Question 11#
A 55-year-old executive who is seen because of severe epigastric pain is found on esophagogastroduodenoscopy to have a large ulcer in the duodenal bulb and tests positive for H. pylori. He is treated for H. pylori and instructed to quit smoking, but his symptoms persist and he is referred to you for further management. At this time, it would be most appropriate to recommend:
A. NSAID cessation and urea breath testB. Highly selective vagotomy
C. Truncal vagotomy and antrectomy
D. Truncal vagotomy and pyloroplasty
Correct Answer is A
Comment:
The indications for surgery in PUD are bleeding, perforation, obstruction, and intractability or nonhealing. Intractability should be an unusual indication for peptic ulcer operation nowadays. The patient referred for surgical evaluation because of intractable PUD should raise red flags for the surgeon: maybe the patient has a missed cancer, is noncompliant, or has Helicobacter despite the presence of a negative test or previous treatment (differential for intractability, Table below). In this setting, the patient with persistent symptoms despite appropriate treatment requires further evaluation before any consideration of operative treatment. If surgery is necessary, a lesser operation may be preferable.
Differential diagnosis of intractability or non-healing peptic ulcer disease:
