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CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2013;11:e3–e4

CME Activities–Exams 1 and 2

CME Credits:The AGA Institute is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medicaleducation for physicians.The AGA Institute designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicianshould only claim credit commensurate with the extent of their participation in the activity.

Faculty Disclosure:In accordance with the Accreditation Council for Continuing Medical Education’s Standards for Commercial Support of Continu-ing Medical Education, all faculty and planning partners must disclose any relevant financial relationship(s) or other relationship(s)held within the past 12 months. The AGA Institute implements a mechanism to identify and resolve all conflicts of interest priorto delivering the educational activity to learners.

Instructions:Category 1 credit can be earned by reading the relevant articles and taking these CME examinations online at http://www.cghjournal.org/content/cme. Answers can be obtained online after completing the exam(s).

Objectives:See article for specific learning objective.

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e4 CME ACTIVITIES CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 11, No. 1

Exam 1: Classification, Diagnosis, and Management ofCholangiocarcinoma

Test ID No.: 0169 Contact Hours: 1.0 Expiration Date: January 31, 2014

Question 1.

The current anatomic classification encompassing all formsof cholangiocarcinoma (CCA) includes the following sub-groups:

Question 2.

pment?

Question 3.

phase. What is the most appropriate next step?

Question 4.

atient’s management?

a. Intrahepatic, perihilar, and distal (or extrahepatic)b. Intrahepatic and extrahepaticc. Bismuth–Corlette stages I–IVd. Liver restricted and metastatic

e. Associated with cirrhosis or absence of cirrhosis

A 50-year-old man presented with painless jaundice associ-ated with weight loss and progressive fatigue. He has a historyof well-controlled human immunodeficiency virus (HIV) andchronic hepatitis C infection, drinks a glass of wine beforesupper every evening, and smokes a pack of cigarettes a week.On initial work-up he was found to have elevated bilirubin(total bilirubin 7.2 mg/dL), mild elevation of alkaline phospha-tase (260 U/L), alkaline aminotransferase (110 U/L), and aspar-tate aminotransferase (90 U/L). His carbohydrate antigen(CA)19-9 is 329 U/mL and �-fetoprotein is 7.9 ng/mL. What ishe strongest risk factor that puts him at risk for CCA devel-

a. Smokingb. Alcohol usec. HIVd. Hepatitis Ce. Gender

You have been following a patient with cirrhosis with portalhypertension due to nonalcoholic steatohepatitis. Routine ab-dominal ultrasound obtained for hepatocellular carcinoma sur-veillance reveals a 2-cm mass in segment VIII, which was recon-firmed by computed tomography (CT) scan. On CT scan, thelesion had minimal contrast enhancement on the arterial phasebut progressive contrast enhancement throughout the venous

a. Positron emission tomography scanb. Biopsy of the lesionc. Liver transplant evaluationd. Magnetic resonance imaginge. Observe with repeat CT scan in 3 months

A 35-year-old man was referred to you for management ofperihilar CCA-complicated primary sclerosing cholangitis(PSC). His tumor is localized to the hilum (�3 cm), and he hasno evidence for regional or distant metastases; his CA19-9 is200 U/mL, total bilirubin 17 mg/dL, international normalizedratio 2.2. He has portal hypertension with splenomegaly andplatelet count of 77 x 109/L. What is the best next step in this

a. Photodynamic therapyb. Cholangiogram with stent placement followed by liver

transplant evaluationc. Surgical referral for resectiond. Chemotherapy with gemcitabine and cisplatine. Radiation therapy