MSC - F. Surgery Answers 2025

1.Correction of Fluid and Electrolyte Disturbances

Intravenous infusion of isotonic saline or Ringer’s solution

Electrolyte replacement: Potassium, sodium, chloride, calcium

Correction of metabolic alkalosis (common due to repeated vomiting)

2.Nutritional Support

Parenteral or enteral nutrition to address hypoproteinemia and cachexia

Use of albumin or amino acid preparations as needed

3.Ulcer Management

Proton pump inhibitors (e.g., omeprazole)

H2-receptor antagonists (e.g., ranitidine)

Eradication therapy for Helicobacter pylori, if indicated

4.Gastric Decompression and Motility Restoration

Gastric lavage with alkaline solutions 2–3 times daily via nasogastric tube

Administration of prokinetics: metoclopramide, strychnine, benzohexonium

Surgical Treatment

Surgery is the definitive treatment and the approach depends on the stage of the disease, the location of the ulcer, and the general condition of the patient.

1.Radical Surgery

Indicated when patient condition allows

Common procedures:

oDistal gastric resection (typically 2/3) with Billroth II gastrojejunostomy

oSelective proximal vagotomy with a drainage procedure (e.g., pyloroplasty or gastrojejunostomy)

Aims to both relieve obstruction and reduce acid secretion to prevent recurrence

Penetrating ulcer is a complication of gastric or duodenal ulcer where the ulcer erodes through the full thickness of the stomach or duodenal wall and invades adjacent organs or tissues such as:

o Liver

o Pancreas (especially the head)

o Lesser omentum

o Transverse colon

oOther nearby structures

Penetration differs from perforation as it does not lead to free perforation into the peritoneal cavity but instead involves adjacent organs, potentially causing secondary complications.

Etiopathogenesis

Chronic or recurrent gastric/duodenal ulceration leads to deep ulcerative defects.

Continuous acid and pepsin exposure combined with impaired mucosal defense causes progressive tissue erosion.

In cases where the ulcer extends beyond the serosa, it penetrates neighboring structures.

Most frequent penetration sites:

o Lesser omentum

oHead of the pancreas

Inflammation and fibrosis may follow, leading to adhesion formation between the stomach/duodenum and affected organs.

Clinical Presentation and Diagnosis

Symptoms

Pain Changes:

oPain becomes intense, persistent, and continuous, unlike the intermittent nature of uncomplicated ulcers.

o It is resistant to ordinary analgesics or antiulcer treatments.

oPain radiation changes depending on the organ penetrated:

Penetration into pancreas: Girdle-like pain around the abdomen/back.

Penetration into lesser omentum: pain radiates to the left thorax or heart region.

Ulcer penetration may mimic symptoms of other diseases:

oPancreatitis

o Chronic cholecystitis

o Cholangitis

Complications

Penetrating ulcers can cause gastrointestinal hemorrhage.

If the ulcer penetrates into hollow organs (colon, sigmoid colon, biliary tract), gastric fistula formation may occur, with clinical features of fistula such as bilious vomiting, passage of gastric contents into colon, or cholangitis symptoms.

Diagnostic Tools

Clinical examination: Changes in pain pattern and radiation, signs of fistula if present.

Endoscopy: May reveal deep ulcer with signs of penetration.

Imaging:

oAbdominal ultrasound or CT scan can show involvement of adjacent organs.

oContrast studies may detect fistula formation.

Laboratory tests: Assess for bleeding and infection.

Treatment

Conservative Measures

Initial medical therapy may be attempted in stable patients with mild symptoms:

o Proton pump inhibitors or H2-blockers to reduce acid secretion o Pain management

o Treat any infections if cholangitis or cholecystitis develops

Surgical Treatment

Indications:

o Persistent pain resistant to medical treatment o Presence of fistula

o Gastrointestinal hemorrhage

oComplications involving adjacent organs

Surgical options depend on the ulcer location and complications:

oSeparation and closure of fistula if present.

o Ulcer excision or oversewing.

o Partial gastrectomy or duodenal resection in complicated cases.

oAddressing involvement of adjacent organs (e.g., pancreatitis management).

Surgery aims to:

oRemove the ulcerated tissue

o Restore gastrointestinal continuity

o Control bleeding

oPrevent recurrence

15.Differential diagnosis of uncomplicated duodenal ulcer and duodenal ulcer penetrating into the head of the pancreas.

1.Uncomplicated Duodenal Ulcer

Symptoms:

oEpigastric pain (burning, gnawing), often relieved by food or antacids.

o Pain occurs 1–3 hours after meals and may wake the patient at night.

oNo signs of peritonitis or systemic inflammation.

Physical Exam:

oMild epigastric tenderness.

o No guarding/rigidity, no rebound tenderness.

oNormal bowel sounds.

Diagnostics:

oEndoscopy (gold standard): Shows a clean ulcer base without penetration.

o H. pylori testing (stool antigen, urea breath test, biopsy).

oImaging (if needed): No free air on X-ray, no pancreatic involvement on CT.

2.Duodenal Ulcer Penetrating into the Pancreas

Symptoms:

oSevere, persistent epigastric pain radiating to the back (due to pancreatic involvement).

o Pain is not relieved by food/antacids and may be constant.

oPossible pancreatitis-like symptoms (nausea, vomiting, bloating).

Physical Exam:

oDeep epigastric tenderness, but no rigid abdomen (unless secondary inflammation).

oNo generalized peritonitis (unless perforation also occurs).

Diagnostics:

o Endoscopy: May show deep ulcer with possible penetration.

oCT/MRI: Shows ulcer extending into pancreatic head, possible fat stranding.

oLab tests: Elevated amylase/lipase (if pancreatic inflammation present).

3.Duodenal Ulcer Perforation (Open vs. Concealed)

Symptoms:

oSudden, severe "knife-like" epigastric pain → spreads to entire abdomen.

o Shock (pallor, sweating, tachycardia, hypotension).

o Peritonitis (abdominal rigidity, rebound tenderness, guarding).

oFree air under diaphragm (X-ray/CT).

Concealed Perforation (into lesser sac/covered by omentum):

oInitial severe pain → partial improvement ("sham well-being").

oLater, localized peritonitis (right upper quadrant or epigastric tenderness).

o No free air on X-ray (may require CT/laparoscopy).

Conclusion

Uncomplicated ulcer: Pain improves with food, no peritonitis, diagnosed by endoscopy.

Penetrating ulcer: Back pain, pancreatic enzyme elevation, CT confirms extension into pancreas.

Perforation: Sudden severe pain → peritonitis, shock, free air on imaging → surgical emergency

16.Gastroduodenal bleeding of ulcer origin. Etiopathogenesis, clinical picture.

Etiopathogenesis:

Mechanism:

oErosion of blood vessels (arteries, veins, capillaries) in the ulcer base due to acid-peptic digestion.

oCommon vessels involved:

Gastric ulcer: Left gastric artery branches.

Duodenal ulcer: Gastroduodenal artery (posterior wall), pancreaticoduodenal arteries.

Risk factors:

o Chronic H. pylori infection.

o NSAID/aspirin use → impaired mucosal defense.

o Smoking, alcohol, stress.

Clinical Picture:

Symptoms:

oHematemesis (vomiting blood: fresh red or "coffee-ground" if partially digested).

o Melena (black, tarry stool due to digested blood).

oWeakness, dizziness, syncope (if massive blood loss → hemorrhagic shock).

Signs:

oPallor, tachycardia, hypotension (signs of hypovolemia).

o Epigastric tenderness (if ulcer is active).

o Digital rectal exam: Melena (black stool on glove).

Severity Classification:

17. Tactics of treatment of patients with gastroduodenal ulcer bleeding. Forrest classification.

Forrest Classification (Endoscopic Findings & Rebleeding Risk):

Treatment Approach:

1. Initial Resuscitation:

o IV access (large-bore cannula), fluid/blood transfusion.

oHemodynamic stabilization (target Hb >7–8 g/dL).

2.Endoscopic Hemostasis (within 24 hrs):

oForrest Ia-IIb: Endotherapy (injection, clips, thermal coagulation).

oForrest III: Medical therapy.

3.Surgery if:

oFailed endotherapy.

o Recurrent bleeding.

o Hemodynamic instability.