A 56-year-old woman with a longstanding history of gastroesophageal reflux presents for follow-up evaluation of endoscopically confirmed gastric and duodenal ulcers. Her symptoms have been unresponsive to proton pump inhibitors and histamine receptor antagonists in the past. Results for H. pylori infection are still pending. Which of the following changes is expected in the patient's duodenum, given her peptic ulcer disease?

Hyperplasia of submucosal bicarbonate-secreting glands

Proliferation of secretin-releasing S cells

Increased secretions from crypts of Lieberkühn

Increased glucose-dependent insulinotropic peptide (GIP) release from K cells

Expansion of gastrointestinal lymphoid tissue

A 30-year-old man who recently emigrated from Southeast Asia presents with heartburn and a bad taste in his mouth. He says the symptoms have been present for the last 6 months and are much worse at night. He describes the pain as moderate to severe, burning in character, and localized to the epigastric region. He mentions that 1 month ago, he was tested for Helicobacter pylori back in his country and completed a course of multiple antibiotics, but there has been no improvement in his symptoms. Which of the following is the most likely diagnosis in this patient?

Gastroesophageal reflux disease

Gastric MALT (mucosa-associated lymphoid tissue) lymphoma

A 28-year-old graduate student visits the university health clinic for 3-weeks of epigastric pain that worsens with meals, associated with retrosternal pain, early satiety, and bloating. She denies vomiting blood or blood in her stool. She has been consuming large volumes of caffeinated-drinks and fast-food for a month, as she has been studying for her tests. Her family and personal history are unremarkable with no history of gastrointestinal cancer. Her vital signs are within normal limits. Physical examination is only positive for a mild epigastric tenderness. Which of the following is the most appropriate approach in this case?

Fecal antigen testing for Helicobacter pylori

A 45-year-old man is brought to the emergency department because of severe abdominal pain for the past 2 hours. He has a 2-year history of burning epigastric pain that gets worse with meals. His pulse is 120/min, respirations are 22/min, and blood pressure is 60/40 mm Hg. Despite appropriate lifesaving measures, he dies. At autopsy, examination shows erosion of the right gastric artery. Perforation of an ulcer in which of the following locations most likely caused this patient's findings?

Lesser curvature of the stomach

Greater curvature of the stomach

A 45-year-old bank manager presents to the emergency department with abdominal pain for the last 2 weeks. The patient also vomited a few times, and in the last hour, he vomited blood as well. His pain was mild in the beginning but now he describes the pain as 8/10 in intensity, stabbing, and relentless. Ingestion of food makes it better as does the consumption of milk. He has a heart rate of 115/min. His blood pressure is 85/66 mm Hg standing, and 96/83 mm Hg lying down. He appears pale and feels dizzy. An intravenous line is started and a bolus of fluids is administered, which improved his vital signs. After stabilization, an esophagogastroduodenoscopy (EGD) is performed. There is a fair amount of blood in the stomach but after it is washed away, there are no abnormalities. A bleeding duodenal ulcer is seen located on the posteromedial wall of the duodenal bulb. Which artery is at risk from this ulcer?

Superior pancreaticoduodenal artery

Inferior pancreaticoduodenal artery

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

"Can you tell me more about the symptoms you have been experiencing?"

"Does the diarrhea typically precede the constipation, or vice-versa?"

"Is the diarrhea foul-smelling?"

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

"Are the symptoms worse in the morning or at night?"

A 46-year-old woman presents to the emergency department complaining of abdominal pain, nausea, and vomiting approximately 4 hours after a fatty meal. She reports that this has happened before, but this episode is worse. The vomit was non-bilious and did not contain any blood. She recalls frequent episodes of vague epigastric pain that often wakes her up during the night. Over the counter omeprazole and a small meal or snack would provide some relief in the past. The patient also mentions recent anorexia and early satiety. She takes over the counter ibuprofen several times a week for headaches. Blood pressure is 125/82 mm Hg, pulse is 102/min, and respiratory rate is 19/min. On physical examination, she has hypoactive bowel sounds, and her abdomen seems grossly distended and tympanic on percussion. Which of the following is most consistent with a duodenal ulcer?

Food ingestion provides relief of the symptoms

Omeprazole provides relief of the symptoms

A 38-year-old man comes to the physician because of an 8-month history of upper abdominal pain. During this period, he has also had nausea, heartburn, and multiple episodes of diarrhea with no blood or mucus. He has smoked one pack of cigarettes daily for the past 18 years. He does not use alcohol or illicit drugs. Current medications include an antacid. The abdomen is soft and there is tenderness to palpation in the epigastric and umbilical areas. Upper endoscopy shows several ulcers in the duodenum and the upper jejunum as well as thick gastric folds. Gastric pH is < 2. Biopsies from the ulcers show no organisms. Which of the following tests is most likely to confirm the diagnosis?

24-hour esophageal pH monitoring

Serum vasoactive intestinal polypeptide level

Peptic ulcer disease for USMLE Step 1: High-Yield Internal Medicine Lessons

Pathophysiology - The Gut's Acid Trip

Gastric Mucosal Balance: Aggressive vs. Defensive Factors

Core Imbalance: Aggressive factors (gastric acid, pepsin) overwhelm mucosal defenses (mucus, bicarbonate, prostaglandins, blood flow).
Two Main Culprits:
- H. pylori: Most common. Produces urease to survive in acid. Toxins (CagA, VacA) incite inflammation, leading to mucosal damage.
- NSAIDs: Inhibit COX-1, decreasing protective prostaglandins ($PGE_2$), which reduces mucus, bicarbonate, and mucosal blood flow.

⭐ In duodenal ulcers, H. pylori in the antrum decreases somatostatin output, leading to unchecked gastrin release and ↑ total acid production.

Presentation & Diagnosis - Spotting the Ulcer

Hallmark: Epigastric pain (dyspepsia), often gnawing or burning.
- Duodenal Ulcer (DU): Pain 2-5 hours post-meal, at night. Relieved by food/antacids.
- Gastric Ulcer (GU): Pain 15-30 mins post-meal. Worsened by food, causing anorexia/weight loss.
Alarm Features: Age >60, unintentional weight loss, progressive dysphagia, persistent vomiting, iron deficiency anemia, GI bleeding (melena/hematemesis).

Endoscopic view of peptic ulcer with clean base

Gold Standard: EGD (Endoscopy) for direct visualization & biopsy.
- Biopsy for histology & rapid urease test (H. pylori).

⭐ Exam Favorite: Any gastric ulcer found on imaging or endoscopy must be biopsied due to malignancy risk. Duodenal ulcers are almost never malignant.

Management - Dousing the Flames

Core Goal: Heal existing ulcers & prevent recurrence.
Acid Suppression: Proton Pump Inhibitors (PPIs) are first-line (e.g., Omeprazole). H2 blockers are second-line.
H. pylori Eradication: Crucial if positive.
- Standard Triple Therapy: Clarithromycin + Amoxicillin + PPI for 14 days.
- Quadruple Therapy: (Used for macrolide resistance or treatment failure).
  - 📌 Buy My Tasty Pepperoni: Bismuth subsalicylate + Metronidazole + Tetracycline + PPI.
NSAID-Induced Ulcers: Discontinue NSAID if possible. If not, co-prescribe a PPI.

⭐ Warning: For gastric ulcers, always repeat endoscopy in 8-12 weeks after treatment to confirm healing and rule out underlying malignancy. Duodenal ulcers rarely harbor malignancy and do not require routine follow-up endoscopy.

Complications - When Ulcers Go Rogue

Hemorrhage (Most Common): Presents as melena, hematemesis, or coffee-ground emesis. Endoscopy is crucial for diagnosis and hemostasis.
Perforation: Acute, severe abdominal pain; a surgical emergency. Classic sign is free air under the diaphragm on upright chest X-ray.
Gastric Outlet Obstruction (GOO): Caused by edema or scarring. Leads to early satiety, projectile non-bilious vomiting, and weight loss.
Penetration: Ulcer erodes into an adjacent organ (e.g., pancreas), causing persistent, radiating back pain.

⭐ A posterior duodenal ulcer may perforate and erode the gastroduodenal artery, leading to massive hemorrhage.

Peptic Ulcer Disease: Complications and Management

High‑Yield Points - ⚡ Biggest Takeaways

Most common causes: H. pylori infection and NSAID use.

Classic symptom: Epigastric pain. Duodenal ulcers improve with food, while gastric ulcers worsen.

Gold standard diagnosis: Upper endoscopy (EGD) with biopsy, especially for gastric ulcers to rule out malignancy.

H. pylori treatment: Triple therapy (a PPI + clarithromycin + amoxicillin) is a standard regimen.

Major complication: Perforation presents as sudden, severe abdominal pain and requires urgent surgery.

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