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Self-Assessment Questions

Gastroenterology

Peptic Ulcer Disease: Review Questions

Douglas G. Adler, MD

Dr. Adler is an assistant professor of medicine and director of therapeutic endoscopy, Division of Gastroenterology and Hepatology, Huntsman Cancer Center, University of Utah, Salt Lake City, UT.



Choose the single best answer for each question.

1. A 34-year-old man presents to the emergency department (ED) with intermittent melena of 3 days’ duration. He is mildly fatigued but hemodynamically stable and denies any hematemesis or coffee ground emesis. His serum hemoglobin level is 8.2 g/dL. Intravenous (IV) fluids are started. Physical examination is essentially unremarkable. What is the next best step in this patient’s evaluation?

  1. Check serum Helicobacter pylori antibody levels
  2. Perform a colonoscopy
  3. Perform an esophagogastroduodenoscopy (EGD)
  4. Start a histamine2 receptor antagonist (H2 blocker)
  5. Transfuse 2 U of packed red blood cells
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2. A 75-year-old man presents to his primary care physician with a painful right great toe. Past medical history is remarkable for recent deep venous thrombosis currently treated with warfarin and hypertension treated with an angiotensin-converting enzyme (ACE) inhibitor and a calcium channel blocker. On examination, he appears to be having an attack of gout. The patient is prescribed indomethacin 50 mg orally 3 times daily and colchicine 0.6 mg orally 3 times daily. The patient calls the office the next day to report that he is feeling better, and his physician advises him to continue with the medication regimen. Two days later, the patient is admitted to the intensive care unit with a life-threatening upper gastrointestinal (GI) bleed. Endoscopy reveals several deep and actively bleeding gastric ulcers, which are treated to good effect. What is the most likely cause of this patient’s bleeding event?

  1. Failure to stop the ACE inhibitor prior to starting therapy for gout
  2. Failure to stop the calcium channel blocker prior to starting therapy for gout
  3. Failure to stop warfarin prior to starting therapy for gout
  4. The addition of colchicine to his regimen
  5. The addition of indomethacin to his regimen
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3. A 45-year-old man with a history of bleeding duodenal ulcers presents to his primary care physician with abdominal pain. Two years ago, the patient was found to have H. pylori infection and was treated with lansoprazole 30 mg twice daily, amoxicillin 1 g twice daily, and clarithromycin 500 mg twice daily for 14 days. He states that he was compliant with the medications. At this visit, he reports that his abdominal pain is similar to what he experienced during the prior episode. A gastroenterology consult is obtained, and upper endoscopy reveals 2 small ulcers in the duodenal bulb that do not require endoscopic treatment. Gastric biopsies obtained at the time of the procedure reveal the presence of H. pylori. What is the most likely explanation for the presence of H. pylori in this patient’s stomach?

  1. Failure of the original treatment regimen 2 years ago
  2. False-positive result on the gastric biopsy
  3. Incorrect drug choices 2 years ago
  4. Incorrect drug doses 2 years ago
  5. Repeat infection following eradication of prior infection
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Figure. Deep ulcer along the lesser curvature of the stomach with a visible vessel in the center of the ulcer found during upper endoscopy in the patient described in question 4.


4. A 68-year-old man presents to the ED with coffee ground emesis, abdominal pain, weakness, and nausea. He states that he has had 3 episodes of coffee ground emesis over the past 2 hours. After appropriate resuscitation, an upper endoscopy is performed, which reveals a deep ulcer along the lesser curvature of the stomach (Figure). There appears to be a visible vessel in the center of the ulcer. The remainder of the endoscopic examination is normal. What is the next best step in this patient’s management?
  1. Begin IV octreotide
  2. Endoscopic therapy
  3. Insert a nasogastric tube
  4. Observation, nothing by mouth status, and IV proton pump inhibitor (PPI)
  5. Surgical consultation
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5. A 21-year-old college football player presents to the ED for copious hematemesis. He recently started taking ibuprofen 800 mg 3 times a day for muscle and joint aches and pains. After IV fluids are started, an upper endoscopy is performed; however, the stomach and proximal intestine is full of fresh and clotted blood, and the gastroenterologist is unable to adequately visualize the gastric or duodenal mucosa. An IV PPI is started and a nasogastric tube is placed, but the thick blood and clots are difficult to aspirate through the tube. What is the next best step in this patient’s management?

  1. Administer IV erythromycin 250 mg and repeat endoscopy in 1 hour
  2. Administer IV levofloxacin 500 mg and repeat endoscopy in 1 hour
  3. Induce vomiting to clear the stomach
  4. Repeat endoscopy in 24 hours after the blood has had time to pass into the distal small bowel
  5. Surgical evaluation
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6. A 56-year-old woman presents to the ED with dehydration, abdominal pain, nausea, and vomiting. The patient states that her vomit appears to contain flecks of blood. She is borderline hypotensive but otherwise hemodynamically stable. The abdominal examination is remarkable for mild epigastric tenderness to deep palpation, but there are no peritoneal signs. IV fluids are administered and the patient’s blood pressure normalizes. EGD is performed, which reveals what appears to be partial gastric outlet obstruction at the level of the pylorus due to several benign-appearing, clean-based ulcers in the pyloric channel. A rapid urease test to assess for the presence of H. pylori is negative. The ulcers do not warrant endoscopic therapy. What is the next best step in this patient’s management?

  1. Endoscopic dilation of the stenosed pylorus
  2. Endoscopic placement of a transpyloric stent
  3. High-dose H2 blocker
  4. High-dose PPI therapy
  5. Surgical evaluation
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