A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 47–year-old man presents to the emergency department with worsening weakness in the setting of persistent abdominal pain. The man arrived to the United States 6 months ago and has been working in a restaurant as a cook. His abdominal pain started 4 months ago, but he could not find time away from work to see a doctor. He reports nausea but denies any vomiting. His temperature is 98.6°F (37°C), blood pressure is 98/61 mmHg, pulse is 110/min, and respirations are 18/min. He has no cardiac murmurs but does have tenderness in his epigastric region. His heme-occult test is positive. His laboratory workup notes the following:
Hemoglobin: 7.2 g/dL
Hematocrit: 23%
Leukocyte count: 11,000/mm^3 with normal differential
Platelet count: 470,000/mm^3
Serum:
Na+: 137 mEq/L
Cl-: 109 mEq/L
K+: 3.1 mEq/L
HCO3-: 23 mEq/L
BUN: 52 mg/dL
Glucose: 89 mg/dL
Creatinine: 0.9 mg/dL
An esophagogastroduodenoscopy reveals the presence of a mass surrounded by bleeding ulcers. On initial shave biopsy, the preliminary diagnosis is mucosa-associated lymphatic tissue lymphoma (MALToma). What is the best next step in management?
-
A
Amoxicillin, clarithromycin, and pantoprazoleCorrect. H. pylori eradication with amoxicillin, clarithromycin, and a PPI is first-line treatment for H. pylori-associated MALT lymphoma and produces remission in most patients.
-
B
Full thickness biopsyIncorrect. Full-thickness biopsy is invasive and unnecessary — the shave biopsy already gave the diagnosis, and treatment is medical.
-
C
Hospice careIncorrect. Hospice care is inappropriate for a curable condition with high response rates to antibiotic therapy.
-
D
Partial gastrectomyIncorrect. Partial gastrectomy is reserved for refractory or transformed disease, not first-line treatment of low-grade MALToma.
-
E
External-beam radiation to the stomachIncorrect. Radiation is a second-line option for H. pylori-negative or antibiotic-refractory gastric MALT lymphoma, but first-line treatment for H. pylori-associated MALToma is triple-therapy eradication.
↑ Tap an answer to reveal the reasoning
Answer: A. A patient with chronic abdominal pain, iron-deficiency anemia from chronic GI blood loss, and an endoscopic mass with surrounding bleeding ulcers diagnosed as gastric MALT lymphoma is described. Gastric MALToma (mucosa-associated lymphoid tissue lymphoma) is strongly associated with Helicobacter pylori infection — chronic gastric H. pylori inflammation drives the clonal B-cell expansion that produces the lymphoma.
First-line therapy for early-stage (limited to stomach, no high-grade transformation) H. pylori-positive MALT lymphoma is H. pylori eradication with TRIPLE THERAPY: amoxicillin, clarithromycin, and a proton-pump inhibitor (omeprazole or pantoprazole) for 10-14 days. Approximately 60-80% of patients achieve lymphoma remission with antibiotic therapy alone — a remarkable example of an oncologic disease cured by treating its infectious driver. Patients are then monitored endoscopically. Surgery, radiation, or chemotherapy are reserved for treatment-resistant or transformed disease (e.g., diffuse large B-cell lymphoma).
Pearl: gastric MALToma + H. pylori = treat with triple therapy first; histologic and endoscopic remission follows in most patients.
**Why each option:**
**A.** Correct. H. pylori eradication with amoxicillin, clarithromycin, and a PPI is first-line treatment for H. pylori-associated MALT lymphoma and produces remission in most patients.
**B.** Full-thickness biopsy is invasive and unnecessary — the shave biopsy already gave the diagnosis, and treatment is medical.
**C.** Hospice care is inappropriate for a curable condition with high response rates to antibiotic therapy.
**D.** Partial gastrectomy is reserved for refractory or transformed disease, not first-line treatment of low-grade MALToma.