Peptic Ulcer

Question 1

Types of gastric cells

Answer 1

Parietal cells

Chief cells

Mucous cells

G-cells

D-cells

Question 2

Boey Score 1)Use 2)components 3)interpretation

Answer 2

1) outcome prediction for PPU (30 day mortality)
2) duration of PPU, presence of preoperative shock level, comorbidities

Question 3

Name several scoring systems for predicting mortality after PPU

Answer 3

Boey

PULP

ASA

Mannheim peritonitis index

APACHEII

Hacateppe score

Jabalpur score

Question 4

Chief cells secrete?

Answer 4

Pepsinogen

Question 5

Parietal cells secrete?

Answer 5

HCl

Intrinsic factor

Question 6

G-cells

1) Secrete
2) Location

Answer 6

1) Gastrin
2) Pylorus

Question 7

D-cells

1) Secrete
2) Location

Answer 7

1) Somatostatin
2) Antrum

Question 8

Stimulating gastric acid

Answer 8

Acetylcholine (parasympathetic vagal neural stimulation of parietal cells

Gastrin

Histamine

Question 9

Inhibition of HCl secretion

Answer 9

Somatostatin

Secretin

CCK

Question 10

Gastric fluid made up of

Answer 10

Water

Mucus

Ions: HCl, HCO3

Pepsinogen

Intrinsic factor

Hormones (Gastrin, Histamine)

Question 11

Phases of acid secretion

Answer 11

1) Cephalic phase: vagal activation -> HCl and Gastrin secretion
2) Gastric phase
3) Intestinal phase: food in duodenum => acid secretion then inhibition

Question 12

Helicobacter pylori

1) Classification
2) Action

Answer 12

1)Gram negative, microaerophilic, spiral bacterium

2)

a. Potent urease activity
b. Direct damage from cytotoxin
c. Dirupt neural pathway by impair inhibitory reflex on acid secretion

Question 13

Methods of H.pylori detection

Answer 13

Histological

Microbiological culture

Urease breath test

Rapid urease test

Serology for antigen

Stool antigen test

Question 14

Risks of prolonged PPI use

Answer 14

Vitamin B12 deficiency

Iron deficiency

Reduced calcium absorption (hip fracture, osteoporosis)

Atrophic gastritis

Intestinal metaplasia

Fundic gland polyps

Increase enteric infections (ex CD)

Question 15

Lap vs Open for PPU surgical intervention

Answer 15

Metanalyses suggest no difference in mortality or postoperative complications, but higher leak rate for ulcers >0.5cm

Conclusion: no evidence lap better than open

Question 16

Graham-Steele operation

Answer 16

Pedicled omental patch laid over perforation site with full thickness interrupted suture with absorbable with atraumatic needle. Traditionally 3 sutures

Question 17

Indications to consider NOM (non-operative management) for PPU

Answer 17

Stable without sepsis/periotonitis

Delayed presentation with improving clinical picture

<70 years old

Unfit for surgery (ASA 5)

Patient unwilling for surgery

Question 18

Reduction in acid secretion

Answer 18

Truncal vagotomy: 60-70%

Antrectomy: 85%

PPI:

• 100% by 6 hours
• 60-70% by 24 hours

Question 19

Types of pyloroplasty techniques

Answer 19

Heinke-Mikulicz

Jaboulay

Finney

Question 20

Heineke-Mikulicz Pyloroplasty

Answer 20

Full thickness longitudinal incision from distal antrum to proximal duodenum and closed transversely to increase diameter of pyloric channel

Question 21

Types of drainage procedure

Answer 21

Pyloroplasty

Gastrojejunostomy

Question 22

Finney pyloroplasty

Answer 22

• Side to side gastroduodenostomy between anterior surfaces of stomach and duodenum,
• the pylorus is excised
• Single inverted U or V -shaped incision through prepyloric antrum, pylorus and
• Continuous full thickness suture of gastroduodenal anastomosis

Question 23

Jaboulay pyloroplasty

Answer 23

• Side to side gastroduodenostomy
• Pylorus not incised
• Separate incisions: at prepyloric antrum and D1
• Greater curvature of prepyloric antrum attached to medial wall of adjacent duodenum

Question 24

Johnson classification

1) Type 1
2) Type 2
3) Type 3
4) Type 4
5) Type 5

Answer 24

Gastric ulcer at

1) lesser curve/incisura
2) combined gastric and duodenal
3) prepyloric
4) juxtaesophageal
5) drug related