ANSWERS // From page 3
Q1: Answer: C
Factors raising suspicion for Zollinger-Ellison syndrome include recurrent peptic ulcer disease, multiple ulcers, post-bul-bar ulcer, non–H. pylori/non-NSAID-related duodenal ulcer,
diarrhea, erosive esophagitis, and family or personal history
of MEN I. The patient in this question presents with duodenal
ulcer without H. pylori or NSAID use, erosive esophagitis, and
diarrhea, which raises suspicion for hypergastrinemia.
His laboratory evaluation also showed hypercalcemia,
which may be due to hyperparathyroidism, a condition
related to MEN I. The initial test to obtain when gastrino-ma is suspected includes a fasting serum gastrin level. In
follow-up of gastrin elevations, a gastric pH assessment
should be performed and, depending on these results, a secretin stimulation test may be useful. Routine repeat upper
endoscopy is not indicated after hemostasis of duodenal
A restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL has been shown to result in improved clinical
outcome compared to a liberal transfusion strategy. While sucralfate may help the healing of duodenal ulcers, it is not the
first-line therapy for long-term secondary prevention.
1. Roy PK, et al. Zollinger-Ellison syndrome. Clinical presentation in 261
patients. Medicine (Baltimore) 2000;79:379.
2. Murugesan SV, Varro A, Pritchard DM. Review article: Strategies to determine whether hypergastrinaemia is due to Zollinger-Ellison syndrome
rather than a more common benign cause. Aliment Pharmacol Ther
3. Villaneuva C, et al. Transfusion strategies for acute upper gastrointestinal
bleeding. N Engl J Med. 2013;368: 11-21.
Q2: Answer D
Objective: Identify the clinical presentation and risk factors
for small intestinal bacterial overgrowth
Rationale: This patient likely has small intestinal bacterial
overgrowth (SIBO) based on her symptoms, the steatorrhea with the positive Sudan stain for fat, and a slight
anemia with an elevated MCV suggestive of B- 12 deficiency secondary to the bacterial overgrowth. She also has
scleroderma, a condition commonly associated with SIBO,
because it impairs gastrointestinal motility.
While hydrogen breath testing may help establish the
diagnosis of SIBO, there is variable sensitivity and specificity of the testing with false-positive and false-negative test
results frequently occurring. An alternative strategy is to
treat empirically with an accepted antibiotic regimen and
assessing response after the course is completed.
1. Bures J, et al. Small intestinal bacterial overgrowth syndrome. World J
2. Abu-Shanab A, Quigley EM. Diagnosis of small intestinal bacterial
overgrowth: The challenges persist! Expert Rev Gastroenterol Hepatol
3. Khoshini R, et al. A systematic review of diagnostic tests for small intestinal bacterial overgrowth. Dig Dis Sci 2008;53:1443-54.