) Which of the following are complications of GERD?

a). Stricture formation

b). Esophageal squamous cell carcinoma

c). Sinusitis

d). H. pylori infection

e). None of the above.

7) A 38-year-old man has 2 months of bothersome retrosternal burning after meals and at bedtime that has not come under control with twice-daily proton-pump inhibitors.

What should be the next step in your management?

a). Continue with current management because he is at maximum treatment, and there is nothing else to offer him.

b). Continue with current management, because he does not have any complications of GERD.

c). Refer to a gastroenterologist, because he needs a long-term management strategy.

d). Refer to a gastroenterologist, because he needs esophageal pH monitoring to confirm the diagnosis of GERD.

e). Refer to a gastroenterologist, because his symptoms are unlikely to be due to GERD.

-END-

Al Durra's picture
Al Durra
بعد التخرج

Quote:
1) A 27-year-old woman presents with a 1-month history of daily burning retrosternal chest pain after meals.

Which of the following could be contributing to her acid reflux?

a). Stress

b). Starting sertraline

c). Starting fexofenadine

d). Weight gain

e). Low-fat diet

-------------------------------------

Quote:
2) A 37-year-old man presents with typical symptoms of GERD and recent difficulty swallowing.

What is true regarding the next step in the workup of this patient?

a). He needs no further workup.

b). He should undergo endoscopy because it is preferable to barium radiography to diagnosis esophageal stricture.

c). He should undergo barium radiography because it is preferable to endoscopy to diagnose esophageal stricture.

d). He should undergo barium radiography or upper endoscopy as they are equivalent in diagnosing esophageal stricture.

e). He should have H. pylori serum testing.

----------------------------------------

Quote:
3) A 45-year-old woman has symptoms of GERD that have not responded to 4 weeks each of over-the-counter antacids or a daily histamine-2 receptor blocker. She reports good adherence to dietary modifications.

The next step in her management is:

a). No further changes, as the symptoms of GERD rarely have significant impact on quality of life.

b). No further changes, as she has not had an adequate trial of H2RAs yet.

c). Once-daily PPI therapy.

d). Twice-daily H2RA blocker.

e). Referral to gastroenterologist for endoscopy.

-------------------------------

Quote:
4) A 26-year-old woman is in the emergency department with fever, cough, and shortness of breath, and is diagnosed with community-acquired pneumonia. Which of the following medications, started in the past 2 weeks, could have contributed to her developing this illness?

a). Lansoprazole

b). Metoclopramide

c). Oral contraceptive pill

d). Isotretinoin

e). Sertraline

----------------------

Quote:
5) A 67-year-old man will be discharged from the hospital today after suffering an inferior wall MI. He takes omeprazole for GERD. Which of the following medications will the omeprazole interfere with?

a). Metoprolol

b). Lisinopril

c). Atorvastatin

d). Aspirin

e). Clopidogre

l

------------------------

Quote:
6) Which of the following are complications of GERD?

a). Stricture formation

b). Esophageal squamous cell carcinoma

c). Sinusitis

d). H. pylori infection

e). None of the above.

--------------------------------------------------

Quote:
7) A 38-year-old man has 2 months of bothersome retrosternal burning after meals and at bedtime that has not come under control with twice-daily proton-pump inhibitors.

What should be the next step in your management?

a). Continue with current management because he is at maximum treatment, and there is nothing else to offer him.

b). Continue with current management, because he does not have any complications of GERD.

c). Refer to a gastroenterologist, because he needs a long-term management strategy.

d). Refer to a gastroenterologist, because he needs esophageal pH monitoring to confirm the diagnosis of GERD.

e). Refer to a gastroenterologist, because his symptoms are unlikely to be due to GERD

.

mbs2380's picture
mbs2380
بعد التخرج


Sorry ,for number 2 I meant the Barium ,,so I would go w C
2 C

mbs2380's picture
mbs2380
بعد التخرج

good job man, 4/7
i have to admit that there r one or two confusing qs that i got them wrong myself, but they r useful for practice though.
Al Durra's picture
Al Durra
بعد التخرج


1) A 27-year-old woman presents with a 1-month history of daily burning retrosternal chest pain after meals.

Which of the following could be contributing to her acid reflux?

a). Stress

b). Starting sertraline

c). Starting fexofenadine

d). Weight gain

e). Low-fat diet

2) A 37-year-old man presents with typical symptoms of GERD and recent difficulty swallowing.

What is true regarding the next step in the workup of this patient?

a). He needs no further workup.

b). He should undergo endoscopy because it is preferable to barium radiography to diagnosis esophageal stricture.

c). He should undergo barium radiography because it is preferable to endoscopy to diagnose esophageal stricture.

d). He should undergo barium radiography or upper endoscopy as they are equivalent in diagnosing esophageal stricture.

e). He should have H. pylori serum testing.

3) A 45-year-old woman has symptoms of GERD that have not responded to 4 weeks each of over-the-counter antacids or a daily histamine-2 receptor blocker. She reports good adherence to dietary modifications.

The next step in her management is:

a). No further changes, as the symptoms of GERD rarely have significant impact on quality of life.

b). No further changes, as she has not had an adequate trial of H2RAs yet.

c). Once-daily PPI therapy.

d). Twice-daily H2RA blocker.

e). Referral to gastroenterologist for endoscopy.

4) A 26-year-old woman is in the emergency department with fever, cough, and shortness of breath, and is diagnosed with community-acquired pneumonia. Which of the following medications, started in the past 2 weeks, could have contributed to her developing this illness?

a). Lansoprazole

b). Metoclopramide

c). Oral contraceptive pill

d). Isotretinoin

e). Sertraline

5) A 67-year-old man will be discharged from the hospital today after suffering an inferior wall MI. He takes omeprazole for GERD. Which of the following medications will the omeprazole interfere with?

a). Metoprolol

b). Lisinopril

c). Atorvastatin

d). Aspirin

e). Clopidogrel

6) Which of the following are complications of GERD?

a). Stricture formation

b). Esophageal squamous cell carcinoma

c). Sinusitis

d). H. pylori infection

e). None of the above.

7) A 38-year-old man has 2 months of bothersome retrosternal burning after meals and at bedtime that has not come under control with twice-daily proton-pump inhibitors.

What should be the next step in your management?

a). Continue with current management because he is at maximum treatment, and there is nothing else to offer him.

b). Continue with current management, because he does not have any complications of GERD.

c). Refer to a gastroenterologist, because he needs a long-term management strategy.

d). Refer to a gastroenterologist, because he needs esophageal pH monitoring to confirm the diagnosis of GERD.

e). Refer to a gastroenterologist, because his symptoms are unlikely to be due to GERD.

-END-

Green Wave's picture
Green Wave


green, 3/7
حليت الصعب و السهل غلطت فيهRolling Eyes

Al Durra's picture
Al Durra
بعد التخرج


1 d
2 c
3 c
4 c
5 e
6 a
7 e

Dr.mTm's picture
Dr.mTm
بعد التخرج


d 1
d 2
c 3
c 4
d 5
e 6
c 7

lonely
طبيب مقيم


I have 2 problems with the above questions
In question 2 there is this ever lasting debate about how to start work up of dysphagia which is practically a mute point since patients will almost always have both EGD and Barium Swallow. SO practically it does not matter with which one you start except in the following conditions
1- When there is documented or suspected malignancy then I always start with barium so I prepare myself with necessary equipemets (size of scope, need for biopsy , thought of placing esophageal stent)
2- Whenever one test is negative the other test is done later (one test is not enough to excludes pathology) .Typically on background of GERD endoscopy is preferred because you can assess for esophagitis and its degree and you can screen for Barrett's (which is another topic for debate)
3- For internal medicine purposes (non specialist approach ) typically students and docotors are taught to start with barium study since it is less invasive and still keeps the patient in the domain of the primary care (before referring to the gastroenterologist endoscopist). However there are no solid and evidence based recommendation to recommed starting one way or another.

In question 6 there are 2 correct choices although there is one classic and well-known and the other one has been identified recently and there is more and more literature to link it to GERD.

ABIM's picture
ABIM


mtm & lonely, u both got 4/7
good for u

دكتور عمر, جواب السؤال الثاني ليس الجواب التقليدي الي انت او انا او كل الشباب متوقعينهEye-wink

سؤال للشباب المشاركين: اختياركم مانعات الحمل كسبب لحدوث ذات الرئة عن علم و لا تشليف؟

Al Durra's picture
Al Durra
بعد التخرج


1- D
2-BYOu have to know few things though
in 1- Although stress do not lead to reflux but it cane lead to more symptoms (all sort of symptoms including symsptoms of reflux
Read:
.
Scand J Gastroenterol. 2010;45(1):21-9.

Stressful psychosocial factors and symptoms of gastroesophageal reflux disease: a population-based study in Norway.
Jansson C, Wallander MA, Johansson S, Johnsen R, Hveem K.
CONCLUSIONS: This population-based study reveals a link between stressful psychosocial factors, including job strain, and GERD symptoms.

2- B
) and insist on it as a gastroenterologist based on ASGE guidelines

http://www.asge.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=4182

3- C

This is a very fair and resobale question: I don't think 2 will disagree

4- A

The evidence comes from observational studies and this was warned against by the ACG (American college of gastroenterology) the theory that acid suppression and lead to bacterial overgrowth in stomach with microaspirations.

5- E
Another question that is stil a source of major debate. Thought the FDA in sep 2009 issued a warning in that regard. Practically every onth a see an artcel about the topic; one says there is a problem with combing PPI and Clopedogril and the other one refutes that concern???!!

6- A and C

see
Gastroesophageal reflux disease and chronic sinusitis: in search of an esophageal-nasal reflex.

Wong IW, Rees G, Greiff L, Myers JC, Jamieson GG, Wormald PJ.

Am J Rhinol Allergy. 2010 Jul-Aug;24(4):255-9.

or just go to PUBmed and type GERD and sinusitis
(unlsess there is trick in the word complication and the meaning is rather manifestation and not necessarly a complication

As for stricturesof esophagus it is a well known complication assoicated with GERD
7- E
see this : just look at the table
http://www.acg.gi.org/physicians/guidelines/EsophagealRefluxTesting.pdf

ABIM's picture
ABIM


شكرا جزيلا دكتور عمر على المشاركة
مصدر الاسئلة John Hopkins Medicine-Internet Learner Center

Answers:
D
D
C
A
E
A
C

Discussion for Question 1
Weight gain can increase reflux because of increased intra-abdominal pressure overcoming the lower esophageal sphincter. Stress may lead to increased acid production, but in and of itself, should not lead to acid reflux. A high fat diet can cause GERD, but not a low-fat diet. Among medications, anti-cholinergic agents, beta-blockers, and calcium channel blockers can cause GERD, but not sertraline or fexofenadine.

ما كان في مشاكل و الجميع أجاب الإجابة الصحيحة
____________________________________________________
Discussion for Question 2
Dysphagia is a worrisome symptom so it should prompt further investigation. Barium radiography or endoscopy should be considered. Barium radiography is not as good as endoscopy for diagnosing Barrett's esophagus, but it is equivalent to EGD in revealing stricture, which would be a possible explanation of the dysphagia . H. pylori has not been implicated in esophageal disease, so testing for it in this patient with heartburn and dysphagia is not indicated.

ببساطة متل ما حكيت دكتور ممكن نعمل أي واحد من الاختبارين و السؤال ليس عن الخطوة الأولى كما تعودنا أن يكون السؤال بل بشكل عام.

________________________________________________________

Discussion for Question 3
Symptomatic GERD can have a significant impact on quality of life. After 4 weeks of OTC treatment, including H2RA blockers, the next step would be addition of a PPI. Increasing the dose of the H2RA blocker may still not be effective. It is premature to consider EGD, given the lack of worrisome symptoms and the fact that she has not had a PPI trial yet.

_____________________________________________________________
Discussion for Question 4
Recent PPI use has been associated with community acquired pneumonia in young adults. No such association has been seen with the other medications listed.

كان في noon conference من حوالي 3 شهور و ذكروا عدم وجود RCTs تدعم الموضوع إلى الآن....لكن هناك توصيات على ما أعتقد بالإقلال من استعمال PPIs للتقليل من خطر CAP الملاحظ خلال observational studies
_______________________________________________________________
Discussion for Question 5
PPI use may interfere with the action of clopidogrel by inhibiting the cytochrome P450 2C19, which clopidogrel requires for activation. No significant drug-drug interactions have been reported between omeprazole and the other medications listed.

أيضاً الاسبوع الماضي كان في Grand round عن الموضوع و الخلاصة أن ال PPI تقلل من خطورة النزف الهضمي و لكن بعض الدراسات وجدت أنها تزيد من الحوادث القلبية الوعائية بسبب تداخل عملها مع clopidogrel/plavix و دراسات اخرى لم تجد هذا الترابط!
الخلاصة على ما أذكر كانت الاقتصار على استعمال PPI في حال كانت خطورة النزف الهضمي عالية و استبدالها بanti-histamie 2 في حال كانت خطورة النزف منخفضة, بانتظار مزيد من الدراسات حول الموضوع.

لما المريض بيكون على clopidogrel و لا بد من إعطائه PPI كنا نعطيه pantoprazole تحديداً و السبب

Among the PPIs, pantoprazole has not been shown to interact with clopidogrel, so pantoprazole would be the best choice for acid suppression in this man with recent unstable angina.
__________________________________________
Discussion for Question 6
GERD can lead to stricture formation and adenocarcinoma, but not esophageal squamous cell carcinoma. It has not been implicated in sinusitis or the loss of smell. H. pylori infection is not a complication of GERD.

_____________________________________________
Discussion for Question 7
He has typical GERD symptoms, but they are not under control, so he needs a long term management strategy. Since he is still symptomatic, a change in his regimen may be in order. Therefore referral to a gastroenterologist should be obtained to get additional treatment recommendations. He has not had the GERD long enough to have developed serious complications like Barrett's esophagus. Esophageal pH monitoring is not needed to make the diagnosis of GERD.
_________________________________________________

و الشكر للجميع!

Al Durra's picture
Al Durra
بعد التخرج


شخصياً حسيت بصعوبة و عدم وضوح بعض الأسئلة و لكن اخترت انزالها لأنها المجموعة الوحيدة المتعلقة بالهضمية التي هي مجال النقاش حالياً.

مجموعات الاسئلة الماضية كانت اكثر وضوحا و كذلك ستكون القادمة بإن الله -طبعاً إن أردتم ذلك-

الهدف أولا و أخيرا طالب الطب Cool
مو الرزدنت المشحر Sad

Al Durra's picture
Al Durra
بعد التخرج


شكرا لك ...(وشكرا دكتور عمر عالمداخلة )
ALDURRA ,,متابعين معك باذن الله Eye-wink

Quote:
لهدف أولا و أخيرا طالب الطب Cool
مو الرزدنت المشحر Sad

يا سيدي , اذا "كون" الواحد رزدنت فهو ال"تشحير" , فالله يجعلنا من اولئك المشحرين ...

And as I said .......Waiting for more cases

mbs2380's picture
mbs2380
بعد التخرج


Couple of last comments:
On question 2: looking for stricture is not the only reason for investigations: They did mention Barrett's (that don't show on barium) and also esophagitis grading is not possible by barium.You can't predict base on the age alone the presence or abscence of Barrett's . Add to that the chance that endoscopy gives you to dilate in case you see a stricture) . So with no doubt in my mind EGD MUST be done while Barium COULD be done .
(This question was not written by an endoscopist)confused

As for the question 6 I encourage everyone to search for themselves and see how many atricles and studies are linking sinusits with GERD. I am not with advertising that or pushing too much for this idea but just to tell you it is still possible

Finally the last question is really pointless. As a primary care physician you need to know when to refer patients to specialists but what they will do later or how long they will keep the patient with them is not up to you to decide. So all three last options are the same from partical point of view (which is to refer the patient to meEye-wink )
Now as gastroenterologists we have certain check points to approach such patients starting with endoscopy and also considering ph study not only to diagnose GERD but also to determine hypersensitive esophagus status , look for symptoms association and evaluate for the need of Nissen Fundoplication (after ruling other diagnoses) and makng sure the patient is taking the PPI the right way.
For more readings you can look up the link providing up

ستجدون بعض الفروق في مقاربة المرضى من زاوية الطب الباطني العام و من زاوية المتخصصين و لكل وجهة نظره .
Thanks AlDurra for the questions.

ABIM's picture
ABIM
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