A 45-year-old man complains of burning epigastric pain that wakes him up at night. The
pain is relieved by eating or using over-thecounter antacids and H2
blockers. Diagnosis is best confirmed by which of the following?
(A) Urea breath test
(B) Serum gastrin levels
(C) Barium meal examination
(D) Upper endoscopy
(E) Upper endoscopy and biopsy
- Duodenal ulcer is best diagnosed by upper endoscopy and biopsy.
- Findings of gastritis and the presence of H.pylori are indications to prescribe appropriate therapy.
- This typically includes a PPI and two antibiotics (one regimen includes amoxicillin and clarithromycin).
- Although the urea breath test is the most sensitive and most specific test used to detect H.pylori it is not readily available in all settings.
A 64-year-old woman with arthritis is a chronic NSAID user. She develops severe epigastric pain and undergoes an upper endoscopy. She is told that she has an ulcer adjacent to the pylorus. Which of the following is TRUE about the pylorus?
(A) It cannot be palpated at laparaotomy.
(B) It is not covered completely by omentum.
(C) It is a distinct anatomic entity that can
be distinguished during laparotomy.
(D) It is a true physiologic sphincter.
(E) It is a site where cancer is rarely found.
The pylorus is palpable but it is not a true physiologic sphincter. It does not demonstrate reciprocal contraction when the stomach relaxes, nor does it relax when the stomach contracts. The pylorus is normally in tonic contraction It is partially covered by omentum and cancer is commonly found there
A 30-year-old executive learns that he has a duodenal ulcer. His gastroenterologist prescribes and outlines medical therapy. The patient worries that if medical therapy fails he may need surgery. Which of the following is the best indication for elective surgical therapy for duodenal ulcer disease?
(A) An episode of melena
(B) Repeated episodes of pain
(C) Pyloric outlet obstruction due to scar
formation from an ulcer
(D) Frequent recurrences of ulcer disease
(E) Referral of pain to the back, suggestive
of pancreatic penetration
- Surgical intervention for peptic ulcer disease is uncommon. It is indicated by four clinical situations—intractable pain, hemorrhage, perforation, and obstruction.
- Noncompliance with medication is often the cause of recurrence.
- Patients with gastic decompression need a nasogastric tube and fluid and electrolyte correction prior to surgery
A 44-year-old dentist was admitted to the hospital with a 1-day history of hematemesis caused by a recurrent duodenal ulcer. He has shown considerable improvement following operative treatment by a truncal vagotomy and pyloroplasty, 10 years prior to this incident.
Which is TRUE of truncal vagotomy?
(A) It is performed exclusively via the thorax.
(B) It can be performed in the neck.
(C) If complete, it will result in increased
(D) It requires a gastric drainage procedure
(E) It has been abandoned as a method to
treat ulcer disease.
- If vagotomy alone is performed, gastric stasis occurs in more than 40% of cases.
- Branches of the vagus nerve innervate the pylorus.
- A drainage procedure is necessary; a pyloroplasty or a gastroenterostomy should be performed and both of these require a laparotomy. Truncal vagotomy can also be done through a thoracic approach.
- Transection of the vagus nerve in the neck results in paralysis of the recurrent laryngeal nerve.
A 42-year-old executive has refractory chronic duodenal ulcer disease. His physican has suggested several surgical options. The patient has chosen a parietal (highly selective) vagotomy instead of a truncal vagotomy and antrectomy because?
(A) It results in a lower incidence of ulcer
(B) It benefits patients with antral ulcers the
(C) It reduces acid secretion to a greater
(D) The complication rate is lower.
(E) It includes removal of the ulcer
- In highly selective vagotomy, the nerve supply to the pylorus is left intact (amd therefore no drainage procedure is necessary) .
- During this operation, the branches of the vagus nerve that supply the parietal cell mass are meticulously divided, leaving the main anterior and posterior nerves of Latarjet intact.
- The main vagal trunks are also left intact, thus sparing the nerve supply to the liver, gallbladder, pancreas and intestines
- To ensure completeness of the procedure, great care is taken to divide the proximal (criminal) nerve of Grassi.
- Although the complication rate is lower, the recurrence rate is higher than that of an antrectomy and truncal vagotomy.
A 63-year-old woman is admitted to the hospital
with severe abdominal pain of 3-hour duration.
Abdominal examination reveals board-like rigidity, guarding, and rebound tenderness. Her
blood pressure is 90/50 mm Hg, pluse 110 bpm
(beats per minute), and respiratory rate is
30 breaths per minute. After a thorough history
and physical, and initiation of fluid resuscitation,
what diagnostic study should be performed?
(A) Supine abdominal x-rays
(B) Upright chest x-ray
(C) Gastrograffin swallow
(D) Computerized axial tomography (CAT)
scan of the abdomen
(E) Abdominal sonogram
B - Upright CXR
- An upright chest x-ray will demonstrate free air below the diaphragm in about 70–75% of patients presenting with a perforated duodenal ulcer.
- An abdominal sonogram may demonstrate free fluid, but not free air. Although a CAT scan will show both free fluid and free air, it will take longer to perform and may delay the definitive treatment.
- The combination of an acute abdomen and an upright chest x-ray with free air under the diaphragm provides enough information to take the patient to the operating room for exploration
A frail elderly patient is found to have an anterior perforation of a duodenal ulcer. He has a
recent history of nonsteroidal anti-inflammatory
drug (NSAID) use and no previous history of
peptic ulcer disease. A large amount of bilious
fluid is found in the abdomen. What should be
the next step?
(A) Lavage of the peritoneal cavity alone
(B) Lavage and omental patch closure of the
(C) Total gastrectomy
(D) Lavage, vagotomy, and
(E) Laser of the ulcer
- Although surgery is generally recommeneded for perforation, conservative measures can be considered in select cases.
- A patient who has a benign clinical presentation or one who is improving might be considered for treatment with antibiotics and nasogastric decompression.
- Patients who have an acute abdomen and are hemodynamically unstable should not be observed
- Board like rigidity of the abdomen occurs as a result of chemical peritonitis.
- These patients should have fluid and electrolyte repletion, antibiotics followed by surgery.
- Choice of the operative procedure should be guided by the information obtained during the history, the presence of comorbid disease, and hemodynamic stability during the operation.
- A omenal (Graham) patch will seal the ulcer, but it will not prevent recurrence.
Three months after recovery from an operation
to treat peptic ulcer disease, a patient complains that she has difficulty eating a large meal. A 99m Tc-labeled chicken scintigraphy
test confirms a marked delay in gastric emptying. A delay in gastric emptying may be due to which of the following?
(A) Zollinger-Ellison syndrome (ZES)
(C) Massive small-bowel resection
(D) Previous vagotomy
(E) Hiatal hernia
- Following truncal land selective vagotomy, gastric emptying is delayed.
- If a vagotomy (truncal or selective) is performed, a drainage procedure is necessary (pyroplasty)
- A disturbance is gastric motility with a delay in gastric emptying may occur with a mechanical gastric outlet obstruction, diabetes, myxema, hypokalemia or the adminstration of anti-cholinergic or opiate drugs.
- Rapid gastric emptying can be seen with ZES, retained gastric antrum syndrome, steatorrhea, or massive small bowel resection where there is impaired ability to reduce gastric acid secretion.
- Failure of swtich off mechanism to inhibit acid secretion also results in increased motility and emptying of the stomach.
A 64-year-old supermarket manager had an elective operation for duodenal ulcer disease. He
has not returned to work because he has diarrhea
with more than 20 bowel movements per day.
Medication has been ineffective. The exact details
of his operation cannot be ascertained. What
operation was most likely performed?
(A) Antrectomy and Billroth I anastomosis
(B) Gastric surgery combined with
(C) Truncal vagotomy
(D) Highly selective vagotomy
(E) Selective vagotomy
- Although a milder type of diarrhea is not uncommon after gastrectomy, fulminant diarrhea may be a problem after vagotomy (it is one of the many complications collectively referred to as post vagotomy syndromes)
- The exact mechanism is not known.
- It occurs in 1-2% of patients following a truncal vagotomy and is less likely to be found after selective or highly selective vagotomy.
A 40-year-old man has had recurrent symptoms
suggestive of peptic ulcer disease for 4 years.
Endoscopy reveals an ulcer located on the
greater curvature of the stomach. A mucosal
biopsy reveals Helicobacter. pylori. What is TRUE
(A) Active organisms can be discerned by
(B) It is protective against gastric carcinoma.
(C) It is associated with chronic gastritis.
(D) It causes gastric ulcer but not duodenal
(E) It can be detected by the urea breath test
in <60% of cases.
- H.pylori (previously called Campylobacter pylori) is associated with chronic gastritis, duodenal ulcers, gastric ulcers and gastric cancer.
- Serology can accurately detect H.pylori but remains positive for up to 1 year post treatment.
- the urea breath test is sensitive (96%) and specific (94%)
A 35-year-old CEO underwent an antrectomy
and vagotomy for a bleeding ulcer. Although
usually careful with his diet, he ate a large
meal during a business lunch. Within 1 hour,
he felt lightheaded and developed abdominal
cramping and diarrhea. His symptoms may
be attributed to:
(B) Jejunogastric intussusception
(C) Dumping syndrome
(D) Afferent loop syndrome
(E) Alkaline reflux gastritis
- Postgastrectomy syndromes collectively refer to complications that can occur after gastric surgery.
- This constellation of syndromes include:
- delayed gastric emptying
- recurrent ulcers
- jejunogastric intussusception
- afferent loop syndrome
- alkaline reflux gastritis
- dumping syndrome - early and late
- Early dumping occurs within 30 minutes and is caused by rapid gastric emptying of a hyperosmolar load into the small bowel.
- Late hypoglycemic dumping occurs 1-3 hours after eating.
- Symptoms are mostly vasomotor.
- They are related to excessive release of insulin in response to the rapid rise in post-prandial gluocse.
A 63-year-old man has an upper gastrointestinal
(UGI) study as part of his workup for abdominal pain. The only abnormal finding was in the
antrum, where the mucosa prolapsed into the
duodenum. There were no abnormal findings
on endoscopy. What should he do?
(A) Sleep with his head elevated.
(B) Be placed on an H 2
(C) Undergo surgical resection of the antrum.
(D) Be observed and treated for pain
(E) Have laser treatment of the antral
- Prolapse of the gastric mucosa into the duodenum may be difficult to distinguish from a polyp in the antrum
- It may be detected in a patient who is asymptomatic.
- Surgically correction sohuld be reserved for patients with obstructive symptoms
- Sleeping with their head elevated, H2 antagonist and laser treatment have no role.
A 63-year-old man underwent gastric resection
for severe peptic ulcer disease. He had complete relief of his symptoms but developed
“dumping syndrome.” This patient is most
likely to complain of which of the following?
(A) Gastric intussusception
(B) Repeated vomiting
(C) Severe diarrhea
(D) Severe vasomotor symptoms after eating
(E) Intestinal obstruction
- Dumping syndrome is a symptom complex occuring after gastric surgery
- It is characterised by:
- Abdominal distension
- Vasomotor symptoms caused by rapid entry of food into the small intestine.
- Feeling light-headed
- There are two types of dumping syndromes - early and late
A 65-year-old man was admitted to the hospital for severe bilious vomiting following gastric
surgery. This occurs in which circumstance?
(A) Following ingestion of gaseous fluids
(C) Following ingestion of fatty foods
(D) Following ingestion of bulky meals
(E) In the evening
- Bilious vomiting is usually spontaneous and should be differentiated from vomiting that occurs after eating.
- The most likely cause of this complication is reflex of bile into the stomach.
- Bile gastritis with intestinalization of the gastric mucosa is a likely cause.
A 64-year-old man has had intermittent
abdominal pain as a result of duodenal ulcer
disease for the past 6 years. Symptoms recurred
6 weeks before admission. He is most likely to
belong to which group?
(A) A and secretor (blood group antigen in
(B) B and Lewis antigen
(D) O and nonsecretor
(E) O and secretor
- Group O is the most common blood type in patients with duodenal ulcer disease.
- In patients who have bled from the duodenal ulcer, this observation is even more striking
- Secretors have an excess of blood group antigen that is absent in nonsecretors.
- The secretor antigen on the red blood cell apears in body fluids also.
- Nonsecretors are more prone to develop duodenal ulcers than secretors.
A 64-year-old man was evaluated for moderate
protein deficiency. He underwent a gastrectomy 20 years earlier. He is more likely to show
which of the following?
(C) Aplastic anemia
(D) Hemolytic anemia
(E) Iron deficiency anemia
- There is a varying degree of impairment in carbohydrate, fat, protein and mineral absorption after gastrectomy.
- These changes are most severe after a subtotal gastrectomy and gastrojejunosotmy
- In most patients these changes are mild
- An acid enviornment is necessary to relieve ferric ion from foo and make it available for absorption in the small intestine.
A 68-year-old woman has been diagnosed with
a benign ulcer on the greater curvature of her
stomach, 5 cm proximal to the antrum. After 3
months of standard medical therapy, she continues to have guaiac positive stool, anemia,
and abdominal pain with failure of the ulcer to
heal. Biopsies of the gastric ulcer have not identified a malignancy. The next step in management is which of the following?
(A) Treatment of the anemia and repeat all
studies in 6 weeks
(B) Endoscopy and bipolar electrocautery or
laser photocoagulation of the gastric
(C) Admission of the patient for total
parenteral nutrition (TPN), treatment of
anemia, and endoscopic therapy
(D) Surgical intervention, including partial
(E) Surgical intervention, including total
- In general, vagotomy with a gastric drainage procedure is less satisfactory in the treatment of primary gastric ulcer.
- Treatment of a gastric ulcer may include partial gastrectomy with a gastroduodenal anastomosis (Billroth I)
- Vagotomy is not necessary because gastric ulcers are usually not associated with acid hypersecretion.
- A gastric ulcer that fails to heal despite medical therapy should be excised.
Investigations of a 43-year-old woman with
pluriglandular syndrome were scheduled to
determine if a gastrinoma (ZES) was present.
The serum gastrin level was slightly elevated.
Further assessment to establish the diagnosis can
be made by repeating the serum gastrin level
after stimulation with which of the following?
- In ZES gastrin levels may only be mildly elevated but can be increased with provocation with intravenous calcium or secretin.
- Most patients with gastrinoma have serum gastrin levels that exceed 500 pg/mL.
- When the range is lower than 200-500 pg/mL, a stimulation test is performed to confirm the diagnosis.
- A rise of 200 pg/mL after 15 minutes or a doubling of the fasting level is diagnostic.
- ZES can occur sporadically or as part of the multiple endocrine neoplasia (MEN Type I)
Over the past 6 months, a 60-year-old woman
with long standing duodenal ulcer disease has
been complaining of anorexia, nausea, weight
loss and repeated vomiting. She recognizes
undigested food in the vomitus. Examination
and workup reveal dehydration, hypokalemia,
and hypochloremic alkalosis. What is the most
(A) Carcinoma of the fundus
(B) Penetrating ulcer
(C) Pyloric obstruction due to cicatricial
stenosis of the lumen of the duodenum
(D) ZES (Zollinger Ellison Syndrome)
(E) Anorexia nervosa
- Chronic duodenal ulcer, with recurrent episode of healing and repair may lead to pyloric obstruction due to scarring and stenosis of the duodenum
- Painless vomiting of undigested food may occur once or twice a day.
- Surgical intervention should be carried out after correction of fluid and electrolyte imbalances.
- Peroperative antibiotics should be used due to bacterial overgrowth secondary to gastric stasis.
A 50-year-old woman presents with duodenal
ulcer disease and high basal acid secretory outputs. Secretin stimulated serum gastrin levels
are in excess of 1000 pg/mL. She has a long history of ulcer disease that has not responded to
intense medical therapy. What is the most likely
(B) Pernicious anemia
(C) Renal failure
(E) Multiple endocrine neoplasia
- ZES is characterised by dudoenal ulcer disease, high basal acid secretory acid output and a pancreatic tumour.
- Stimulated serum gastrin levels may be in excess of 1000pg/mL or as high as 10,000 pg/mL.
- ZES is due to a true pancreatic tumour in adults, but may be secondary to hyperplasia in chilren.
- Growth of the tumour is usually slow and survival is often prolonged.
- If an isolated tumour is found on the CAT scan, surgical resection is indicated.
- About 2/3rds of these tumours are malignant.
- About 14 of patients have MEN I syndrome tumours of parathyroid, pituitary and pancreas.
A 44-year-old man underwent partial resection
of the stomach. Following the operation, there
was a reduction in serum gastrin levels. The
site of resection of the stomach that removed
the normal source of gastrin is which of the
(A) Gastroduodenal junction
(B) Lower esophagus
(D) Body of the stomach
(E) Fundus of the stomach
- Gastrin is produced in the antrum, duodenum and small intestine.
- It is not present in the fundus of the stomach
- When the distal stomach is removed gastrin levels decrease significantly
- Gastrin stimulates parietal cells to secrete acid and it stimulates chief cells to secrete pepsinogen.
A 50-year-old man presents with vague gastric
complaints. Findings on physical examination
are unremarkable. The serum albumin level is
markedly reduced (1.8 g/100 mL). A barium
study of the stomach shows massive gastric
folds within the proximal stomach. These findings are confirmed by endoscopy. What is the
(A) Hypertrophic pyloric stenosis
(B) Gallstone ileus
(C) Mallory-Weiss tear
(D) Hypertrophic gastritis
(E) Crohn’s disease
- Hypertrophic gastritis is characterised by massive loss of plasma protein through the affected gastric mucosa.
- Most cases can be managed medically by maintenance of adequate nutrition.
- An increased incidence of gastric cancer has been reported in some series.
A 2-cm ulcer on the greater curvature of the
stomach is diagnosed in a 70-year-old woman
by a barium study. Gastric analysis to maximal acid stimulation shows achlorhydria. What is the next step in management?
(A) Antacids, H2 blockers, and repeat barium study in 6 to 8 weeks
(B) Proton pump inhibitor (PPI)
(e.g., omeprazole) and repeat barium
study in 6 to 8 weeks
(C) Prostoglandin E (misoprostol)
and repeat barium study in 6 to
(D) Immediate elective surgery
(E) Upper endoscopy with multiple
biopsies (at least 8 or 9) for the ulcer
A 55-year-old school bus driver was diagnosed
3 months ago with an antral ulcer. He was
treated for H. pyloriand continues to take a
PPI. Repeat endoscopy demonstrates that the
ulcer has not healed. What is the next treatment option?
(A) Treatment with H 2
(B) Vagotomy alone without additional
(C) Endoscopy and laser treatment of the
(D) Distal gastrectomy with gastroduodenal
anastomosis (Billroth I)
(E) Elevating the head of the bed when
A 70-year-old woman complains of abdominal
discomfort, anorexia, and a 10-lb weight loss.
Endoscopy reveals a polypoid lesion in the
antrum. The lesion is biopsied and the patient
is informed that she has early gastric cancer
(A) Because it involves only the mucosa and
does not invade the muscular wall of
(B) Because it is demonstrable on a barium
(C) Because it has a 5 year survival rate of 5%
(D) Because surgery always cures it
(E) Because it does not require tumor free
margins when resected
A 62-year-old man presents with guaiac positive stool. He is asymptomatic. Workup reveals
a 2-cm ulcerated carcinoma on the antral lesser
curvature. Tumor markers are negative. A CAT
scan is negative for metastatic disease and lymphadenopathy liver function tests are normal.
What is the correct treatment for this patient?
(A) Chemotherapy only
(B) Radiation therapy only
(C) Combination chemotherapy and
radiation therapy without resection
(D) Total gastrectomy
(E) Distal gastrectomy with en bloc removal
of lymph nodes
A 55-year-old man complains of anorexia,
weight loss, and fatique. A UGI study demonstrates an ulcerated lesion at the incisura. Where is the incisura?
(C) Greater curvature
(D) Lesser curvature
(E) Gastrocolic ligament
A 36-year-old man presents with weight loss
and a large palpable tumor in the upper
abdomen. Endoscopy reveals an intact gastric
mucosa without signs of carcinoma. Multiple
biopsies show normal gastric mucosa. A UGI
study shows a mass in the stomach. At surgery, a 3-kg mass is removed. It is necessary to
remove the left side of the transverse colon.
What is the most likely diagnosis?
(A) Gastric cancer
(B) Gastrointestinal stromal tumor (GIST)
(C) Choledochoduodenal fistula
(D) Eosinophilic gastroenteritis
(E) Linitis plastica
A 74-year-old man presents with anorexia and
self-limited hematemesis. During endoscopy a
mass is discovered and a biopsy is done. A
hematopathologis diagnoses non-Hodgkin’s
lymphoma. What is the recommended therapy?
(A) Chemotherapy alone
(C) Radiation and chemotherapy
(D) Surgery, radiation, and chemotherapy
(E) Surgery alone
A 63-year-old woman is admitted to the hospital with a UGI bleed that subsides spontaneously within a short time after admission. A
barium study shows a gastric ulceration that is
described by the radiologist as having a “doughnut sign.” What is the most likely diagnosis?
(B) Gastric ulcer
(C) Ectopic pancreas
D - GIST
- A GIST (previously called leiomyoma or leiomyosarcoma) can occur in any part of the stomach.
- Most commonly they are found in the submucosa and grow towards the lumen.
- Ulceration may occur and give rise to the characteristic ''doughnut sign'' on barium studies.
- Hematemesis and/or melena may sometimes be massive.
- Local resection is curative.
A 50-year-old woman is diagnosed with multiple hyperplastic polyps in the stomach during endoscopy and biopsy. How are these best treated?
(A) Total gastrectomy
(B) Partial gastrectomy
(C) Staged endoscopic removal after
brushing for cytologic examination
(D) Ablation by laser
(E) No treatment other than repeated
endoscopy and multiple brush biopsie