Welcome to End Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for 90 students studying to pass their N.P. certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So if you're ready, let's jump right in.
A 37-year-old adult was diagnosed with dyspepsia with documented H. pylori infection. An appropriate course of antimicrobial and proton pump inhibitor (PPI) therapy was prescribed and completed about 4 weeks ago. The patient states that the presenting symptoms have resolved and states, “My stomach feels much better.” Which of the following is the most appropriate next step in care?
A. A serologic test for H. pylori antibodies should be checked today.
B. The patient should be referred to gastroenterology for biopsy via endoscopy.
C. No further testing is needed as the patient’s symptoms have resolved.
D. Urea breath test should be conducted to confirm H. pylori eradication.
The correct answer is D urea breath test should be conducted to confirm H. pylori eradication.
Where do you start? First, determine what kind of a question this is given. The patient has been diagnosed and treated. This clinical scenario is focused on response to care. Therefore, of course, it's an evaluation question.
Let's take a look at some background information first. H pylori is a gram negative spiral shaped organism transmitted by the fecal oral route found frequently in patients with duodenal ulcer. At least 90% of duodenal ulcer patients will have evidence of acute H. pylori infection and up to 70% of patients with gastric ulcer or gastritis. The presence of acute H. pylori infection can result in a weakening of the protective lining of the stomach in the duodenum, allowing for damage of the underlying tissue.
Infection with this organism can produce symptoms of dyspepsia as was reported in the patient in this scenario. And I do want to reinforce, as I have on other podcasts, if it says the person needed treatment for H. pylori infection, assume that that was actually correct. So, in other words, the information about the patient, the patient's treatment presented to you in each exam question, you simply have to accept that that's accurate and definitely contributes to the answer you're going to come up with.
Treatment of H. pylori infection with anti-microbial and PPI therapy allows for the protective lining of the GI tract to heal and facilitates symptom eradication. Here's the key point with this question. There is at least a 20% possibility that even appropriate evidence-based practice H. pylori therapy fails to eradicate the organism. Given that persistent H. pylori infection is a risk factor for peptic ulcer disease to recur, a post-treatment test of cure should be conducted. In order to be accurate, this test should be conducted at least four weeks after anti-microbial and at least two weeks after PPI therapy has been completed. To conduct this test earlier can lead to mis-reading. To conduct this test earlier can lead to false negative results.
Let's take a look at the options for answers to this question. So to repeat the question, 37 year old adult is diagnosed with dyspepsia with documented H. pylori infection. An inappropriate course of anti-microbial and PPI therapy was prescribed and completed about four weeks ago. The patient states that the presenting symptoms have resolved and, “My stomach feels much better.” Which of the following is the most appropriate next step in care?
A. A serologic test for H. pylori antibodies should be checked today. This is incorrect. While this patient does need a test cure, H. pylori, serology is not the right test. So remember, whenever you're ordering a lab test, what you have to order is the test that’s going to give you the information you need to help that patient out. H. pylori serology can remain elevated for months to years after acute infection. In reality, you're going to see serologic H. pyloric error. In reality, this test is often ordered, but its clinical utility is truly questioning what — In reality, you're going to see Serum H. pylori testing often ordered, but its clinical utility is truly truly questionable. In fact You're going to find a number of patients who have had serologic H. pylori testing done — they're going to come back and say, “Hey, insurance didn't pay for this because they said it's an unreliable test” — be aware of that.
B. The patient should be referred to GI for biopsy, the upper endoscopy. This is also incorrect. While upper endoscopy with stomach or duodenal biopsy can confirm the presence or absence of H. pylori infection, there is much less invasive and much less expensive methods available. Endoscopy is more often indicated for patients with complicated disease or a questionable diagnosis. In this scenario, we're told the patient feels better after treatment; therefore, less invasive testing is indicated.
C. No further testing is needed since the patient's symptoms have resolved. As was mentioned, with a 20%, sometimes even higher, treatment failure rate and the need to confirm cure or organism eradication, this answer is not correct. Untreated, H. pylori can lead to recurrence of symptoms and upper GI damage, and protracted infection with H. pylori has been correlated with gastric mucosal associated lymphoid tissue lymphoma, and this is sometimes called MALT lymphoma.
D. Urea breath tests should be conducted to confirm H. pylori eradication. This is the correct answer. Eradication of the organism dramatically alters the risk of relapse and reduces it profoundly. Numerous antimicrobial combinations are effective in treating symptomatic H. pylori infection. Additional noninvasive testing includes stool H. pylori antigen. And what happens with this, the reason it's called noninvasive, is the patient is sent home with the equipment needed to get a stool specimen and bring it back in. And what if there is still H. pylori in the stool, if there still is. H. pylori in the GI tract active current infection. The H. pylori stool antigen test will be positive as the urea breath test would be positive as well for active H. pylori infection. This test of cure now needs to be done at least four weeks after the completion of the antibiotic therapy and at least two weeks after the patient has not taken a PPI to avoid a false negative test.
Takeaway message: A test of cure is required for some, but not all infectious diseases. Knowing when a test is required and equally as importantly, why the test is required is a key to safe and effective NP practice and board success.
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