1) The patient is a 53-year-old woman seeking pharmacotherapy for weight loss in addition to lifestyle modifications. She has a history of anxiety treated with paroxetine and past narcotic abuse. 2) Orlistat is recommended as it inhibits fat absorption and has beneficial effects on lipids, important for this patient with dyslipidemia. 3) Lorcaserin is not recommended due to potential interaction with paroxetine. Phentermine is not recommended due to risk of addiction given her history of abuse.

1. MCQs
Dr.Hafeez Yaqoob
Resident Gastroenterology
BMCH Quetta

2. A 29-year-old woman with fistulizing Crohn’s disease who had multiple
resections of small bowel in the past has been on total parenteral
nutrition (TPN) for the last 2 months. She continues to have watery
diarrhea and some discharge from an enterocutaneous fistula despite not
taking anything by mouth. She presented to your clinic and complains of
impaired taste, hair loss, skin rash, and difficult vision at night in the last
2 weeks. In the physical exam you note several erythematous and
vesicular lesions on her elbows and hands. Basic blood tests are as
follows:
WBC 9000/μL
Hemoglobin 11g/dL
MCV 88 fL
Electrolytes normal
Albumin 3.2 g/dL
What would be your next step in the management of her
recent manifestations?
A. Check plasma zinc level
B. Empiric zinc supplementation
C. Check blood niacin level
D. Empiric niacin supplementation
E. Empiric copper supplementation

3. Ans: B
Zinc depletion is a particularly important issue to rememberin patients with
chronic diarrhea or fistula in inflammatory bowel disease. It can be seen in
patients on total parenteral nutrition solutions lacking appropriate amount of
zinc supplementation to compensate for ongoing GI loss. Dysgeusia (impaired
taste), alopecia, glossitis, dermatitis on the extremities, and loss of dark
adaptation are commonly seen in marked zinc deficiency. Plasma or other
body fluid zinc levels are not accurate indicators of zinc status because it can
shift from serum into the liver in acute illness. For this reason, it is usually
recommended to proceed with zinc supplementation in patients with high
risk of zinc deficiency based on the clinical scenario. Copper or niacin
deficiency is not completely consistent with the clinical scenario mentioned in
the question. Although copper deficiency can be seen in individuals on
longterm total parenteral nutrition without copper, it usually manifests with
skin or hair depigmentation, leukopenia, microcytic anemia, and neurologic
abnormalities. Marked deficiency can be detected by low serum copper and
ceruloplasmin level. Niacin deficiency (pellagra) is often seen in carcinoid
syndrome or individuals in which corn is the major source of nutrition. Blood
concentration is not reliable to detect deficiency. Measurement of urinary
excretion of the niacin metabolites is the most reliable tests of assessment.

4. Q#2
A 47-year-old man with history of Crohn’s disease has had multiple resections
of the small bowel, including the last surgery around 6 months ago, which
resected most of the terminal ileum secondary to stricture. Currently, he
has about 90 cm of intact small intestine remaining, and his colon is
present without any disease involvement. In the last month, you have
attempted to wean parenteral nutrition for him and introduce oral
feeding, but severe diarrhea has been the main limiting factor to reach
this goal.
Which of the following therapeutic measures could potentially
cause worsening of the diarrhea in this patient?
A. Bile-binding resins
B. Fat restriction
C. Atropine
D. Pantoprazole
E. Teduglutide

5. Ans# A
• A (S&F ch6)
In patients with short bowel syndrome who only have a limited length of ileum
remaining and an intact colon, bile-binding resins like cholestyramine, can cause
relative bile salt deficiency and fat malabsorption, which will lead to worsening
of the diarrhea. Fat restriction in the oral diet may be useful in these patients for
reducing the diarrhea. On the other hand, in a patient with less extensive ileal
resection and an intact colon, diarrhea could be the result of the colonic
irritation by unabsorbed bile salts and, for that reason, bile-binding resins can be
used to reduce bile salt–induced diarrhea. Anticholinergic agents like atropine
are used to slow intestinal transit. However, larger doses of anticholinergics are
generally required because absorption of the oral medication may be limited in
patients with short bowel syndrome. Proton pump inhibitors are also used to
reduce gastric secretions and can help with diarrhea. Glucagon-like peptide-2
(GLP-2) is a small intestine mucosal stimulator for improved absorption.
Teduglutide binds and activates GLP-2 receptors and was shown in a randomized
placebo-controlled study to significantly decrease the volume and number of
days of parenteral support required by patients with intestinal failure.

6. A 53-year-old woman presents to your clinic for consultation regarding weight
loss. She has tried lifestyle modification, including appropriate diet and
exercise in the last year with minimal effect in her weight. She has been
suffering from anxiety, which is under control with paroxetine. She has
history of narcotic abuse about 4 years ago and had to go to rehabilitation.
Currently, she denies any drug abuse. On the physical exam, her body mass
index (BMI) today is 29 kg/m2. Blood pressure is 130/80 mm Hg and heart rate
is 80 bpm. Abdominal exam shows central obesity. Recent blood tests showed
ALT 20 U/L, AST 19 U/L, alkaline phosphatase 82 U/L, total bilirubin 1.1 mg/dL,
creatinine 1.1 mg/ dL, thyroid-stimulating hormone 1.5 mIU/L, fasting glucose
100 mg/dL, low-density lipoprotein (LDL) 190 mg/dL, HDL 338 mg/dL, and
triglycerides 220 mg/dL. You have a long discussion with her and the final
decision is to consider pharmacotherapy for 1 year in addition to continuing
lifestyle modifications. Which of the following drugs would you recommend
for her?
A. Orlistat
B. Lorcaserin
C. Phentermine-topiramate ER
D. Phendimetrazine
E. Diethylpropion

7. • A (S&F ch7)
• Currently, there are only three FDA-approved
drugs for long-term (12 months) treatment of
obesity. They include orlistat, lorcaserin, and
phentermine-topiramate (extended release).
Orlistat inhibits pancreatic lipase and reduces
fat absorption. For this reason, it has beneficial
effects on lowdensity lipoprotein cholesterol
that make it a better option for this patient
with dyslipidemia. Lorcaserin is a potent
selective serotonin 5-HT2C agonist and results
in weight loss with promoting satiety and
regulating food intake.

8. Its use is contraindicated in patients who take
selective serotonin reuptake inhibitors (SSRI) like
paroxetine. Phentermine is a sympathomimetic
drug with risk for addiction. Its combination with
topiramate (an anticonvulsant drug) has been
proved in at least 2 clinical trials to be effective
and safe for weight loss. Although this
combination drug has less prominent behavioral
side effects, it is not recommended in individuals
with history of drug abuse. Phendimetrazine and
diethylpropion are 2 noradrenergic agents, which
are only approved for short-term use (less than 3
months).