COMEDK 2007 MCQ Answer 17

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The correct answer is C

Duodenal Ulcer

  1. characteristics: mostly occurs in 40-65 yo, M:F = 2:1, more than twice as common as gastric ulcers, bleed 4x as often as gastric ulcers, 25% of total UGI bleeds
  2. etiology
    1. most (95%) due to H. Pylori
    2. increased gastric acid production
    3. environmental factors – smoking, NSAIDs
  3. risk factors: male, smoking, aspirin/NSAID use, uremia, Zollinger-Ellison syndrome, H. pylori infection, trauma, burn injury
          1. sx: epigastric pain (burning or aching, several hrs after meal, initially relieved by food, milk, or antacids), back pain, N/V, anorexia, decreased appetite
          2. signs: tenderness in epigastric area (possibly), guaiac-positive stool, melena, hematochezia, hematemesis
          3. ddx: acute abdomen, pancreatitis, cholecystitis, all causes of UGI bleeding, Zollinger-Ellison syndrome, gastritis, MI, gastric ulcer
          4. diagnose with H&P, EGD, UGI series (if not actively bleeding), urea breath test, H. pylori serology

            a. with EGD, visible vessel in ulcer crater a/w 90% rebleed rate

          1. location
            1. majority within 2 cm of pylorus in duodenal bulb
            2. posterior – more likely to bleed b/c erodes into gastroduodenal artery
            3. anterior – most likely to perforate (see free air under diaphragm on upright AXR)
          1. medical tx
            1. Antacids (Mg, Al, Ca): control gastric pH, promote healing
            2. H2 receptor blockers: usually heal ulcers in 4-6 wks
            3. Sucralfate: coats ulcer
            4. Proton pump inhibitors (omeprazole): decrease acid production; used for refractory ulcers and ulcers a/w Zollinger-Ellison syndrome
            5. Prostaglandins: provide mucosal protection
            6. Bismuth
            7. Antibiotics: triple therapy for H. pylori (see above)
          1. surgical tx
            1. indications: I HOP

              I = Intractability

              H = Hemorrhage (massive or relentless)

              Note: exsanguination is the most common cause of death from a duodenal ulcer

              O = Obstruction (gastric outlet obstruction)

              P = Perforation

            1. goal: decrease gastric acid secretion and fix IHOP
            2. options for Intractability
              1. highly selective vagotomy (preserves pyloric branches, operation of choice b/c only 0.5% mortality, but increased recurrence, 10-25%)
              2. vagotomy and pyloroplasty (0.5-1% mortality, 10-12% recurrence)
              3. vagotomy and antrectomy Billroth I or II (1-2% mortality, 1-2% recurrence) (see Surg Recall p.235 for Billroth I, II explanations)
            1. for Hemorrhage, open duodenum through pylorus, oversew bleeding vessel, perform vagotomy and pyloroplasty
            2. options for Obstruction
              1. truncal vagotomy, antrectomy, and gastroduodenostomy (Billroth I) or gastrojejunostomy (Billroth II)
              2. truncal vagotomy and drainage procedure (gastrojejunostomy)
            1. options for Perforation
            1. Graham patch for poor candidates, shock, or prolonged perforation (Graham patch is a piece of omentum incorporated into the suture closure of a perforation)
            2. truncal vagotomy and pyloroplasty, incorporating ulcer
            3. Graham patch and highly selective vagotomy
            4. truncal vagotomy and antrectomy
          1. complications
            1. early
              1. hemorrhage (may need to reoperate)
              2. gastric retention from vagotomy
              3. duodenal stump leakage with Bilroth II (must usually reoperate)
            1. late

              1. dumping: ealy dumping: uncontrolled emptying of hypertonic fluid from intravascular space to intraluminal space, leading to intravascular volume depletion and diarrhea; late dumping: rapid absorption of glucose due to improper gastric emptying, leads to large insulin increase – over-correction of blood glucose leads to transient hypoglycemia approx. 3 hrs after meal

            2. diarrhea (tx with Lomotil, Kaopectate, Imodium)

              3. reflux gastritis (convert Billroth I/II to gastrojejunostomy)

              1. gallstones
              2. weight loss
              3. iron/vit B-12 deficiency due to decreased intrinsic factor secretion (tx with supplementation)

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