Gastric Ulcers Quiz: Types and Treatments
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Questions and Answers

Which of the following statements is TRUE about Type I gastric ulcers?

  • They are typically located on the greater curvature of the stomach.
  • They are always associated with high acid secretion.
  • They are commonly associated with chronic aspirin use.
  • They are characterized by a low acid secretion due to a decrease in parietal cells. (correct)

    • Which type of gastric ulcer is considered secondary to duodenal ulcer?

  • Type IV
  • Type III
  • Type II (correct)
  • Type I

    • What is a distinguishing characteristic of Type III gastric ulcers?

  • Location on the greater curvature.
  • Association with duodenal reflux.
  • Low acid secretion.
  • Antral location near the pylorus. (correct)

    • Which type of gastric ulcer is associated with chronic ingestion of NSAID's?

    <p>Type V (B)</p> Signup and view all the answers

    What is the primary characteristic that distinguishes Type IV gastric ulcers from other types?

    <p>Location on the lesser curvature. (C)</p> Signup and view all the answers

    Which of the following is NOT a characteristic of Type II gastric ulcers?

    <p>High acid secretion. (D)</p> Signup and view all the answers

    Which two types of gastric ulcers were NOT included in Johnson's original classification?

    <p>Type IV and Type V (D)</p> Signup and view all the answers

    What is the primary method for gathering information about the periodicity and rhythm of symptoms in duodenal ulcers?

    <p>Anamnesis. (A)</p> Signup and view all the answers

    Which medication is known for its cytoprotective action?

    <p>Misoprostol (D)</p> Signup and view all the answers

    What is the primary mode of action of proton pump inhibitors?

    <p>Inhibiting the ATPase that exchanges H+ ions with K+ ions (C)</p> Signup and view all the answers

    Which of the following is NOT a relative indication for surgical intervention in gastric ulcers?

    <p>Perforated ulcer (C)</p> Signup and view all the answers

    What is the mechanism of action of anticholinergic substances like Pirenzepine in treating gastric ulcers?

    <p>Blocking the action of acetylcholine on parietal cells (D)</p> Signup and view all the answers

    Which drug is a prototype of proton pump inhibitors?

    <p>Omeprazole (B)</p> Signup and view all the answers

    Which of the following is an absolute indication for surgical intervention in duodenal ulcers?

    <p>Hemorrhagic ulcer that cannot be controlled conservatively (A)</p> Signup and view all the answers

    What is the primary therapy for a patient with a gastric ulcer who is also positive for Helicobacter pylori?

    <p>Triple therapy (D)</p> Signup and view all the answers

    Which of the following medications is NOT used for the treatment of gastric ulcers?

    <p>Metoprolol (A)</p> Signup and view all the answers

    Which of the following is NOT a characteristic of rhythmicity as it relates to pain in the context of ulcers?

    <p>Pain is usually constant and unrelated to eating habits. (C)</p> Signup and view all the answers

    When does pain typically present itself in a gastric ulcer located in the gastric body (Johnson type I)?

    <p>1-2 hours after eating. (D)</p> Signup and view all the answers

    Which type of ulcer is associated with pain that appears 2-3 hours after eating?

    <p>Pre-pyloric ulcer (Johnson type III). (D)</p> Signup and view all the answers

    What is the characteristic pain pattern associated with duodenal ulcers?

    <p>Pain occurs 3-4 hours after eating and is associated with hunger pangs. (D)</p> Signup and view all the answers

    What is a possible symptom that differentiates an uncomplicated gastroduodenal ulcer from one with a more severe complication?

    <p>Vomiting and nausea. (A)</p> Signup and view all the answers

    Which of the following is NOT typically considered a dyspeptic symptom associated with ulcers?

    <p>Nocturnal pain. (D)</p> Signup and view all the answers

    What is the distinction between ulcerative dyspeptic syndrome and typical ulcer pain?

    <p>Ulcerative dyspeptic syndrome involves pain that is not directly related to the ulcer itself. (A)</p> Signup and view all the answers

    Which of the following statements about epigastric and retrosternal burns is TRUE?

    <p>They can be a symptom of both gastroesophageal reflux and ulcerous disease. (D)</p> Signup and view all the answers

    What is a potential disadvantage of branch-level vagotomy?

    <p>It can disrupt the vagal muscular activity of the stomach. (G)</p> Signup and view all the answers

    Which of the following is NOT a reason for considering surgery as a treatment option for a duodenal ulcer?

    <p>Persistent ulcers over 3 months of active drug therapy. (D)</p> Signup and view all the answers

    What is a key advantage of selective vagotomy compared to branch-level vagotomy?

    <p>It preserves the vagal innervation of the liver, biliary pathways, and duodenum. (D)</p> Signup and view all the answers

    Which of the following surgical interventions is specifically designed to interrupt acid secretion?

    <p>Vagotomy (B)</p> Signup and view all the answers

    What is the primary objective of pyloroplasty in conjunction with vagotomy?

    <p>To facilitate the emptying of the stomach and prevent post-vagotomy stasis. (A)</p> Signup and view all the answers

    What is the underlying rationale for considering surgical treatment of duodenal ulcers?

    <p>To achieve symptom relief when medical treatment fails or is inadequate. (C)</p> Signup and view all the answers

    Why is selective vagotomy often combined with pyloroplasty?

    <p>To minimize the impact of the vagotomy on gastric motility (F)</p> Signup and view all the answers

    Which of these is NOT a type of vagotomy?

    <p>Perivagotomy (D)</p> Signup and view all the answers

    What is the main purpose of proximal selective vagotomy?

    <p>To target acid secretory parcels while preserving antrum branches (D)</p> Signup and view all the answers

    Which surgical technique is primarily used for enlarging the pylorus?

    <p>Mikulicz technique (D)</p> Signup and view all the answers

    In a Billroth II procedure, what is a key feature regarding the gastric section?

    <p>It can involve a whole gastric section or a half gastric section (D)</p> Signup and view all the answers

    What is often done during a limited resection procedure?

    <p>Antrectomy with vagotomy and Gastro-Duodenal anastomosis (A)</p> Signup and view all the answers

    Which surgical method aims to maintain the continuity of the gastrointestinal tract?

    <p>Gastro-Duodenal T-T Anastomosis (B)</p> Signup and view all the answers

    What is one of the primary objectives of pyloroplasty?

    <p>To facilitate better drainage pathways (D)</p> Signup and view all the answers

    What characteristic distinguishes a gastro-jejunal T-L procedure?

    <p>It features a 45 cm Roux loop to limit biliary reflux (A)</p> Signup and view all the answers

    Which technique is employed during a classic resection involving gastric outlet obstruction?

    <p>Gastro-Duodenal anastomosis (D)</p> Signup and view all the answers

    What is the main indicator of a complication related to duodenal ulcers?

    <p>Decreased appetite (D)</p> Signup and view all the answers

    Which of the following is NOT a radiological sign observed during a barium intake examination for ulcers?

    <p>Gastric peristalsis (B)</p> Signup and view all the answers

    According to the provided content, what does the objective exam contribute to the diagnosis of ulcerative disease?

    <p>It has limited value in establishing a positive diagnosis, as ulcerative disease is poor in clinical signs. (D)</p> Signup and view all the answers

    How is a duodenal ulcer located during a physical examination?

    <p>Deep palpation of a painful area to the right of the median line in the epigastric region. (C)</p> Signup and view all the answers

    What does the term "Haudeck`s niche" refer to?

    <p>A round stain surrounded by a clear halo observed during barium intake, resembling a cockade. (D)</p> Signup and view all the answers

    What aspect of the patient's condition indicates a possible complication of a duodenal ulcer?

    <p>Decreased appetite (B)</p> Signup and view all the answers

    Which of the following is a direct sign of an ulcer observed during a barium intake examination?

    <p>Haudeck`s niche (A)</p> Signup and view all the answers

    What does the text emphasize about nutrition in relation to duodenal ulcers?

    <p>It can alleviate pain and maintain appetite in uncomplicated ulcers. (D)</p> Signup and view all the answers

    Study Notes

    Course Information

    • Course number: 05
    • Course topic: Gastric Ulcer
    • Institution: Titu Maiorescu University of Bucharest
    • Faculty: Faculty of Medicine
    • Program: Medicine in English program

    Definition and Classification

    • Peptic ulcer is a general term used for gastric or duodenal ulcers, regardless of location.
    • Relapsed peptic ulcer is used for ulcers occurring after surgery with ulcerative visa.

    Classification (1)

    • Acute ulcers are defined by two forms:
      • Erosion: A loss of substance in the gastric mucosa that doesn't penetrate the muscularis mucosae layer. Often multiple and hemorrhagic, healing without scars.
      • Deep acute ulcer: A round lesion up to 1 cm in diameter penetrating all layers of the gastric wall, surrounded by edema and hyperemia, leaving a gastric wall scar after healing.
    • Chronic ulcer: A loss of substance in the gastric wall, typically 2-3 cm in diameter, progressing in depth through all gastric layers, with chronic inflammatory tissue rich in lymph and plasma cells. Sometimes develops into a perforated ulcer. It's distinguishable from the surrounding stomach surface by a white-pearl star-shaped scar. A "kissing ulcer" is also a particular form where two mirrored ulcer sites are present.

    Classification (2)

    • Type I: Ulcer is located high on the small gastric curvature with lower acid secretion due to reduced parietal cell mass, gastritis, and duodenal reflux.
    • Type II: Ulcer is located on the small curvature of the stomach body, associated with pyloric or duodenal ulcers; sometimes stenotic. Gastric acidity is moderate to high and evacuation is delayed. May be secondary to duodenal ulcers.
    • Type III: Ulcer is located within the pre-pyloric region, acting similarly to duodenal ulcers with high acid secretion
    • Type IV and V: These additional types were added later and described Type IV as located high on the lesser curvature and Type V as randomly located on the gastric mucosa, typically resulting from chronic ingestion of aspirin or other NSAIDs.

    Classification (3)

    • A table of Modified Johnson Classification is provided. It details the type, location, and acid hypersecretion status for each ulcer type.

    Signs and Symptoms (1)

    • The clinical picture of duodenal ulcers is characterized by periodicity and rhythm in symptoms, easily obtained through anamnesis.
    • Types of onset include unsystematic dyspeptic syndrome, complications like hemorrhage, perforation or stenosis; and systematized dyspeptic syndromes centered on pain.

    Signs and Symptoms (2)

    • Ulcer pain may show periodicity with pain-free periods, often seasonal, with spring and autumn being common.
    • Pain may be triggered by physical/psychological exertion, fatigue, stress, or nutrition

    Signs and Symptoms (3)

    • Rhythmicity: Pain is often constant, linked to daily schedules and food intake.
    • Pain timings differ based on ulcer type.
      • Type IV: Pain immediately post-food.
      • Type I: Pain 1-2 hours post-food.
      • Type III: Pain 2-3 hours post-food.
      • Type II: Pain 3-4 hours post-food, potentially related to hunger

    Signs and Symptoms (4)

    • Epigastric and retrosternal burns: Often associated with gastroesophageal reflux but can also signal ulcer disease.
    • Vomiting and nausea: Not typical of uncomplicated ulcers, but may signal complications like stenosis or Zollinger-Ellison syndrome.
    • Dyspeptic symptoms: Pain, and symptoms like bloating, eructation, fullness, or cramps are not uniquely related to ulcers, but may be associated with them or accompanying complications.
    • Appetite Preservation/Loss: Complicated ulcers may change appetite or produce it in certain cases.

    Signs and Symptoms (5)

    • The objective examination is not very helpful in simple ulcers due to a generally satisfactory condition and nutrition status,
    • Some tenderness can occur on palpation, with the presence of tenderness in the upper stomach indicating possible pyloric or gastric ulcers

    Paraclinical Diagnosis

    • Imaging Techniques:
      • Radiological (Barium intake, CT scan)
      • Upper digestive endoscopy (UE)

    Radiology

    • Radiological examination: Used to highlight aspects like stomach filling, ulcer shape/location; gastric peristalsis and transit, and stomach clearance.
    • Direct signs of ulcer: Haudeck's niche (characterized shade protruding from gastric contour).
    • Indirect signs of ulcer: Medio-bulbar incision and deformed ectopic pyloric canal.

    Paraclinical Diagnosis // Ba. Intake

    • Images of barium intakes are presented

    Paraclinical Diagnosis // Gastrographin Intake

    • Images of gastrographin intake are presented

    Paraclinical Diagnosis // Upper Endoscopy (UE)

    • UE: The main diagnostic method, revealing ulcerous and associated lesions; biopsy to check for cancer, identifying Helicobacter pylori (HP) highlighting using histological analysis and a rapid urease test.
    • Images highlighting different types of endoscopic findings are presented

    Clinical Forms

    • Standard clinical forms: Juxta-cardial ulcers (immediate post-food pain), post-bulbar ulcers (delayed pain associated with vagotomy), ulcers of the small gastric curvature, juxta-pyloric ulcer, stomach ulcers (bilateral), gastric ulcers associated with duodenal ones, bulbar-duodenal ulcers, double ulcers, and stress ulcers.

    Clinical Forms // Stress Ulcers

    • Factors associated with stress ulcers include infections, peritonitis, fistulas, sepsis, large electrolyte imbalances, extensive burns, craniocerebral trauma, acute respiratory insufficiency, and extrarenal dialysis.

    Treatment // Medication (1)

    • Antisecretory medication: Intercepts acid secretion
    • H2-receptor blockers: Prevent histamine penetration into secretory parietal cells. Drugs include Cimetidine, Ranitidine, and Famotidine.
    • Proton pump inhibitors: Inhibit ATP that exchanges H+ ions with K+ in oxyntic cells, completely blocking acid secretion. Omeprazole is a major example.
    • Prostaglandins(e.g. Misoprostol): In addition to acid inhibition, it has protective functions for the gastric mucosa, especially from NSAID-induced ulcers.
    • Anticholinergic substances: Block muscarinic receptors and hinder acetylcholine stimulation of parietal cells (e.g., Pirenzepine).
    • Eradication of Helicobacter pylori: Needed in many cases to prevent ulcer relapse.

    Treatment // Medication (2)

    • A table lists the drugs, dosages and treatment length for triple therapy-antisecretory scheme for treating ulcer symptoms in relation to 2-3 antibiotic combinations.

    Treatment // Surgery (1)

    • Surgical indications for G-D ulcers: Absolute and relative indications for both gastric and duodenal types of ulcers are presented.

    Treatment // Surgery (2)

    • Absolute indications: Perforated ulcers, uncontrolled hemorrhages post-endoscopy failure, pyloric stenosis, gastric ulcers that didn't heal after 3 months of therapy, suspicion of malignancy, multiple ulcers or Zollinger-Ellison syndrome (ZES) associated ulcers.

    Treatment // Surgery (3)

    • Relative indications (gastric ulcer): Ulcer persistence beyond three months despite conservative treatment. Multiple ulcers responding partially to conservative measures or frequent ulcer recurrences.
    • Relative indications (duodenal ulcer): Gradual decrease in pain or the recurrence of pain after effective treatment, coupled with diet and other regimen recommendations. Frequent painful episodes during nighttime and pain changes alongside the condition

    Treatment // Surgery (4)

    • Objectives: Aiming at interruption of acid secretion. Conservation of the gastric reservoir to the maximum extent possible. Re-establishing continuity of the gastrointestinal tract.

    Treatment // Surgery (5)

    • Vagotomy types: Troncular, selective, and supra-selective types.
    • Branch-level vagotomy: Bilateral, high level.
    • Selective vagotomy: Cuts vagal fibers targeting the stomach only, leaving other branches intact, such as for liver and biliary pathways, and celiac branch for pancreas and bowel. May need pyloroplasty.
    • Supra-selective vagotomy: Proximal/Highly Selective Vagotomy/Parietal Cell Vagotomy; preserves some vagal function and doesn't require pyloroplasty.

    Treatment // Surgery (6)

    • Drainage pathways: Pyloroplasty to enlarge the pyloric opening (various techniques exist) and gastro-jejunal anastomosis.

    Treatment // Surgery (5)

    • Ulcer Resection Objectives:
      • Classic resection (2/3 lower part) with gastro-duodenal anastomosis (Billroth I/Pean-type surgery).
      • Classic resection (2/3 lower part) with gastro-jejunal T-L anastomosis (Billroth II/Reichel-Polya).
      • Limited resection (antrectomy, vagotomy, and gastro-duodenal/Gastro-jejunal anastomoses) (used for specific conditions).
      • Resection of the ulcer alone (used in specific limited cases).

    Treatment // Surgery (5)

    • Objectives - Continuity of the G-I tract:
      • Gastro-Duodenal T-T Anastomosis: Maintains the biliary-duodenal-pancreatic block.
      • Gastro-Jejunal T-L Anastomosis (Billroth II): Described with two variations: The whole and ½ gastric sections (e.g., Reichel-Polya, and Hoffmeister-Finsterer types).
      • Gastro-Jejunal L-L w a-la-Roux intestinal loop: For situations involving the biliary tract to minimize reflux.

    Treatment // Surgery - (Pean-Billroth I Procedure)

    • Images of Pean-Billroth I procedure are provided.

    Thank You!

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    Description

    Test your knowledge on the different types of gastric ulcers, their characteristics, and treatment methods. This quiz delves into classifications, medications, and surgical interventions related to gastric health. Perfect for students and professionals in healthcare.

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