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Duodenal Ulcers
SubhadraAcharya
Way Questions May BeAsked?
A 65-year-old male with a long standing history of peptic
ulcer disease presents with nausea and vomiting for the last
3days.
How toAnswer?
• Start with a complete history and physical exam
• Important history:
– NSAID/tobacco/alcohol use
– History of ulcer disease
– Family history (Multiple Endocrine Neoplasia (MEN)
1,Zollinger-Ellison syndrome)
– Foreign body ingestion
– History of Helicobacter pylori treatment
– Prior H2 blocker or proton pump inhibitor therapy
– Important to consider other differentials: pancreatitis,
gastritis, esophagitis, gallbladder disease, myocardial
infarction, pneumonia, aortic dissection
– Chronicity: history of weight loss, prior dyspepsia
– Bleeding: hematemesis, melena/hematochezia, ane-
mia, hypotension, hemorrhagic shock
– Obstruction: nausea, bilious emesis, distension
• Exam:
– Vital signs
– Signs of peritonitis/tenderness
These will be less impressive in an elderly patient,
those on steroids or immunosuppressants/
chemotherapy
• Labs:
– Basic labs, including complete blood count, basal met-
abolic panel, liver function tests, and amylase/lipase
– Type and screen+coagulation parameters if bleeding
S. Acharya (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
45
– Calcium if suspect that hyperparathyroidism is a cause
– Serum Gastrin if suspicion for gastrinoma
• Imaging:
– Perforation:
Upright abdomen X-ray
CT scan if patient stable to rule out other perforated
viscus
– Obstruction:
Upper GI after NGT placement
– Bleeding:
CTA to rule out other etiologies of bleed
Endoscopic evaluation of bleeding source and to
rule out other pathology
Risk of rebleeding by endoscopic appearance of
ulcer based on modied Forrest criteria
Clean based ulcers (Forrest III) have a very low rebleed risk
Ulcers with adherent clot or visible vessels have a
higher rebleed risk
Surgical Treatment
• Obstruction:
– Initial conservative treatment with NGT decompres-
sion, PPI
– Upper GI series to follow if does not decompress (will
not if caused by ulcer)
– Surgical options
Gastrojejunostomy±vagotomy
Antrectomy with Billroth 1 vs. 2 reconstruction and
vagotomy
– Notes:
Billroth 1 preferred over 2, avoids 2 staple lines and
duodenal stump complications
If a patient requires pyloroplasty, scarring of the
duodenum may prevent a Heineke-Mikulicz pyloroplasty; in that case, a Finney or a Jaboulay would
be necessary. If pyloroplasty is not possible, best
option is a gastrojejunostomy
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_45
141
142
S. Acharya
Truncal vagotomy involves stripping the esophagus
bare of areolar tissue in the distal 5–7cm of esophagus and ligating the nerves at least 4cm above the
gastroesophageal junction
If the patient has had prior surgery, and preoperative work-up reveals no specic cause for
recurrence, take the next most aggressive option: If
prior vagotomy with drainage → antrectomy. If
prior antrectomy with vagotomy → subtotal
gastrectomy
Way Question May BeAsked?
A 53-year-old male presents to the Emergency Department
with severe, sudden onset upper abdominal pain. X-ray
shows a large amount of intraperitoneal free air. The patient
has rebound tenderness and guards to palpation of abdomen
diffusely.
Way toAnswer?
• Perforation:
– Should not be managed conservatively. Prompt opera-
tive treatment is the mainstay along with initial
resuscitation
– Fluid resuscitation and broad spectrum antibiotics
Antifungals in high risk populations (elderly,
immunocompromised)
Modify regimen based on peritoneal uid cultures
– Minimally invasive intervention acceptable here but
generally only on stable patients
Surgeons should maintain a low threshold to convert to open procedure depending on the extent of
contamination and difculty of procedure
– Surgical options are:
Omental patch ± vagotomy (if lower risk
patient)±antrectomy
Way Question May BeAsked?
A 53-year-old male with a history of peptic ulcer disease
presents with 2days of melena. He has a prior history of
duodenal ulcers seen on upper endoscopy.
Helicobacter pylori treatment initiation. NSAIDs and
aspirin should be stopped
– Endoscopic evaluation of bleeding source and to rule
out other pathology. Can attempt twice upon rebleed-
ing after rst endoscopic intervention
– Biopsies for Helicobacter pylori
– Treat bleeding endoscopically with energy (electro-
cautery or heater probe), clips, epinephrine injections
or application of hemostatic agents
NGT lavage can be performed to conrm upper GI
source of bleeding
– Patients who are unstable despite adequate resuscita-
tion (>6units of blood in 24 h) should be considered
for operative repair
• Operative repair—a few choices:
– For high risk patients
Oversew ulcer, vagotomy/pyloroplasty,
gastrojejunostomy
– Large ulcers (>2cm)
Antrectomy/Highly selective vagotomy
– Lower risk patients
Oversew ulcer, vagotomy
Clean Kills
• Not ruling out other etiologies of epigastric pain
• Trying to treat perforated ulcer conservatively
• Not trying to conservatively treat a bleeding ulcer at rst
presentation
• Not being prepared to perform a different operation in
someone with chronic symptoms
• Not performing EGD for bleeding ulcer
• Trying to treat gastric outlet obstruction with endoscopic
balloon dilatation
• Not knowing how to manage the difcult duodenal
stump
• Not knowing how to manage duodenal stump leak
• Not oversewing bleeding site when performing vagot-
omy/pyloroplasty
• Forgetting Helicobacter pylori workup and treatment
• Trying to perform highly selective vagotomy in unstable
patients
Words ofWisdom
Way toAnswer?
• Bleeding:
– Ensure good IV access, adequate resuscitation and
transfusion as needed, proton pump inhibitor and
Although rare, duodenal ulcers requiring surgical treatment
are still encountered frequently enough that they are a
favorite oral board topic. On review of multiple surgeons’
oral boards questions, one nds that almost every surgeon
gets asked a version of a peptic ulcer question. Be prepared
for it.
45 Duodenal Ulcers
143
Bibliography
Ocasio Quinones GA, Woolf A.Duodenal ulcer. Treasure Island, FL:
StatPearls Publishing; 2023. https://www.ncbi.nlm.nih.gov/books/
NBK557390/#:~:text=Duodenal%20ulcers%20are%20part%20of.
Score. https://www.surgicalcore.org/modulecontent.aspx?id=1000204.
Seeras K, Qasawa RN, Prakash S.Truncal vagotomy. Treasure Island,
FL: StatPearls Publishing; 2021. https://www.ncbi.nlm.nih.gov/
books/NBK526104/.
Tarasconi A, Coccolini F, Bif WL, Tomasoni M, Ansaloni L, Picetti E,
etal. Perforated and bleeding peptic ulcer: WSES guidelines. World
J Emerg Surg. 2020;15(1):3.
Gastric Cancer
AzimAsad andAndreaS.Porpiglia
46
Clinical Scenarios
• A 63-year-old man presents to the ED with UGI bleeding.
After stabilization, an EGD is performed that reveals a
large ulcer on the greater curvature of the stomach.
Biopsies return with well-differentiated adenocarcinoma.
• A 55-year-old homeless man presents with acute onset of
severe epigastric pain for 3h and one episode of bloody
vomiting. Physical examination shows epigastric and
right upper quadrant tenderness and guarding. CT scan
shows small amount of extraluminal air and free uid
near the lesser curvature of the stomach.
• A 42-year-old woman of Asian descent with a 3-month
history of vague abdominal pain, dyspepsia, early satiety
and 15-pound weight loss. EGD shows diffuse thickening
of the gastric rugae with no obvious ulcer or mass.
Other presentations include gastric outlet obstruction and
abdominal distension with malignant ascites.
Table 46.1 Hereditary Syndromes associated with gastric cancer
Hereditary syndrome Germline mutation Lifetime risk (%) Associated cancers
Hereditary diffuse gastric cancer syndrome (HDGC) CDH1, PLAB2 67 Breast Ca (lobular)
Peutz Jeghers syndrome (PJS) STK11 29 Hamartomatous polyps
Juvenile polyposis syndrome (JPS) SMAD4 or BMPR1A 21 Breast Ca, colorectal Ca
Hereditary non- polyposis colorectal cancer (HNPCC)
Lynch Syndrome
Familial adenomatous polyposis syndrome (FAP) APC 2 Colorectal Ca
MMR genes; MLH1, MSH2, MSH6 13 Endometrial Ca
History
• Risk Factors
– Dietary habits: High salt diet, smoked food, food pre-
servative (N-nitroso compounds)
– Peptic ulcer disease
– Atrophic Gastritis; Helicobacter pylori, Autoimmune
– Smoking
• Hereditary Syndrome: Most gastric cancers are sporadic; however up to 5–10% are associated with family
history (Table46.1)
• Symptoms
– Unintentional weight loss
– Epigastric pain
– Early satiety
– Bloating
– Dyspepsia
– Vomiting
Pancreatic Ca
Ovarian Ca
Duodenal Ca
Desmoids
A. Asad
Altanticare, Atlantic City, NJ, USA
A. S. Porpiglia (
Fox Chase Cancer Center, Philadelphia, PA, USA
e-mail: Andrea.Porpiglia@fccc.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_46
*)
145
146
A. Asad and A. S. Porpiglia
Physical Examination
• Palpable abdominal mass
• Abdominal distension with ascites
• Lymphadenopathy
– Left supraclavicular—Virchow’s Lymph node
– Umbilical—Sister Mary Joseph’s nodule
– Rectal examination—rectouterine/recto-vesical depos-
its (Blumer’s shelf)
• Acanthosis Nigricans
Dierential Diagnosis forGastric Mass
• Gastric Adenocarcinoma
• GE junction Adenocarcinoma
• Gastric GIST
• Gastric MALToma
• Leiomyoma/Leiomyosarcoma
• Gastric B Cell (non-Hodgkin’s) Lymphoma
Diagnostic Tests
– CT scan is required to determine resectability (inva-
sion into surrounding structures, i.e., pancreas, celiac
axis) and to rule out metastatic disease (M stage).
– CT scans are also useful in delineating anatomy and
surgical planning.
– CT scans are low yield in identifying peritoneal carci-
nomatosis, especially for lesions less than 5mm.
– MRI abdomen is reserved for evaluation of any liver
lesions suspicious for metastasis.
• Diagnostic Laparoscopy and Peritoneal Washings:
– Detects occult metastasis in up to 40% of patients who
are considered resectable on cross-sectional imaging.
– Should be considered in all patients with tumor size
T1B or greater who are planned to receive preoperative
therapy to rule out occult metastatic disease and accurate staging.
– Positive peritoneal cytology represents M1 disease and
is indicative of poor prognosis.
• Laboratory Tests
– Full laboratory panel, i.e., CBC, BMP, LFTs, coagula-
tion panel including PT, INR.
– Tumor Markers, CEA, CA19-9.
• Esophagogastroduodenoscopy (EGD) with Endoscopic
Ultrasound (EUS)
– Most important tool for diagnosis—multiple biopsies
of any ulcer or suspicious lesions.
– Linitis Plastica usually will have mucosal sparing and
diffuse submucosal inltration, EUS evaluation aids
diagnosis by identifying submucosal inltration and
thickening.
– EUS guided FNA to rule out GIST and Lymphoma.
Mucosal biopsies are non-diagnostic due to mucosal
sparing.
– EUS to determine depth of invasion (T staging) and
Siewert Classication
lymphadenopathy (N staging).
• Cross-sectional Imaging:
– CT Chest Abdominal Pelvis with PO and IV contrast.
• Important to classify GE junction cancers for appropriate
staging and treatment (Table46.2).
– FDG PET/CT—consider if high suspicion for meta-
static disease.
Table 46.2 Siewert classication (NCCN n.d.)
Siewert class Location Treatment
I Within 1–5cm above GE junction Staged and treated as esophageal cancer
II 1cm above or 2cm below GE junction Staged and treated as esophageal cancer
II Within 2–5cm below GE junction Staged and treated as gastric cancer
46 Gastric Cancer
147
Staging
See Table46.3.
Treatment
• Principles of Oncologic Resection (Tables 46.4 and
46.5)
– Resect with 5cm margins to achieve R0 resection.
– Gastrectomy; always resect pylorus with proximal
2–3cm of duodenum.
– Perform vagotomy for any resection less than total
gastrectomy.
– Modied D2 lymphadenectomy with the goal of har-
vesting 16 Lymph nodes.
– Routine splenectomy is not indicated unless evidence
of hilar lymphadenopathy or direct involvement of
spleen.
– Unresectable: Inltration into root of mesentery, para-
aortic lymphadenopathy, encasement of major vessels
(excluding splenic), evidence of peritoneal carcinomatosis or distant metastasis.
– Minimally invasive approach not recommended for
T4b or N2 or more advanced disease, open approach is
preferred to ensure adequacy of resection and negative
margins.
Table 46.3 TNM classication of gastric cancer (AJCC Cancer Staging Manuel 8th edition, NCCN n.d.)
TNM staging
Primary tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ; intraepithelial tumor without invasion of lamina propria
T1 Tumor invades lamina propria, muscularis mucosae or submucosa
T1a Tumor invades lamina propria or muscularis mucosae
T1b Tumor invades submucosa
T2 Tumor invades muscularis propria
T3 Tumor penetrates subserosal connective tissue without invasion of visceral peritoneum or adjacent structures
T4 Tumor invades serosa (visceral peritoneum) or adjacent structures
T4a Tumor invades serosa (visceral peritoneum)
T4b Tumor invades adjacent structures
Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph nodes
N1 Metastasis in 1–2 regional lymph nodes
N2 Metastasis in 3–6 regional lymph nodes
N3 Metastasis in 7 or more regional lymph nodes
N3a Metastasis in 7–15 regional lymph nodes
N3b Metastasis in 16 or more regional lymph nodes
Distant metastasis (M)
M0 No distant metastasis
M1 Distant metastasis
148
A. Asad and A. S. Porpiglia
Table 46.4 Surgical approach based on T-stage (NCCN n.d.)
T stage Surgical approach
Tis/T1a, N0, M0 Endoscopic mucosal resection vs gastrectomy
T1b/T2/T3/T4a, Nx, M0 Gastrectomy with D2 lymphadenectomy MIS or
open
T4b, >N1, M0 Gastrectomy with D2 lymphadenectomy, MIS
not recommended
Table 46.5 Reconstruction option based on type of Resection (Mukkamalla etal. 2023; NCCN n.d.)
Tumor location Surgical approach Reconstruction
Antrum, distal stomach Distal gastrectomy with D2 lymphadenectomy Billroth II gastro-jejunostomy
Body of the stomach Subtotal gastrectomy with D2 lymphadenectomy Billroth II gastro-jejunostomy
Fundus, GE junction Total gastrectomy, for GEJ tumors distal esophagectomy may be required
for adequate margins
Lesion ≤2cm, well or moderately differentiated tumor, no
LVI or mucosal ulceration
Distal vs. subtotal vs. total gastrectomy based on tumor
location. Siewert type III require total gastrectomy
Often require en-bloc resection of the involved viscera
Billroth II gastro-jejunostomy
Roux en Y gastro-jejunostomy
Roux-en-Y esophago- Jejunostomy
• Lymphadenectomy:
– D1 Lymphadenectomy entails resection of both the
greater and lesser omentum (which would include the
lymph nodes along right and left cardia, lesser and
greater curvature, supra-pyloric along the right gastric
artery, and infra-pyloric area).
46 Gastric Cancer
149
– D2 Lymphadenectomy includes all D1 plus lymph
nodes along the left gastric artery, common hepatic
artery, celiac artery, and splenic artery.
– Current data suggests against extended D2 or D3
lymphadenectomy due to increased morbidity with no
difference in oncologic outcomes.
• Chemo-radiation:
– Perioperative chemoradiation should be considered in
all resectable gastric cancer ≥T2, or any node positive
disease.
– FLOT4 Regimen: Fluorouracil, Leucovorin,
Oxaliplatin and Docetaxel. Total of eight cycles (four
cycles pre and four cycles post-surgery).
– Restaging CT scan for all patients receiving preopera-
tive treatment with chemo or chemoradiation prior to
surgery.
– In patients who have received curative intent surgery
without perioperative chemotherapy or chemoradiation (for gastric perforation or GI bleed) adjuvant chemotherapy should be considered for those with pT3 or
node positive disease.
• Palliative Treatment:
– For locally advanced unresectable disease, palliative
chemoradiation and for metastatic disease chemotherapy with supportive care should be considered.
– If not performed previously, HER2, PD1, and MSI/
MMR testing should be performed to consider targeted
therapy with trastuzumab and/or Immunotherapy.
– Gastric resections should be reserved for the palliation
of symptoms (e.g., obstruction or uncontrollable
bleeding) in patients with incurable disease. Lymph
node dissection is not required.
– In patients t for surgery and who have a reasonable
prognosis, gastro-jejunostomy (open or laparoscopic)
is preferable to endoluminal stenting in patients with
gastric outlet obstruction.
– Venting gastrostomy and/or feeding jejunostomy tube
may be considered.
• Surveillance:
– H&P every 3–6 months for 1–2 years, every
6–12months for 3–5years, and annually thereafter.
– CT Chest Abdomen and Pelvis with IV contrast every
6months for 2years and every year for 3–5years.
– EGD, Lab work up as clinically indicated.
Post-operative Complications
• GI Bleeding:
– Most common cause suture line bleeding
– Common if distal gastrectomy is performed
– EGD>Clip placement or cauterization
– If continued bleeding > Consider CTA and
Embolization
• Anastomotic Leak:
– More common with Esophago-jejunostomy
– Manage with drain, NPO, NG tube decompression and
TPN
– Repeat gastrogran swallow study in 7 days to
reassess
• Duodenal Stump Blow-Out:
– Manage with drains if not in place, consider IR guided
drain placement
– NPO, TPN, Octreotide
• Dumping Syndrome:
– More common after total gastrectomy
– Sx: Abdominal Pain, Bloating, Diarrhea, ushing, diz-
ziness, Diaphoresis
– Occurs due to rapid entering of carbohydrates into
small bowel in the absence of pylorus
– Early Dump: Hyperosmotic load uid shift causing
hypotension
– Late Dump: Rapid release of Insulin due to rapid
absorption of glucose causing hypoglycemia
– Tx: Dietary modications, Small multiple meals, High
Protein low carb diet, no liquids with meals
• Chronic Gastric Atony:
– Can occur after distal gastrectomy
– Early satiety, nausea, vomiting, bloating
– Dx: Gastric Emptying study: Delayed emptying
– Tx: Prokinetic agents, i.e., metoclopramide,
erythromycin
– Surgical option: Near total gastrectomy with Roux-
en- Y esophago-jejunostomy
Clean Kills
• Operating on metastatic disease, i.e., peritoneal carcino-
matosis or locally advanced disease with involvement of
major vessels, i.e., SMA
• Performing less than total gastrectomy for a tumor <5cm
from GE junction
• Incomplete staging
• Offering any therapy besides surgery for a resectable
disease
• Discussing endoscopic mucosal resections for ≥T1A or
N+ disease
• Performing gastrostomy for feeding access
150
A. Asad and A. S. Porpiglia
Summary
• Follow principles of surgical oncology: name it, stage
it, and treat it.
• Always obtain chest CT to rule out metastatic
disease.
• For resectable disease, perioperative chemo-radiation is a must followed by restaging and then
surgery.
• Select appropriate surgical management based on T
stage and location of the tumor.
• Central gastrectomy, partial or wedge gastrectomy
are non-oncological resections and should not be considered for gastric cancer.
• If a patient was taken emergently to the OR and gastric cancer was diagnosed intraoperatively or on
pathology, give adjuvant chemotherapy or
chemoradiation.
• Palliative chemo-radiation for unresectable or metastatic disease, consider Gastro-jejunostomy for
obstruction, can also consider palliative gastrectomy
for recurrent local symptoms (i.e., bleeding, pain,
obstruction).
Bibliography
Amin MB, Edge SB, Greene FL, et al, eds. AJCC Cancer Staging
Manual. 8th ed. New York, NY; Springer: 2017.
Gastric cancer: ESMO Clinical Practice Guideline for diagnosis treat-
ment and follow-up Annals of Oncology. 2022;33(10):1005–20.
https://doi.org/10.1016/j.annonc.2022.07.004.
https://seer.cancer.gov/statfacts/html/stomach.html.
Mukkamalla SKR, Recio-Boiles A, Babiker HM.Gastric cancer. In:
StatPearls. Treasure Island, FL: StatPearls Publishing; 2023. https://
www.ncbi.nlm.nih.gov/books/NBK459142/.
NCCN. https://www.nccn.org/professionals/physician_gls/pdf/gastric_
blocks.pdf.
Feeding Tubes andNutritional Support
RachelCaiafa, NishaniHewage, andTanyaEgodage
47
Concept
Feeding tubes and nutritional support are topics that are
likely to come up during the oral boards in the context of
other questions. The important concepts to remember are
indications and timing to start nutritional support, risks and
benets of enteral versus parenteral nutrition, bedside and
surgical options for placement of feeding tubes, and associated complications with each type of feeding tube.
Way Question May BeAsked
This topic will likely be addressed in the context of a critically ill trauma, emergency general surgery, or malnourished
oncology patient. It may also be a part of a question addressing ethical issues and palliative care in surgery. It is unlikely
that this topic will be presented as a stand-alone question.
How toAnswer
History
• Previous abdominal surgeries?
– Anatomy—B1/B2/Roux reconstruction
– Intra-abdominal adhesions
– Previous feed tube?
• How is patient currently receiving nutrition
Physical Exam
• Abdominal scars
• Body habitus
• Presence of wounds/ostomies/stulas
Diagnostic Tests
• Labs (coagulation studies)
• If CT abdomen is available, can review but not necessary
• CT can be helpful if anatomy is anticipated to be unusual,
especially if history of B1/B2/Roux reconstruction
Indications
These include critical illness, poor caloric intake, oropharyngeal dysfunction, neurologic disorders, acute and chronic
pancreatitis, short bowel syndrome, serious trauma and
burns, and malnutrition before major elective surgery. Tubes
can also be placed for palliative reasons, such as malignant
bowel obstruction, to allow for symptom relief. It is strongly
recommended to have a goals of care discussion around
placement of feeding tubes, especially surgical ones.
Contraindications
• Severe ascites
• Peritonitis
• Coagulation disorder/anticoagulation
• Hemodynamic instability
R. Caiafa (*)
Division of Acute Care Surgery, Department of Surgery,
Maimonides Medical Center, Brooklyn, NY, USA
e-mail: rcaiafa@maimo.org
N. Hewage · T. Egodage
Department of Surgery, Cooper University Medical Center,
Camden, NJ, USA
e-mail: hewage-nishani@cooperhealth.edu;
egodage-tanya@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_47
Calculating Nutritional Needs
A good general estimate for nutritional needs is 25–30kcal/
kg/day. Patients with burns, sepsis, and multisystem trauma
may have higher requirements. Accepted practice is to provide 70–80% of estimated caloric needs. Propofol provides
1.1kcal/mL, so patients receiving it for sedation will need
151