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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_40_библиотеки_им_акад_М_И_Перельмана
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CHAPTER 2 | OESOPHAGEAL DISORDERS
protect the airway if there is evidence of compromise. Neutralization should be avoided because of
the risk of causing an exothermic injury and worsening oesophageal damage. There is no evidence
that antibiotics reduce stricture formation or infection rates. Similarly, there is no good evidence for
steroids. Urgent cross- sectional abdominal imaging and consideration of surgery is needed when
there is evidence of perforation or peritonitis.
Endoscopic evaluation should be delayed until 2– 24 hours after ingestion to stage the initial
damage (Grades – 3). Oesophageal stricturing will occur in 80% and 50% of those with grade 3 and
grade 2 damage respectively.Anasogastric tube should be inserted to provide a route for feeding in
patients with early stricturing. Endoscopy should be avoided between days 2 and 5 after ingestion
because of increased risk of oesophageal perforation. After this time, dilatation, or oesophageal
stenting may be needed.
Lupa M, Magne J, Guarisco JL etal. Update on the diagnosis and treatment of caustic ingestion.
Ochsner J. 2009;9(2):54– 9.
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chapter
STOMACH AND DUODENAL
DISORDERS
1. A 66- year- old woman with a history of peptic ulcer disease (PUD)
3
QUESTIONS
and ischaemic heart disease was diagnosed with rheumatoid arthritis.
She was prescribed regular ibuprofen (400 mg three times daily) and
methotrexate.
In view of her history of peptic ulcer disease, which of the following is
the most appropriate precaution to take?
A. Add Omeprazole 20 mg od
B. Commence Helicobacter pylori (H.pylori) eradication therapy
C. Gastroscopy
D. Switch to celecoxib
E. Urea breath test
2. A 33- year- old woman of Indian descent was referred with dyspepsia.
This had been resistant to omeprazole 20 mg daily and metoclopramide
10 mg three times daily, which she was taking at the time of her
gastroscopy. She was on no other medications.
Investigations:
Gastroscopy Antral erosions and three large duodenal
ulcers in D1 (Forrest classIII)
Antral rapid urease test Negative
Haemoglobin 138 g/ L
Plasma viscosity 1.70 mPa/ s
Serum C- reactive protein (CRP) 8 mg/ L
Plasma gastrin 90 pmol/ L
Which of the following is the most likely diagnosis?
A. Crohn’s disease
B. H.pylori infection
C. Human immunodeciency virus (HIV)
D. Tuberculosis
E. Zollinger– Ellison syndrome (ZES)
Best of Five MCQs for the European Specialty Examination in Gastroenterology and Hepatology. Thomas Marjot, Colleen G C McGregor,
Tim Ambrose, Aminda N De Silva, Jeremy Cobbold, and Simon Travis, Oxford University Press (2021). © Oxford University Press.
DOI: 10.1093/oso/9780198834373.003.0003
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CHAPTER 3 | STOMACH AND DUODENAL DISORDERS
3. A 53- year- old woman was referred to gastroenterology with ongoing
dyspepsia despite adequate treatment. She had required H.pylori
eradication therapy twice before.
Which of the following is not a factor related to H. pylori treatment
failure?
A. Acid suppression
B. Host IL- β polymorphism
C. Low body mass index (BMI)
D. Smoking
E. Treatment duration
4. A 75- year- old man with coee ground vomiting was referred for a
gastroscopy. His notes stated that he had had a Billroth II procedure
20years before.
Which of the following most accurately describes his surgery?
A. Division of the vagus nerve and a gastrojejunostomy
B. Division of the vagus nerve and lateral division of the pylorus, followed by longitudinal
resuturing
C. Formation of a gastric pouch; small bowel divided at the duodenojejunal junction;
anastomosis of the jejunum to the gastric pouch; anastomosis of the duodenum to the
small bowel distal to the jejunal anastomosis
D. Longitudinal division of the pylorus
E. Resection of the gastric antrum, formation of a gastrojejunostomy, and closure of the rst
part of the duodenum and gastric outow
5. A 65- year- old man who underwent a Billroth Ipartial gastrectomy
20years ago for recurrent gastric ulcers was seen in the
gastroenterology clinic.
Which of the following deciencies is he most likely to suer from?
A. Calcium
B. Folate
C. Iron
D. Vitamin B
E. Vitamin D
2
CHAPTER 3 | QUESTIONS
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6. A 55- year- old man, originally from China, had a gastroscopy to
investigate epigastric discomfort unresponsive to omeprazole. The
gastroscopy showed mild erythema in the body and biopsies were taken.
Investigations:
Histology (stomach body):See Fig. 3.1
Fig.3.1 Histology specimen from stomach body. See also Plate 4
Image courtesy of Dr Eve Fryer, Consultant Histopathologist, Oxford University Hospitals NHS Foundation Trust
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Which of the following intervals is the most appropriate surveillance
strategy for this man based on the histological ndings?
A. One year
B. Two years
C. Three years
D. Five years
E. No surveillance
7. A 57- year- old woman with dyspepsia and weight loss was referred for a
gastroscopy. Her medications included omeprazole and ranitidine.
Investigations:
Gastroscopy Multiple fundic gland polyps, largest measuring 1.5cm. Targeted
What is the appropriate next step?
A. Repeat the gastroscopy in a year’s time
B. Repeat the gastroscopy with chromoendoscopy
C. Repeat the gastroscopy with excision of polyps >cm
D. Request a H.pylori breath test
E. Request colonoscopy to screen for colonic polyps
biopsies taken.
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CHAPTER 3 | STOMACH AND DUODENAL DISORDERS
8. A 63- year- old librarian with pernicious anaemia was referred for a
gastroscopy. This demonstrated features of atrophic gastritis. Performed
without sedation, the procedure was poorly tolerated and only one
biopsy was taken.
What is the correct protocol for biopsies in atrophic gastritis?
A. Biopsies of two topographic sites (antrum and corpus, at the lesser and greater curvature)
B. Biopsies of two topographic sites (antrum and corpus, at the lesser and greater curvature)
in the same vial
C. Biopsies of two topographic sites (antrum and corpus, at the lesser and greater curvature)
plus additional biopsies of suspicious lesions
D. Targeted biopsies of suspicious lesions only
E. Two gastric biopsies every 4cm
9. A 60- year- old woman presented to the gastroenterology clinic
with abdominal pain and nausea. An abdominal examination was
unremarkable. She had some investigations performed.
Investigations:
Haemoglobin 108 g/ L
Mean corpuscular
varices
Serum ferritin 9 ng/ ml
Transferrin saturation 7%
Serum C- reactive
protein
Serum gastrin 300 pmol/ L
Serum B12 88 ng/ L
Antibodies to intrinsic
factor
Gastroscopy 5mm red lesion on the lesser curve of the body of the stomach
Histology Gastric mucosa showing infiltration by a tumour composed of
Computed tomography
(CT) chest, abdomen,
and pelvis
75 ƒL
9 mg/ L
Positive
(Fig. 3.2) and biopsies were taken
sheets, cribriform islands, and glandular structures. The tumour
cells are relatively uniform, with a small amount of eosinophilic
cytoplasm and stippled chromatin. Positive immunostaining
for chromogranin and synaptophysin, with dot- like positivity for
pan- cytokeratin.
Ki- 67 proliferation rate is 2%. The adjacent mucosa shows
chronic atrophic gastritis with focal intestinal metaplasia.
No metastatic disease
Fig.3.2 Endoscopic image of lesion in stomach. See also Plate 5
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Courtesy of Oxford University Hospitals NHS Foundation Trust
CHAPTER 3 | QUESTIONS
43
What is the most likely diagnosis?
A. Gastrointestinal stromal tumour (GIST)
B. Grade neuroendocrine tumour (NET)
C. Grade 2 NET
D. Grade 3 NET
E. Leiomyoma
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CHAPTER 3 | STOMACH AND DUODENAL DISORDERS
10. A 50- year- old man was referred for investigation of dyspepsia.
Agastroscopy showed a gastric lesion in the fundus. Biopsies were taken
from the lesion and immunohistochemistry showed positivity for CD117
(c- KIT). Fig. 3.3 shows a retroexed view of the stomach with the fundal
lesion.
Fig.3.3 Endoscopic view of stomach in retroexion. See also Plate 6
Courtesy of Oxford University Hospitals NHS Foundation Trust
What is the most appropriate next step of management?
A. CT scan
B. Endoscopic ultrasound
C. H.pylori eradication and repeat gastroscopy in 2months
D. Refer for genetic counselling
E. Repeat gastroscopy in three years’ time
CHAPTER 3 | QUESTIONS
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11. An 82- year- old woman was referred for a gastroscopy to investigate
dyspepsia and normocytic anaemia. Alesion was identied in the gastric
antrum.
Investigations:
Gastroscopy Fig. 3.4
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Fig.3.4 Endoscopic image of gastric antrum. See also Plate 7
Image courtesy of Dr Tim Ambrose, Oxford University Hospitals NHS Foundation Trust
What is the most appropriate next step in investigating and managing
this lesion?
A. CT thorax, abdomen, and pelvis
B. Endoscopic ultrasound (EUS)
C. No further action required
D. Repeat the gastroscopy after six weeks high- dose proton pump inhibitor (PPI) therapy
E. Test and treat for H.pylori
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CHAPTER 3 | STOMACH AND DUODENAL DISORDERS
12. A 45- year- old man was referred by his GP for investigation of epigastric
discomfort that had not resolved despite an adequate trial of PPI
therapy. Agastroscopy showed a lesion in the antrum. An EUS
examination was performed to further characterize the lesion.
The endoscopic ultrasonographic appearance of the lesion is shown in
Fig. 3.5.
Fig.3.5 Endoscopic ultrasound image of gastric lesion
In which layer of the stomach does the lesion lie?
A. Interface
B. Mucosa
C. Muscularis propria
D. Serosa
E. Submucosa
13. A 76- year- old man was referred by his GP for endoscopy complaining
of a six- month history of dyspepsia, despite adequate trials of PPI
treatment. His H.pylori breath test was negative. His stepmother had
died from gastric carcinoma.
Among patients who are referred for gastroscopy for alarm features, the
prevalence of gastric cancer (GC) is most appropriately described as:
A. 0.8%
B. 4%
C. 6%
D. 28%
E. 32%
CHAPTER 3 | QUESTIONS
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47
14. A 27- year- old secretary was referred by her GP with heartburn,
abdominal pain, and diarrhoea. Her symptoms had persisted despite
high doses of omeprazole. She denied the use of non- steroidal antiinammatory drugs (NSAIDs) and was a non- smoker. She reported that
her father had a ‘pancreas tumour’.
Investigations:
Gastroscopy Severe peptic ulcer disease. Predominant ulceration in distal
duodenum with multiple small ulcers. Large gastric folds.
What is the next appropriate investigation?
A. CLO test
B. Fasting serum gastrin
C. Magnetic resonance (MR) pancreas
D. Secretin stimulation test
E. Serum calcium
15. A 46- year- old woman was recently diagnosed with gastric
adenocarcinoma. She enquired about her son’s risk of developing GC.
Which is the weakest independent risk factor for gastric
adenocarcinoma?
A. Age
B. Family history
C. Female sex
D. H.pylori infection
E. Smoking
16. A 69- year- old retired builder was recently diagnosed with a diuse T2N
gastric adenocarcinoma. Imaging and laparoscopy excluded occult and
distant metastatic disease. He had no signicant past medical history
of note.
Which is the most appropriate treatment option?
A. Chemoradiotherapy
B. Endoscopic resection
C. Pre- operative chemotherapy and radical gastrectomy
D. Radical gastrectomy
E. Subtotal gastrectomy
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