Peptic Ulcer Disease

Question 1

Forrest classification of actively-bleeding, pulsatile peptic ulcer and 30-day risk of recurrence

Answer 1

Grade 1a, 20% 30-day re-bleeding risk

Question 2

Forrest classification of actively-bleeding, non-pulsatile peptic ulcer and 30-day risk of recurrence

Answer 2

Grade 1b, <10% risk of re-bleeding

Question 3

Forrest classification of non-bleeding peptic ulcer with visible vessel and 30-day risk of recurrence

Answer 3

Grade 2a, 15% risk of re-bleeding

Question 4

Forrest classification of non-bleeding peptic ulcer with adherent clot and 30-day risk of recurrence

Answer 4

Grade 2b, <5% risk of re-bleeding

Question 5

Forrest classification of non-bleeding peptic ulcer with hematin-covered base and 30-day risk of recurrence

Answer 5

Grade 2c, 7% risk of re-bleeding

Question 6

Forrest classification of non-bleeding peptic ulcer with a clean base and 30-day risk of recurrence

Answer 6

Grade 3, 3% risk of re-bleeding

Question 7

Johnson classification and etiology of lesser curve gastric ulcers

Answer 7

Type I, etiology varies but is not related to acid hypersecretion

This is the most common type, 60% of peptic ulcers.

Question 8

Johnson classification and etiology of two ulcers, one in duodenum and one in gastric body

Answer 8

Type II, etiology is acid hypersecretion

Question 9

Johnson classification and etiology of prepyloric gastric ulcers

Answer 9

Grade III, etiology is acid hypersecretion

Question 10

Johnson classification and etiology of GE junction gastric ulcers

Answer 10

Type IV, etiology is variable but is not related to acid hypersecretion

Question 11

Johnson classification and etiology of gastric ulcers seen in “any location”

Answer 11

Type V, etiology is NSAIDs

Question 12

Surgical approach for unstable patients with bleeding peptic ulcers

Answer 12

Upper midline laparotomy, anterior gastrotomy and oversewing of ulcer. Biopsy ulcer if possible.

Distal gastrectomy in unstable patients significantly increases chances of morbidity and mortality and should be avoided.

Question 13

Medication to ameliorate effects of NSAIDs on gastric mucosa

Answer 13

Misoprostol

Question 14

Origin of the criminal nerve of Grassi

Answer 14

First gastric branch of the posterior vagus

Question 15

Surgical indications for PUD

Answer 15

Hemorrhage
Obstruction
Perforation
Refractory ulcer disease

Question 16

What are the relative in-hospital mortalities of duodenal and gastric ulcer disease?

Answer 16

3. 7% mortality for duodenal ulcer disease

2. 1% mortality for gastric ulcer disease

Question 17

How does H. pylori predispose to ulcer disease?

Answer 17

Disrupts mucosal integrity and stimulates increased acid secretion through excretion of histamine N-methyltransferase

Question 18

Steps for eradication of H. pylori

Answer 18

Triple therapy (amoxicillin, clarithromycin and PPI), smoking cessation and avoidance of ASA and NSAIDs

Question 19

Which patients are less likely to undergo successful definitive endoscopic management of a bleeding duodenal ulcer? (4 risk factors)

Answer 19

Hemodynamically unstable at presentation

Ulcer base of >2cm

Ulcer in a deep, posterior location

Transfusion requirement >4 U in 24h

Question 20

How to find the posterior vagus intra-operatively

Answer 20

Retract the GEJ caudally with a Penrose and feel for the “violin string” of the posterior vagus. It is often up to a centimeter posterior to the back wall of the esophagus.

Be careful of the spleen when applying traction to the stomach!

Question 21

Risk factors for the development of NSAID-related ulcers (5)

Answer 21

Advanced age

History of prior ulcer

Serious systemic illness

Concomitant use of anticoagulation or corticosteroids

High NSAID doses

Question 22

How far up the esophagus should one dissect to avoid missing the criminal nerve of Grassi while doing a truncal vagotomy?

Answer 22

6cm. Criminal nerve of Grassi is the first branch of the posterior vagus and innervates the antrum.