Review Questions

1.
Which of the following is a likely cause of duodenal ulceration in patients who are Helicobacter pylori negative?
1. a.
  
  Bordetella pertussis infection
2. b.
  
  Zollinger-Ellison syndrome
3. c.
  
  Pheochromocytoma
4. d.
  
  Mercury poisoning
5. e.
  
  None of the above
Show Answer
Answer: B Zollinger-Ellison syndrome is caused by a gastrin-producing endocrine tumor, which is usually in the pancreas or small bowel and leads to marked hyperacidity. This syndrome usually gives rise to severe peptic ulcer disease with multiple, concomitant duodenal ulcers that are resistant to conventional acid suppressive therapy. The other conditions listed are not known to be associated with an increased risk for peptic ulcer.
2.
An 80-year-old woman with degenerative joint disease involving her fingers presents with a gastric ulcer with smooth edges. She denies being prescribed nonsteroidal anti-inflammatory drugs (NSAIDs), and biopsies and serology for H. pylori are negative. Which of the following is the most likely cause of her ulcer?
1. a.
  
  Gastric rheumatoid nodules
2. b.
  
  Systemic lupus erythematosus
3. c.
  
  Over-the-counter medications containing NSAIDs
4. d.
  
  Ankylosing spondylitis
5. e.
  
  Surreptitious laxative abuse
Show Answer
Answer: C Over-the-counter NSAID use is very common, in particularly in elderly patients. Patients often do not recognize that they use NSAIDs even when specifically asked. Targeted questioning and checking of home medication is therefore indicated. In some series, surreptitious use of NSAIDs or aspirin was found as the underlying cause in 30 to 60% of patients with previously unexplained peptic ulcer.
3.
Which of the following is the major factor contributing to current changes in the incidence of peptic ulcer disease in developed countries?
1. a.
  
  The rise in H. pylori−associated gastric ulcers
2. b.
  
  The fall in NSAID-associated duodenal ulcers
3. c.
  
  The rise in NSAID-related gastric ulcers
4. d.
  
  The rise in NSAID-related duodenal ulcers
5. e.
  
  The rise in intensive care unit (ICU)-related stress ulcers
Show Answer
Answer: C H. pylori−related ulcers have considerably decreased in developed countries owing to a decrease in the declining prevalence of the bacterium in recent generations and the use of eradication therapy. ICU-related stress ulcers have become less common owing to improvements in overall management, including respiratory and hemodynamic care, acid inhibition, and emphasis on adequate feeding. NSAID use has become more common and has given rise to an increase of NSAID-related ulcer disease.
4.
Which of the following is correct about peptic ulcer disease?
1. a.
  
  Risk is greatest in females.
2. b.
  
  The highest relative risk is in persons younger than 20 years.
3. c.
  
  Treatment of autoimmune diseases with biologic agents (e.g., anti−tumor necrosis factor [TNF]-α agents) has increased risk.
4. d.
  
  Most deaths are due to gastric cancer.
5. e.
  
  Smoking increases risk.
Show Answer
Answer: E Peptic ulcer is more common in men and in elderly people. Anti-TNF-α treatment is not causally related to peptic ulcer disease, and most patients with peptic ulcers do not develop gastric cancer. In H. pylori−positive subjects, however, smoking increases the risk for peptic ulceration. This increased relative risk has been reported to be up to 12-fold.
5.
Which of the following involves an increased risk for peptic ulcer disease?
1. a.
  
  Scleroderma
2. b.
  
  Pernicious anemia
3. c.
  
  Celiac disease
4. d.
  
  Systemic mastocytosis
5. e.
  
  Cryptococcosis
Show Answer
Answer: D In vitamin B₁₂ deficiency with pernicious anemia, gastric atrophy is caused by an autoimmune gastritis. However, this inflammation is not associated with peptic ulcer disease. Autoimmune inflammation of the small bowel due to celiac disease also does not cause ulceration. Various infectious conditions can give rise to peptic ulcer, but cryptococcosis is not one of them. Systemic vasculitides can be associated with peptic ulcers, but they are not a common presenting manifestation of scleroderma. Systemic mastocytosis is, however, associated with a clearly increased risk for peptic ulceration.
6.
The effect of H. pylori eradication therapy always needs to be assessed in patients with which of the following?
1. a.
  
  A bleeding peptic ulcer
2. b.
  
  Reflux esophagitis
3. c.
  
  Nonulcer dyspepsia
4. d.
  
  Uncomplicated peptic ulcer
5. e.
  
  Chronic active gastritis
Show Answer
Answer: A Patients with complicated peptic ulcer disease, such as peptic ulcer bleeding, are at considerably increased risk for recurrent ulcer complications. Patients with previous peptic ulcer bleeding in the presence of H. pylori therefore always need to be assessed to document the success of eradication therapy. If treatment has failed, they need repeat eradication treatment.
7.
Which of the following statements is false in patients with peptic ulcer bleeding?
1. a.
  
  Endoscopic treatment is the mainstay of therapy.
2. b.
  
  Preemptive proton pump inhibitor (PPI) therapy reduces the need for endoscopic treatment.
3. c.
  
  High-dose continuous intravenous PPI treatment reduces the risk for rebleeding.
4. d.
  
  Patients with a low Blatchford score usually do not require intervention.
5. e.
  
  Recurrent bleeding requires surgery.
Show Answer
Answer: E In patients with peptic ulcer bleeding, endoscopic treatment is the mainstay to stop ongoing bleeding and reduce the risk for rebleeding. Preemptive PPI therapy reduces the need for endoscopic treatment, but it has no effect on rebleeding and mortality. High-dose continuous intravenous PPI treatment reduces the risk for rebleeding, the need for blood transfusion, and mortality in patients with a high risk for rebleeding. The Blatchford scale can be used to predict the need for intervention, such as endoscopic treatment and blood transfusion; a low score is associated with a low chance that an intervention is needed. Patients with recurrent bleeding despite endoscopic and PPI treatment can often first be retreated endoscopically. If this retreatment fails, both angiographic embolization of the feeding vessel and surgery are alternative rescue treatments. Recurrent bleeding is thus not a routine indication for surgery.