DDSEP® 8 Quick Quiz

Q2. Correct answer: A - No monitoring of PPI side effects. 

Rationale 

There are several putative risks associated with long-term PPI use: chronic kidney disease, dementia, vitamin and mineral deficiencies, and others. However, the overall quality of evidence to support these conclusions is low or very low, and the majority of the findings have low effect sizes that may be attributed to confounding. An American Gastroenterological Association clinical practice update recommended against routine monitoring for patients receiving long-term PPI treatment. However, data show that more than one-third of gastroenterologists still check for PPI side effects at least annually in their patients. 

 
References 

Freedberg DE, Kim LS, Yang YX. The Risks and Benefits of Long-Term Use of Proton Pump Inhibitors: Expert Review and Best Practice Advice From the American Gastroenterological Association. Gastroenterology. 2017;152(4):706-15. doi: 10.1053/j.gastro.2017.01.031. 
 
Leiman DA, Ravi K, Freedberg DE, Gyawali CP. Proton Pump Inhibitor Prescribing and Monitoring Patterns Among Gastroenterology Practitioners (published online ahead of print, 2021 Oct 4). J Clin Gastroenterol. 2021;10.1097/MCG.0000000000001623. doi: 10.1097/MCG.0000000000001623.

Q2. Correct answer: A - No monitoring of PPI side effects. 

Rationale 

There are several putative risks associated with long-term PPI use: chronic kidney disease, dementia, vitamin and mineral deficiencies, and others. However, the overall quality of evidence to support these conclusions is low or very low, and the majority of the findings have low effect sizes that may be attributed to confounding. An American Gastroenterological Association clinical practice update recommended against routine monitoring for patients receiving long-term PPI treatment. However, data show that more than one-third of gastroenterologists still check for PPI side effects at least annually in their patients. 

 
References 

Freedberg DE, Kim LS, Yang YX. The Risks and Benefits of Long-Term Use of Proton Pump Inhibitors: Expert Review and Best Practice Advice From the American Gastroenterological Association. Gastroenterology. 2017;152(4):706-15. doi: 10.1053/j.gastro.2017.01.031. 
 
Leiman DA, Ravi K, Freedberg DE, Gyawali CP. Proton Pump Inhibitor Prescribing and Monitoring Patterns Among Gastroenterology Practitioners (published online ahead of print, 2021 Oct 4). J Clin Gastroenterol. 2021;10.1097/MCG.0000000000001623. doi: 10.1097/MCG.0000000000001623.

Q2. Correct answer: A - No monitoring of PPI side effects. 

Rationale 

There are several putative risks associated with long-term PPI use: chronic kidney disease, dementia, vitamin and mineral deficiencies, and others. However, the overall quality of evidence to support these conclusions is low or very low, and the majority of the findings have low effect sizes that may be attributed to confounding. An American Gastroenterological Association clinical practice update recommended against routine monitoring for patients receiving long-term PPI treatment. However, data show that more than one-third of gastroenterologists still check for PPI side effects at least annually in their patients. 

 
References 

Freedberg DE, Kim LS, Yang YX. The Risks and Benefits of Long-Term Use of Proton Pump Inhibitors: Expert Review and Best Practice Advice From the American Gastroenterological Association. Gastroenterology. 2017;152(4):706-15. doi: 10.1053/j.gastro.2017.01.031. 
 
Leiman DA, Ravi K, Freedberg DE, Gyawali CP. Proton Pump Inhibitor Prescribing and Monitoring Patterns Among Gastroenterology Practitioners (published online ahead of print, 2021 Oct 4). J Clin Gastroenterol. 2021;10.1097/MCG.0000000000001623. doi: 10.1097/MCG.0000000000001623.

Q1. Correct answer: B - Adding calcium carbonate (antacid) to her current regimen  

Rationale 

Compared with proton pump inhibitors (PPIs), vonoprazan is a potassium-competitive acid blocker (PCAB), which inhibits acid secretion by competitively blocking availability of potassium to hydrogen-potassium ATPase. Vonoprazan is rapidly absorbed independent of eating and is not affected by CYP2C19 polymorphisms. Several studies have compared PPIs with vonoprazan. Although vonoprazan is highly effective for treating LA Grade A and B esophagitis, so is lansoprazole, and healing rates at 8 weeks are 100% versus 99.2%, respectively. In contrast, vonoprazan healing of LA Grade C and D esophagitis at 8 weeks is 98.7% compared with 87.5% for lansoprazole. 
Sleeping on pillows is not a reliable way to reduce reflux, as patients often move during sleep and lose any benefit from being propped on them. Antacids would not provide superior acid inhibition, compared with vonoprazan, and avoiding spicy foods would not address the underlying permissive reflux barrier that exists (hiatal hernia). 

Reference 

Graham DY and Dore MP. Update on the Use of Vonoprazan: A Competitive Acid Blocker. Gastroenterology. 2018;154(3):462-6. doi: 10.1053/j.gastro.2018.01.018.

Q1. Correct answer: B - Adding calcium carbonate (antacid) to her current regimen  

Rationale 

Compared with proton pump inhibitors (PPIs), vonoprazan is a potassium-competitive acid blocker (PCAB), which inhibits acid secretion by competitively blocking availability of potassium to hydrogen-potassium ATPase. Vonoprazan is rapidly absorbed independent of eating and is not affected by CYP2C19 polymorphisms. Several studies have compared PPIs with vonoprazan. Although vonoprazan is highly effective for treating LA Grade A and B esophagitis, so is lansoprazole, and healing rates at 8 weeks are 100% versus 99.2%, respectively. In contrast, vonoprazan healing of LA Grade C and D esophagitis at 8 weeks is 98.7% compared with 87.5% for lansoprazole. 
Sleeping on pillows is not a reliable way to reduce reflux, as patients often move during sleep and lose any benefit from being propped on them. Antacids would not provide superior acid inhibition, compared with vonoprazan, and avoiding spicy foods would not address the underlying permissive reflux barrier that exists (hiatal hernia). 

Reference 

Graham DY and Dore MP. Update on the Use of Vonoprazan: A Competitive Acid Blocker. Gastroenterology. 2018;154(3):462-6. doi: 10.1053/j.gastro.2018.01.018.

Q1. Correct answer: B - Adding calcium carbonate (antacid) to her current regimen  

Rationale 

Compared with proton pump inhibitors (PPIs), vonoprazan is a potassium-competitive acid blocker (PCAB), which inhibits acid secretion by competitively blocking availability of potassium to hydrogen-potassium ATPase. Vonoprazan is rapidly absorbed independent of eating and is not affected by CYP2C19 polymorphisms. Several studies have compared PPIs with vonoprazan. Although vonoprazan is highly effective for treating LA Grade A and B esophagitis, so is lansoprazole, and healing rates at 8 weeks are 100% versus 99.2%, respectively. In contrast, vonoprazan healing of LA Grade C and D esophagitis at 8 weeks is 98.7% compared with 87.5% for lansoprazole. 
Sleeping on pillows is not a reliable way to reduce reflux, as patients often move during sleep and lose any benefit from being propped on them. Antacids would not provide superior acid inhibition, compared with vonoprazan, and avoiding spicy foods would not address the underlying permissive reflux barrier that exists (hiatal hernia). 

Reference 

Graham DY and Dore MP. Update on the Use of Vonoprazan: A Competitive Acid Blocker. Gastroenterology. 2018;154(3):462-6. doi: 10.1053/j.gastro.2018.01.018.

Q2. Correct answer: A. Enteric infection 

Rationale 

Despite the numerous side effects associated with long-term PPI use, the quality of evidence and risk of confounding from these studies limits the ability to ascribe sufficient cause and effect between PPI use and these outcomes. However, a recent large randomized controlled trial that evaluated the use of pantoprazole versus placebo demonstrated a statistically significant difference between the pantoprazole and placebo groups only in enteric infections (1.4% vs 1.0%; odds ratio, 1.33; 95% confidence interval, 1.01-1.75). Despite a nearly double increased risk of Clostridioides difficile infection in the PPI group, compared with the placebo group, the number of events was low, and the difference did not reach statistical significance. In the context of these data, and more recent studies suggesting an increased risk of COVID-19 in patients who take PPIs, compared with those who do not, the risk of enteric infections is likely small but significantly increased among long-term PPI users. 

References 

• Freedberg DE et al. Gastroenterology. 2017;152(4):706-15. doi: 10.1053/j.gastro.2017.01.031. 
• Moayyedi P et al. Gastroenterology. 2019;157(3):682-91.e2. doi: 10.1053/j.gastro.2019.05.056.

Q2. Correct answer: A. Enteric infection 

Rationale 

Despite the numerous side effects associated with long-term PPI use, the quality of evidence and risk of confounding from these studies limits the ability to ascribe sufficient cause and effect between PPI use and these outcomes. However, a recent large randomized controlled trial that evaluated the use of pantoprazole versus placebo demonstrated a statistically significant difference between the pantoprazole and placebo groups only in enteric infections (1.4% vs 1.0%; odds ratio, 1.33; 95% confidence interval, 1.01-1.75). Despite a nearly double increased risk of Clostridioides difficile infection in the PPI group, compared with the placebo group, the number of events was low, and the difference did not reach statistical significance. In the context of these data, and more recent studies suggesting an increased risk of COVID-19 in patients who take PPIs, compared with those who do not, the risk of enteric infections is likely small but significantly increased among long-term PPI users. 

References 

• Freedberg DE et al. Gastroenterology. 2017;152(4):706-15. doi: 10.1053/j.gastro.2017.01.031. 
• Moayyedi P et al. Gastroenterology. 2019;157(3):682-91.e2. doi: 10.1053/j.gastro.2019.05.056.

Q2. Correct answer: A. Enteric infection 

Rationale 

Despite the numerous side effects associated with long-term PPI use, the quality of evidence and risk of confounding from these studies limits the ability to ascribe sufficient cause and effect between PPI use and these outcomes. However, a recent large randomized controlled trial that evaluated the use of pantoprazole versus placebo demonstrated a statistically significant difference between the pantoprazole and placebo groups only in enteric infections (1.4% vs 1.0%; odds ratio, 1.33; 95% confidence interval, 1.01-1.75). Despite a nearly double increased risk of Clostridioides difficile infection in the PPI group, compared with the placebo group, the number of events was low, and the difference did not reach statistical significance. In the context of these data, and more recent studies suggesting an increased risk of COVID-19 in patients who take PPIs, compared with those who do not, the risk of enteric infections is likely small but significantly increased among long-term PPI users. 

References 

• Freedberg DE et al. Gastroenterology. 2017;152(4):706-15. doi: 10.1053/j.gastro.2017.01.031. 
• Moayyedi P et al. Gastroenterology. 2019;157(3):682-91.e2. doi: 10.1053/j.gastro.2019.05.056.

Q1. Correct answer: D. Rabeprazole 

Rationale 

Within-class switching of proton pump inhibitors (PPIs) for patients with incomplete control of symptoms is frequently done in clinical practice. For the management of gastroesophageal reflux disease, this practice can be "considered" according to guidelines. More recent data suggest varying potencies of PPIs might be responsible for some patient's incomplete response. When measured as omeprazole equivalents, the relative potencies of standard-dose pantoprazole, lansoprazole, omeprazole, esomeprazole, and rabeprazole have been estimated at 0.23, 0.90, 1.00, 1.60, and 1.82 OEs, respectively. 

References 

• Graham DY and Tansel A. Clin Gastroenterol Hepatol. 2018;16(6):800-8.e7. doi: 10.1016/j.cgh.2017.09.033 
• Katz PO et al. Am J Gastroenterol. 2022;117(1):27-56. doi: 10.14309/ ajg.0000000000001538 
• Kirchheiner J et al. Eur J Clin Pharmacol. 2009;65(1):19-31. doi: 10.1007/s00228-008-0576-5

Q1. Correct answer: D. Rabeprazole 

Rationale 

Within-class switching of proton pump inhibitors (PPIs) for patients with incomplete control of symptoms is frequently done in clinical practice. For the management of gastroesophageal reflux disease, this practice can be "considered" according to guidelines. More recent data suggest varying potencies of PPIs might be responsible for some patient's incomplete response. When measured as omeprazole equivalents, the relative potencies of standard-dose pantoprazole, lansoprazole, omeprazole, esomeprazole, and rabeprazole have been estimated at 0.23, 0.90, 1.00, 1.60, and 1.82 OEs, respectively. 

References 

• Graham DY and Tansel A. Clin Gastroenterol Hepatol. 2018;16(6):800-8.e7. doi: 10.1016/j.cgh.2017.09.033 
• Katz PO et al. Am J Gastroenterol. 2022;117(1):27-56. doi: 10.14309/ ajg.0000000000001538 
• Kirchheiner J et al. Eur J Clin Pharmacol. 2009;65(1):19-31. doi: 10.1007/s00228-008-0576-5

Q1. Correct answer: D. Rabeprazole 

Rationale 

Within-class switching of proton pump inhibitors (PPIs) for patients with incomplete control of symptoms is frequently done in clinical practice. For the management of gastroesophageal reflux disease, this practice can be "considered" according to guidelines. More recent data suggest varying potencies of PPIs might be responsible for some patient's incomplete response. When measured as omeprazole equivalents, the relative potencies of standard-dose pantoprazole, lansoprazole, omeprazole, esomeprazole, and rabeprazole have been estimated at 0.23, 0.90, 1.00, 1.60, and 1.82 OEs, respectively. 

References 

• Graham DY and Tansel A. Clin Gastroenterol Hepatol. 2018;16(6):800-8.e7. doi: 10.1016/j.cgh.2017.09.033 
• Katz PO et al. Am J Gastroenterol. 2022;117(1):27-56. doi: 10.14309/ ajg.0000000000001538 
• Kirchheiner J et al. Eur J Clin Pharmacol. 2009;65(1):19-31. doi: 10.1007/s00228-008-0576-5

Correct answer: B. Selenium exposure. 
 
Rationale 
Helicobacter pylori infection is by far the most important risk factor for gastric cancer worldwide. Less common risk factors for gastric cancer include Lynch syndrome, Peutz-Jeghers syndrome, Menetrier's disease, and germline mutations in the CDH gene (encoding E-cadherin). However, there is some evidence that selenium, as well as high consumption of fruits and vegetables, may have protective effects against gastric cancer.  
 
References  
de Martel C et al. Gastroenterol Clin North Am. 2013 Jun;42(2):219-40.  
Giardiello FM et al. N Engl J Med. 1987 Jun 11;316(24):1511-4.  
Qiao YL et al. J Natl Cancer Inst. 2009 Apr 1;101(7):507-18. 

Correct answer: B. Selenium exposure. 
 
Rationale 
Helicobacter pylori infection is by far the most important risk factor for gastric cancer worldwide. Less common risk factors for gastric cancer include Lynch syndrome, Peutz-Jeghers syndrome, Menetrier's disease, and germline mutations in the CDH gene (encoding E-cadherin). However, there is some evidence that selenium, as well as high consumption of fruits and vegetables, may have protective effects against gastric cancer.  
 
References  
de Martel C et al. Gastroenterol Clin North Am. 2013 Jun;42(2):219-40.  
Giardiello FM et al. N Engl J Med. 1987 Jun 11;316(24):1511-4.  
Qiao YL et al. J Natl Cancer Inst. 2009 Apr 1;101(7):507-18. 

Correct answer: B. Selenium exposure. 
 
Rationale 
Helicobacter pylori infection is by far the most important risk factor for gastric cancer worldwide. Less common risk factors for gastric cancer include Lynch syndrome, Peutz-Jeghers syndrome, Menetrier's disease, and germline mutations in the CDH gene (encoding E-cadherin). However, there is some evidence that selenium, as well as high consumption of fruits and vegetables, may have protective effects against gastric cancer.  
 
References  
de Martel C et al. Gastroenterol Clin North Am. 2013 Jun;42(2):219-40.  
Giardiello FM et al. N Engl J Med. 1987 Jun 11;316(24):1511-4.  
Qiao YL et al. J Natl Cancer Inst. 2009 Apr 1;101(7):507-18. 

Correct answer: E. Cervical dysplasia. 
 
Rationale  
In a nationwide cohort study, women with Crohn's disease and ulcerative colitis were found to have an increased risk of cervical dysplasia. Patients with ulcerative colitis had increased risks of low- and high-grade squamous intraepithelial lesions, whereas patients with Crohn's disease also had increased risks of cervical cancer. Age-appropriate screening with pap smears is important for women diagnosed with inflammatory bowel disease regardless of treatment type.  
 
Reference  
Rungoe et al. Clin Gastroenterol Hepatol. 2015 Apr;13(4):693-700.e1.

Correct answer: E. Cervical dysplasia. 
 
Rationale  
In a nationwide cohort study, women with Crohn's disease and ulcerative colitis were found to have an increased risk of cervical dysplasia. Patients with ulcerative colitis had increased risks of low- and high-grade squamous intraepithelial lesions, whereas patients with Crohn's disease also had increased risks of cervical cancer. Age-appropriate screening with pap smears is important for women diagnosed with inflammatory bowel disease regardless of treatment type.  
 
Reference  
Rungoe et al. Clin Gastroenterol Hepatol. 2015 Apr;13(4):693-700.e1.

Correct answer: E. Cervical dysplasia. 
 
Rationale  
In a nationwide cohort study, women with Crohn's disease and ulcerative colitis were found to have an increased risk of cervical dysplasia. Patients with ulcerative colitis had increased risks of low- and high-grade squamous intraepithelial lesions, whereas patients with Crohn's disease also had increased risks of cervical cancer. Age-appropriate screening with pap smears is important for women diagnosed with inflammatory bowel disease regardless of treatment type.  
 
Reference  
Rungoe et al. Clin Gastroenterol Hepatol. 2015 Apr;13(4):693-700.e1.

Q2. Correct answer: D. Treatment for recurrent or metastatic disease is imatinib.  

Rationale  
This patient has a gastrointestinal stromal tumor (GIST) of the stomach. GISTs are the most common mesenchymal tumor found in the stomach. Gastric GISTs have a better prognosis than those found in the small intestine. GISTs are often found incidentally but can cause symptoms such as bleeding due to ulceration. Pathology of a GIST shows spindle cells that stain positive for CD117 and harbor KIT mutations. Malignant potential and decreased survival are associated with size more than 2 cm and high mitotic index (more than 5/50 high power field). Endoscopic ultrasound with tissue sampling is the preferred diagnostic technique. High-risk features include lobulated or irregular borders, invasion into adjacent structures and heterogeneity. Fine needle aspirate may be suboptimal, and core biopsy is an acceptable alternative. Resection is indicated for lesions that are symptomatic, size more than 2 cm or high-risk EUS features. Lesions less than 2 cm without high-risk features can be surveyed by EUS annually. Endoscopic resection might be possible for small lesions but should be done in specialized centers. Metastatic or recurrent lesions are treated with imatinib.  
 
Reference  
ASGE Standards of Practice Committee. Gastrointest Endosc. 2015 Jul;82(1):1-8.

Q2. Correct answer: D. Treatment for recurrent or metastatic disease is imatinib.  

Rationale  
This patient has a gastrointestinal stromal tumor (GIST) of the stomach. GISTs are the most common mesenchymal tumor found in the stomach. Gastric GISTs have a better prognosis than those found in the small intestine. GISTs are often found incidentally but can cause symptoms such as bleeding due to ulceration. Pathology of a GIST shows spindle cells that stain positive for CD117 and harbor KIT mutations. Malignant potential and decreased survival are associated with size more than 2 cm and high mitotic index (more than 5/50 high power field). Endoscopic ultrasound with tissue sampling is the preferred diagnostic technique. High-risk features include lobulated or irregular borders, invasion into adjacent structures and heterogeneity. Fine needle aspirate may be suboptimal, and core biopsy is an acceptable alternative. Resection is indicated for lesions that are symptomatic, size more than 2 cm or high-risk EUS features. Lesions less than 2 cm without high-risk features can be surveyed by EUS annually. Endoscopic resection might be possible for small lesions but should be done in specialized centers. Metastatic or recurrent lesions are treated with imatinib.  
 
Reference  
ASGE Standards of Practice Committee. Gastrointest Endosc. 2015 Jul;82(1):1-8.

Q2. Correct answer: D. Treatment for recurrent or metastatic disease is imatinib.  

Rationale  
This patient has a gastrointestinal stromal tumor (GIST) of the stomach. GISTs are the most common mesenchymal tumor found in the stomach. Gastric GISTs have a better prognosis than those found in the small intestine. GISTs are often found incidentally but can cause symptoms such as bleeding due to ulceration. Pathology of a GIST shows spindle cells that stain positive for CD117 and harbor KIT mutations. Malignant potential and decreased survival are associated with size more than 2 cm and high mitotic index (more than 5/50 high power field). Endoscopic ultrasound with tissue sampling is the preferred diagnostic technique. High-risk features include lobulated or irregular borders, invasion into adjacent structures and heterogeneity. Fine needle aspirate may be suboptimal, and core biopsy is an acceptable alternative. Resection is indicated for lesions that are symptomatic, size more than 2 cm or high-risk EUS features. Lesions less than 2 cm without high-risk features can be surveyed by EUS annually. Endoscopic resection might be possible for small lesions but should be done in specialized centers. Metastatic or recurrent lesions are treated with imatinib.  
 
Reference  
ASGE Standards of Practice Committee. Gastrointest Endosc. 2015 Jul;82(1):1-8.

Q1. Correct answer: D. Lorcaserin (Belviq). 
 
Rationale 
Lorcaserin may cause valvulopathy, attention, or memory disturbance. This patient has normal ECHO and does not work with heavy machinery. Given his other history, this may be the best choice for him. Naltrexone/bupropion extended release is contraindicated in patients with seizure disorder, chronic opioid use, anorexia nervosa, bulimia, and abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic drugs because bupropion lowers the seizure threshold. Liraglutide is contraindicated with personal or family history of medullary thyroid carcinoma or MENII. In addition, GLP1 receptor agonists can increase the risk of pancreatitis in patients with a history of pancreatitis. Phentermine/topiramate can increase the risk of nephrolithiasis. All of these medications are contraindicated in pregnancy and in patients with hypersensitivity to the drug and drug class. 
 
References 
Bays HE et al. Obesity algorithm, presented by the Obesity Medical Association. 2016-2017. https://cmcoem.info/pdf/curso/evaluacion_preoperatoria/oma_obesity-algorithm.pdf.  
Steelman M and Westman E. Obesity: Evaluation and Treatment Essentials. Boca Raton: CRC press, 2016. https://www.abom.org/wp-content/uploads/2016/06/Obesity-Evaluation-and-Treatment-Essentials.pdf.  
Liraglutide Prescribing Information (Saxenda). https://www.novo-pi.com/saxenda.pdf.  
Lorcaserin (Belviq) Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/022529lbl.pdf.  
Naltrexone HCl/Bupropion HCl Extended Release Prescribing Information (CONTRAVE). https://contrave.com/contrave-pi/.  
Phentermine HCl/Topiramate Extended Release Prescribing Information (Qsymia). https://qsymia.com/patient/include/media/pdf/prescribing-information.pdf

Q1. Correct answer: D. Lorcaserin (Belviq). 
 
Rationale 
Lorcaserin may cause valvulopathy, attention, or memory disturbance. This patient has normal ECHO and does not work with heavy machinery. Given his other history, this may be the best choice for him. Naltrexone/bupropion extended release is contraindicated in patients with seizure disorder, chronic opioid use, anorexia nervosa, bulimia, and abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic drugs because bupropion lowers the seizure threshold. Liraglutide is contraindicated with personal or family history of medullary thyroid carcinoma or MENII. In addition, GLP1 receptor agonists can increase the risk of pancreatitis in patients with a history of pancreatitis. Phentermine/topiramate can increase the risk of nephrolithiasis. All of these medications are contraindicated in pregnancy and in patients with hypersensitivity to the drug and drug class. 
 
References 
Bays HE et al. Obesity algorithm, presented by the Obesity Medical Association. 2016-2017. https://cmcoem.info/pdf/curso/evaluacion_preoperatoria/oma_obesity-algorithm.pdf.  
Steelman M and Westman E. Obesity: Evaluation and Treatment Essentials. Boca Raton: CRC press, 2016. https://www.abom.org/wp-content/uploads/2016/06/Obesity-Evaluation-and-Treatment-Essentials.pdf.  
Liraglutide Prescribing Information (Saxenda). https://www.novo-pi.com/saxenda.pdf.  
Lorcaserin (Belviq) Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/022529lbl.pdf.  
Naltrexone HCl/Bupropion HCl Extended Release Prescribing Information (CONTRAVE). https://contrave.com/contrave-pi/.  
Phentermine HCl/Topiramate Extended Release Prescribing Information (Qsymia). https://qsymia.com/patient/include/media/pdf/prescribing-information.pdf

Q1. Correct answer: D. Lorcaserin (Belviq). 
 
Rationale 
Lorcaserin may cause valvulopathy, attention, or memory disturbance. This patient has normal ECHO and does not work with heavy machinery. Given his other history, this may be the best choice for him. Naltrexone/bupropion extended release is contraindicated in patients with seizure disorder, chronic opioid use, anorexia nervosa, bulimia, and abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic drugs because bupropion lowers the seizure threshold. Liraglutide is contraindicated with personal or family history of medullary thyroid carcinoma or MENII. In addition, GLP1 receptor agonists can increase the risk of pancreatitis in patients with a history of pancreatitis. Phentermine/topiramate can increase the risk of nephrolithiasis. All of these medications are contraindicated in pregnancy and in patients with hypersensitivity to the drug and drug class. 
 
References 
Bays HE et al. Obesity algorithm, presented by the Obesity Medical Association. 2016-2017. https://cmcoem.info/pdf/curso/evaluacion_preoperatoria/oma_obesity-algorithm.pdf.  
Steelman M and Westman E. Obesity: Evaluation and Treatment Essentials. Boca Raton: CRC press, 2016. https://www.abom.org/wp-content/uploads/2016/06/Obesity-Evaluation-and-Treatment-Essentials.pdf.  
Liraglutide Prescribing Information (Saxenda). https://www.novo-pi.com/saxenda.pdf.  
Lorcaserin (Belviq) Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/022529lbl.pdf.  
Naltrexone HCl/Bupropion HCl Extended Release Prescribing Information (CONTRAVE). https://contrave.com/contrave-pi/.  
Phentermine HCl/Topiramate Extended Release Prescribing Information (Qsymia). https://qsymia.com/patient/include/media/pdf/prescribing-information.pdf

Q2. Correct answer: A. Reassurance and consideration of cow milk protein soy intolerance with elimination of these antigens in mother's diet. 
 
Rationale 
The differential diagnosis of hematochezia in infants is relatively small. The most likely considerations are anal fissures, vascular malformations, cow milk protein soy intolerance, bleeding diatheses, swallowed maternal blood in the first 1-2 days of life, and necrotizing enterocolitis in preterm infants. In the setting of an otherwise healthy term infant who presents with hematochezia without anorectal malformations, the most likely etiology is cow milk protein soy intolerance. This is an IgG-mediated disorder that does not necessarily construe other predilections to food allergies. Most infants outgrow this by 1 year of life or thereafter. In mother's who are breastfeeding, it is recommended that they eliminate both cow milk and soymilk proteins from their diet. There is a 70% cross-reactivity between cow milk and soymilk proteins. In infants who are formula feeding or those who do not respond to maternal elimination diets, it is recommended that they consume partially hydrolyzed or fully hydrolyzed formula. Such infants are usually able to tolerate cow and soy proteins later in life. 
 
Reference 
Mäkinen OE et al. Crit Rev Food Sci Nutr. 2016;56(3):339-49.

Q2. Correct answer: A. Reassurance and consideration of cow milk protein soy intolerance with elimination of these antigens in mother's diet. 
 
Rationale 
The differential diagnosis of hematochezia in infants is relatively small. The most likely considerations are anal fissures, vascular malformations, cow milk protein soy intolerance, bleeding diatheses, swallowed maternal blood in the first 1-2 days of life, and necrotizing enterocolitis in preterm infants. In the setting of an otherwise healthy term infant who presents with hematochezia without anorectal malformations, the most likely etiology is cow milk protein soy intolerance. This is an IgG-mediated disorder that does not necessarily construe other predilections to food allergies. Most infants outgrow this by 1 year of life or thereafter. In mother's who are breastfeeding, it is recommended that they eliminate both cow milk and soymilk proteins from their diet. There is a 70% cross-reactivity between cow milk and soymilk proteins. In infants who are formula feeding or those who do not respond to maternal elimination diets, it is recommended that they consume partially hydrolyzed or fully hydrolyzed formula. Such infants are usually able to tolerate cow and soy proteins later in life. 
 
Reference 
Mäkinen OE et al. Crit Rev Food Sci Nutr. 2016;56(3):339-49.

Q2. Correct answer: A. Reassurance and consideration of cow milk protein soy intolerance with elimination of these antigens in mother's diet. 
 
Rationale 
The differential diagnosis of hematochezia in infants is relatively small. The most likely considerations are anal fissures, vascular malformations, cow milk protein soy intolerance, bleeding diatheses, swallowed maternal blood in the first 1-2 days of life, and necrotizing enterocolitis in preterm infants. In the setting of an otherwise healthy term infant who presents with hematochezia without anorectal malformations, the most likely etiology is cow milk protein soy intolerance. This is an IgG-mediated disorder that does not necessarily construe other predilections to food allergies. Most infants outgrow this by 1 year of life or thereafter. In mother's who are breastfeeding, it is recommended that they eliminate both cow milk and soymilk proteins from their diet. There is a 70% cross-reactivity between cow milk and soymilk proteins. In infants who are formula feeding or those who do not respond to maternal elimination diets, it is recommended that they consume partially hydrolyzed or fully hydrolyzed formula. Such infants are usually able to tolerate cow and soy proteins later in life. 
 
Reference 
Mäkinen OE et al. Crit Rev Food Sci Nutr. 2016;56(3):339-49.

Q1. Correct answer: A. Normal Ph/Impedance probe findings during sleeping. 
 
Rationale  
Rumination syndrome is a functional gastrointestinal disorder that can present in all age groups. The true prevalence of the disorder is unknown, but the condition can be seen more commonly in patients with developmental disorders and other high-risk groups like teenage females. The ROME IV criteria for the condition include at least 2 months of the following: Repeated regurgitation and rechewing or expulsion of food that begins soon after eating and stops with sleeping, is not proceeded by retching, and has no other clear etiology for symptoms. This patient is at higher risk for rumination syndrome with her developmental differences. Her painless regurgitation after eating meets criteria for the condition. Prolonged high-resolution esophageal manometry can identify specific subgroups of rumination. Antroduodenal manometry can detect simultaneous contractions called R-waves that can be seen in some patients with rumination syndrome. Since regurgitation stops with sleeping, pH/Impedance probes demonstrate resolution of symptoms with sleep. The condition is primarily diagnosed clinically, with other studies performed as clinically indicated. Treatment typically consists of behavioral management.  
 
Reference  
Hyams J et al. Gastroenterology. 2006 Apr;130(5):1527-37.

Q1. Correct answer: A. Normal Ph/Impedance probe findings during sleeping. 
 
Rationale  
Rumination syndrome is a functional gastrointestinal disorder that can present in all age groups. The true prevalence of the disorder is unknown, but the condition can be seen more commonly in patients with developmental disorders and other high-risk groups like teenage females. The ROME IV criteria for the condition include at least 2 months of the following: Repeated regurgitation and rechewing or expulsion of food that begins soon after eating and stops with sleeping, is not proceeded by retching, and has no other clear etiology for symptoms. This patient is at higher risk for rumination syndrome with her developmental differences. Her painless regurgitation after eating meets criteria for the condition. Prolonged high-resolution esophageal manometry can identify specific subgroups of rumination. Antroduodenal manometry can detect simultaneous contractions called R-waves that can be seen in some patients with rumination syndrome. Since regurgitation stops with sleeping, pH/Impedance probes demonstrate resolution of symptoms with sleep. The condition is primarily diagnosed clinically, with other studies performed as clinically indicated. Treatment typically consists of behavioral management.  
 
Reference  
Hyams J et al. Gastroenterology. 2006 Apr;130(5):1527-37.

Q1. Correct answer: A. Normal Ph/Impedance probe findings during sleeping. 
 
Rationale  
Rumination syndrome is a functional gastrointestinal disorder that can present in all age groups. The true prevalence of the disorder is unknown, but the condition can be seen more commonly in patients with developmental disorders and other high-risk groups like teenage females. The ROME IV criteria for the condition include at least 2 months of the following: Repeated regurgitation and rechewing or expulsion of food that begins soon after eating and stops with sleeping, is not proceeded by retching, and has no other clear etiology for symptoms. This patient is at higher risk for rumination syndrome with her developmental differences. Her painless regurgitation after eating meets criteria for the condition. Prolonged high-resolution esophageal manometry can identify specific subgroups of rumination. Antroduodenal manometry can detect simultaneous contractions called R-waves that can be seen in some patients with rumination syndrome. Since regurgitation stops with sleeping, pH/Impedance probes demonstrate resolution of symptoms with sleep. The condition is primarily diagnosed clinically, with other studies performed as clinically indicated. Treatment typically consists of behavioral management.  
 
Reference  
Hyams J et al. Gastroenterology. 2006 Apr;130(5):1527-37.