Peptic Ulcer Disease — MCQs

10 questions

What is the treatment of choice in duodenal ulcer without any complications of hemorrhage?

All of the following are risk factors for gastric cancer except?

A 45 year old lawyer presents with pain in the abdomen more so in the epigastric region that worsens with eating spicy food and is relieved by bending forward. Complications of the above mentioned condition could be all except:

An adult male presents with chronic atrophic gastritis. Growth on Skirrow's medium and a positive rapid urease test were observed. What is the most likely diagnosis?

The causative agent for duodenal ulcer is:

A young child of 7 years of age is seen with indurated ulcers, lymphadenopathy and fever. The likely treatment is:

All of the following are used for treatment of *H. pylori*, except:

A 54-year-old man presents to the clinic for epigastric discomfort during the previous month. He states he has not vomited, but reports of having epigastric pain that worsens after most meals. The patient states that his stool “looks black sometimes.” The patient does not report of any weight loss. He has a past medical history of gastroesophageal reflux disease, diabetes mellitus, peptic ulcer disease, and Crohn’s disease. The patient takes over-the-counter ranitidine, and holds prescriptions for metformin and infliximab. The blood pressure is 132/84 mm Hg, the heart rate is 64/min, the respiratory rate is 14/min, and the temperature is 37.3°C (99.1°F). On physical examination, the abdomen is tender to palpation in the epigastric region. Which of the following is the most appropriate next step to accurately determine the diagnosis of this patient?

Which of the following is an absolute contraindication to the use of nonsteroidal anti-inflammatory drugs (NSAIDs)?

Q10

A patient presents with hematemesis and is diagnosed with esophageal varices. What is the first line of treatment?

Peptic Ulcer Disease Indian Medical PG Practice Questions and MCQs

Question 1: What is the treatment of choice in duodenal ulcer without any complications of hemorrhage?

A. Highly selective vagotomy
B. Trunkal vagotomy
C. Proton pump inhibitors (Correct Answer)
D. None of the options

Explanation: ***Proton pump inhibitors*** - **Proton pump inhibitors (PPIs)** are the first-line and most effective treatment for uncomplicated duodenal ulcers due to their potent and sustained acid suppression [1]. - They work by irreversibly inhibiting the **H+/K+-ATPase pump** in the stomach's parietal cells, reducing acid secretion and allowing the ulcer to heal [1]. *Highly selective vagotomy* - This is a surgical procedure that was historically used to reduce acid secretion by denervating the acid-producing parietal cells of the stomach, but it is **not the primary treatment** for uncomplicated ulcers today due to the availability of effective medical therapy [1]. - It carries surgical risks and is generally reserved for **refractory cases** or those with complications not amenable to endoscopic or medical management [1]. *Trunkal vagotomy* - **Trunkal vagotomy** involves cutting the main vagal trunks, which leads to significant side effects such as **gastric stasis** (delayed emptying) and diarrhea, often requiring a drainage procedure (e.g., pyloroplasty). - It was used in the past but is **rarely performed** for uncomplicated duodenal ulcers due to its associated morbidity and the effectiveness of modern medical treatments [1]. *None of the options* - This option is incorrect because **proton pump inhibitors** are indeed a highly effective and standard treatment for uncomplicated duodenal ulcers [1].

Question 2: All of the following are risk factors for gastric cancer except?

A. Diet high in pickled vegetables
B. Smoking
C. Helicobacter pylori infection
D. Duodenal ulcer (Correct Answer)

Explanation: ***Duodenal ulcer*** - A history of **duodenal ulcers** is generally protective against gastric cancer, possibly due to the increased acid production in the duodenum or differences in the distribution of *H. pylori* strains [1]. - While *H. pylori* can cause both duodenal ulcers and gastric cancer, specific strains associated with duodenal ulcers may be less virulent in terms of oncogenic potential for the stomach [1]. *Diet high in pickled vegetables* - Diets high in **salted and pickled foods** are associated with an increased risk of gastric cancer. - These foods often contain **nitrosamines** and other carcinogenic compounds that can directly damage gastric mucosa. *Smoking* - **Smoking** is a well-established and significant risk factor for gastric cancer, increasing the risk by 1.5 to 2.5 times compared to non-smokers. - Carcinogens in tobacco smoke can reach the stomach mucosa, promoting cellular damage and malignant transformation. *Helicobacter pylori infection* - **Chronic *Helicobacter pylori* infection** is the strongest known risk factor for gastric cancer, particularly for the intestinal type [2]. - It causes chronic inflammation and atrophy of the gastric mucosa, leading to a cascade known as Correa's pathway (chronic gastritis → atrophic gastritis → intestinal metaplasia → dysplasia → carcinoma) [2].

Question 3: A 45 year old lawyer presents with pain in the abdomen more so in the epigastric region that worsens with eating spicy food and is relieved by bending forward. Complications of the above mentioned condition could be all except:

A. Splenic Vein Thrombosis (Correct Answer)
B. Bleeding
C. Gastric Outlet Obstruction
D. Perforation

Explanation: ***Splenic Vein Thrombosis*** - The patient's symptoms (epigastric pain worsening with spicy food, relieved by bending forward) are highly suggestive of **pancreatitis**, not peptic ulcer disease [1]. **Splenic vein thrombosis** is a known complication of chronic pancreatitis due to inflammation and compression of the splenic vein [2]. - While pancreatitis can cause significant morbidity, **splenic vein thrombosis** is a specific vascular complication associated with prolonged inflammation of the pancreas, leading to localized portal hypertension and potentially isolated gastric varices. *Perforation* - **Perforation** (specifically of a peptic ulcer or potentially surrounding bowel in severe pancreatitis) is a severe complication that can occur in conditions causing abdominal pain, but it is not the *exception* among the given options for the likely underlying condition indicated by the patient's symptoms (pancreatitis) [3]. - This complication typically leads to **peritonitis**, a medical emergency requiring immediate surgical intervention [3]. *Bleeding* - **Bleeding** (e.g., from a pancreatic pseudocyst rupturing into the gastrointestinal tract or from localized varices secondary to portal hypertension in pancreatitis) is a recognized complication of the patient's likely underlying condition [1]. - Gastrointestinal bleeding can also result from **gastric erosions** or ulcers exacerbated by ongoing inflammation. *Gastric Outlet Obstruction* - **Gastric outlet obstruction** can occur as a complication of severe or chronic pancreatitis, often due to **inflammation**, **fibrosis**, or **pseudocyst formation** compressing the duodenum [1]. - This typically presents with **postprandial vomiting** and early satiety, which can arise in the context of chronic pancreatic inflammation.

Question 4: An adult male presents with chronic atrophic gastritis. Growth on Skirrow's medium and a positive rapid urease test were observed. What is the most likely diagnosis?

A. H. pylori (Correct Answer)
B. V. cholerae
C. H. influenzae
D. K. pneumoniae

Explanation: ***H pylori*** - The combination of **chronic atrophic gastritis**, growth on **Skirrow's medium**, and a **positive rapid urease test** is highly characteristic of *Helicobacter pylori* infection. - *H. pylori* is a known cause of **gastritis**, peptic ulcers, and is the only bacterium that produces large amounts of **urease**, which is detected by the rapid urease test. *H. influenzae* - This bacterium is primarily associated with **respiratory tract infections**, meningitis, and otitis media, not gastric conditions. - It does not typically grow on Skirrow's medium and is not known to produce significant urease for a positive rapid urease test. *K. pneumoniae* - *Klebsiella pneumoniae* is a common cause of **pneumonia**, urinary tract infections, and sepsis, with no direct involvement in chronic atrophic gastritis or urease production in the stomach. - It does not typically grow on selective media like Skirrow's, which is designed for microaerophilic organisms. *V. cholerae* - *Vibrio cholerae* is the causative agent of **cholera**, characterized by severe watery diarrhea, and is not associated with gastric inflammation or positive urease tests in this context. - It grows on specific media like TCBS agar and does not cause chronic atrophic gastritis.

Question 5: The causative agent for duodenal ulcer is:

A. Lactobacilli
B. E. coli
C. H. Pylori (Correct Answer)
D. Shigella

Explanation: ***H. pylori*** - ***H. pylori*** is a **Gram-negative spiral-shaped bacterium** that colonizes the stomach and duodenum, causing inflammation and increasing the risk of peptic ulcers, including duodenal ulcers. - It produces **urease**, which neutralizes stomach acid by converting urea to ammonia, protecting the bacteria and contributing to mucosal damage. *Lactobacilli* - **Lactobacilli** are **Gram-positive, rod-shaped bacteria** commonly found in the digestive tract and fermented foods. - They are generally considered **beneficial probiotics** and do not cause duodenal ulcers. *E. coli* - ***E. coli*** is a **Gram-negative, rod-shaped bacterium** typically found in the intestines of humans and animals. - While some strains can cause **gastrointestinal infections** (e.g., traveler's diarrhea), *E. coli* is not a known cause of duodenal ulcers. *Shigella* - **Shigella** is a **Gram-negative, rod-shaped bacterium** that causes **shigellosis**, an intestinal infection characterized by severe diarrhea (dysentery). - It primarily affects the **large intestine** and does not cause duodenal ulcers.

Question 6: A young child of 7 years of age is seen with indurated ulcers, lymphadenopathy and fever. The likely treatment is:

A. Excise the lesion
B. Symptomatic treatment
C. I.V. fluids
D. Systemic antibiotics (Correct Answer)

Explanation: ***Systemic antibiotics*** - This clinical triad of **indurated ulcers, lymphadenopathy, and fever** in a child is highly suggestive of **ulceroglandular tularemia** (Francisella tularensis), **cat-scratch disease** (Bartonella henselae), or **atypical mycobacterial infection**. - **Tularemia** presents with a painful ulcer at the inoculation site with regional lymphadenopathy and systemic symptoms - treated with **streptomycin or gentamicin**. - **Cat-scratch disease** may present similarly after feline contact - treated with **azithromycin**. - **Atypical mycobacteria** (M. marinum) cause "swimming pool granuloma" with similar features - requiring **clarithromycin and rifampicin**. - **Systemic antibiotic therapy is essential** to prevent complications and disease progression. *Symptomatic treatment* - **Symptomatic treatment alone is inadequate** for bacterial infections presenting with indurated ulcers and lymphadenopathy. - While fever and pain management may be adjunctive, **definitive antimicrobial therapy is required** for these infectious conditions. - Failure to treat appropriately can lead to **systemic dissemination** and serious complications. *Excise the lesion* - **Surgical excision is not the primary treatment** for infectious ulcers with lymphadenopathy. - Excision may be considered for **localized atypical mycobacterial lymphadenitis** that fails medical therapy, but is not first-line. - The presence of **systemic symptoms (fever)** indicates need for medical rather than surgical management. *I.V. fluids* - **Intravenous fluids are supportive therapy** for dehydration, not definitive treatment. - The clinical presentation requires **antimicrobial therapy**, not just hydration. - IV fluids may be needed as adjunctive therapy if the child is unable to maintain oral hydration, but do not address the underlying infection.

Question 7: All of the following are used for treatment of H. pylori, except:

A. Metronidazole
B. Amoxicillin
C. Clarithromycin
D. Gentamicin (Correct Answer)

Explanation: ***Gentamicin*** - **Gentamicin** is an **aminoglycoside antibiotic** primarily used for severe Gram-negative bacterial infections and is **not effective** against *H. pylori*. - Its mechanism of action and **toxicity profile** (ototoxicity, nephrotoxicity) make it unsuitable for typical *H. pylori* eradication regimens. *Clarithromycin* - **Clarithromycin** is a **macrolide antibiotic** frequently used in **triple therapy regimens** for *H. pylori* eradication. - It works by **inhibiting bacterial protein synthesis**, significantly contributing to the eradication of the bacteria. *Metronidazole* - **Metronidazole** is an **antibiotic** and **antiprotozoal agent** commonly included in *H. pylori* **quadruple therapy** or when penicillin allergies are present. - It acts by forming **cytotoxic compounds** that disrupt bacterial DNA, making it effective against anaerobic and microaerophilic bacteria like *H. pylori*. *Amoxicillin* - **Amoxicillin** is a **beta-lactam antibiotic** that is a cornerstone of many *H. pylori* **eradication regimens**, particularly in standard triple therapy. - It works by **inhibiting bacterial cell wall synthesis**, leading to bacterial lysis.

Question 8: A 54-year-old man presents to the clinic for epigastric discomfort during the previous month. He states he has not vomited, but reports of having epigastric pain that worsens after most meals. The patient states that his stool “looks black sometimes.” The patient does not report of any weight loss. He has a past medical history of gastroesophageal reflux disease, diabetes mellitus, peptic ulcer disease, and Crohn’s disease. The patient takes over-the-counter ranitidine, and holds prescriptions for metformin and infliximab. The blood pressure is 132/84 mm Hg, the heart rate is 64/min, the respiratory rate is 14/min, and the temperature is 37.3°C (99.1°F). On physical examination, the abdomen is tender to palpation in the epigastric region. Which of the following is the most appropriate next step to accurately determine the diagnosis of this patient?

A. Treat with PPI, clarithromycin, and amoxicillin before doing lab and imaging tests
B. Urea breath testing
C. Serology for Helicobacter pylori
D. CT abdomen
E. Endoscopy with biopsy (Correct Answer)

Explanation: ***Endoscopy with biopsy*** - Given the patient's age (>50 years), new-onset epigastric pain, history of **peptic ulcer disease**, and "black sometimes" stools suggesting **melena** or **upper gastrointestinal bleeding**, an endoscopy with biopsy is crucial [1]. - This procedure allows direct visualization of the esophageal, gastric, and duodenal mucosa, enabling identification of ulcers, erosions, or masses, and tissue collection for **histopathological examination** (e.g., for *H. pylori* infection, malignancy, or Crohn's disease involvement) [1]. *Treat with PPI, clarithromycin, and amoxicillin before doing lab and imaging tests* - This approach, known as **"triple therapy,"** is a treatment for **H. pylori infection**, but it should not be initiated without a confirmed diagnosis in this patient presenting with alarm symptoms [2]. - Doing so without a prior diagnosis could mask underlying pathology, such as **malignancy**, and delay appropriate treatment. *Urea breath testing* - **Urea breath testing** is a non-invasive method to detect active *H. pylori* infection [2]. - While useful, it does not allow for direct visualization of the mucosa or biopsy collection, which is essential given the patient's **alarm features** like age and potential bleeding [2]. *Serology for Helicobacter pylori* - **H. pylori serology** detects antibodies to *H. pylori*, indicating past or present infection [2]. - It cannot differentiate between active and past infection and, importantly, does not provide information about the **mucosal integrity** or allow for biopsy of suspicious lesions [2]. *CT abdomen* - A **CT scan of the abdomen** can visualize abdominal organs and detect masses or significant inflammation. - However, it is not the primary diagnostic tool for evaluating the **upper gastrointestinal mucosa** and cannot directly identify ulcers, erosions, or provide tissue for biopsy in the same way an endoscopy can.

Question 9: Which of the following is an absolute contraindication to the use of nonsteroidal anti-inflammatory drugs (NSAIDs)?

A. Asthma
B. Rheumatoid arthritis
C. Hypertension
D. Active peptic ulcer disease (Correct Answer)

Explanation: ***Active peptic ulcer disease*** - NSAIDs **inhibit cyclooxygenase (COX)** enzymes, which are responsible for producing **prostaglandins** that protect the gastric mucosa. - In patients with **active peptic ulcers**, this inhibition can lead to serious complications like **bleeding** or **perforation**, making it an **absolute contraindication**. - A history of peptic ulcer disease is a relative contraindication, but active disease is an absolute contraindication. *Asthma* - While NSAIDs can exacerbate asthma in susceptible individuals (**NSAID-exacerbated respiratory disease or aspirin-exacerbated respiratory disease**), it is usually a **relative contraindication** rather than an absolute one. - This reaction typically affects a specific subset of asthmatic patients (around 10-20%) with aspirin sensitivity and nasal polyps. *Rheumatoid arthritis* - NSAIDs are commonly used to **manage pain and inflammation** associated with rheumatoid arthritis. - It is a condition where NSAIDs are **indicated** for symptom relief, not a contraindication. *Hypertension* - NSAIDs can contribute to **elevated blood pressure** due to their effects on renal prostaglandin synthesis, leading to sodium and water retention. - Although NSAIDs should be used cautiously in hypertensive patients, it is considered a **relative contraindication**, requiring close monitoring rather than an absolute prohibition.

Question 10: A patient presents with hematemesis and is diagnosed with esophageal varices. What is the first line of treatment?

A. Surgery
B. Steroid therapy
C. Endoscopic banding (Correct Answer)
D. Proton pump inhibitors

Explanation: ***Endoscopic banding*** - **Endoscopic variceal ligation (EVL)**, or banding, is the **first-line treatment** for acute variceal bleeding [1]. - It involves placing elastic bands over the varices to **occlude blood flow** and prevent further hemorrhage [1]. *Surgery* - **Surgical shunting procedures** or **liver transplantation** are generally reserved for patients who fail endoscopic and pharmacologic therapies [1]. - These are **invasive options** with significant risks and are not considered first-line for acute bleeding. *Steroid therapy* - **Steroids** are typically used as **anti-inflammatory agents** and are not indicated for controlling bleeding from esophageal varices. - Their use would have **no direct impact** on stopping the hemorrhage. *Proton pump inhibitors* - **Proton pump inhibitors (PPIs)** are used to **reduce gastric acid production**, which is beneficial in conditions like peptic ulcer disease or reflux esophagitis [2]. - They are **not effective** in treating or preventing bleeding from esophageal varices, as the bleeding source is venous [2].

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