chapter 3
Stomach and duodenal disorders
Questions
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 class III) |
| 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?
Which of the following is not a factor related to H. pylori treatment failure?
4.A 75-year-old man with coffee ground vomiting was referred for a gastroscopy. His notes stated that he had had a Billroth II procedure 20 years before.
Which of the following most accurately describes his surgery?
5.A 65-year-old man who underwent a Billroth I partial gastrectomy 20 years ago for recurrent gastric ulcers was seen in the gastroenterology clinic.
Which of the following deficiencies is he most likely to suffer from?
Investigations:
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
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 1.5 cm. Targeted biopsies taken. |
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 >1 cm
D. Request a H. pylori breath test
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)
D. Targeted biopsies of suspicious lesions only
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 | 75 ƒL |
| Serum ferritin | 9 ng/ml |
| Transferrin saturation | 7% |
| Serum C-reactive protein | 9 mg/L |
| Serum gastrin | 300 pmol/L |
| Serum B12 | 88 ng/L |
| Antibodies to intrinsic factor | Positive |
| Gastroscopy | 5 mm red lesion on the lesser curve of the body of the stomach (Fig. 3.2) and biopsies were taken |
| Histology | Gastric mucosa showing infiltration by a tumour composed of 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 |
| Computed tomography (CT) chest, abdomen, and pelvis | No metastatic disease |
Fig. 3.2 Endoscopic image of lesion in stomach. See also Plate 5
Courtesy of Oxford University Hospitals NHS Foundation Trust
What is the most likely diagnosis?
10.A 50-year-old man was referred for investigation of dyspepsia. A gastroscopy showed a gastric lesion in the fundus. Biopsies were taken from the lesion and immunohistochemistry showed positivity for CD117 (c-KIT).Fig.3.3shows a retroflexed view of the stomach with the fundal lesion.
Fig. 3.3 Endoscopic view of stomach in retroflexion. See also Plate 6
Courtesy of Oxford University Hospitals NHS Foundation Trust
What is the most appropriate next step of management?
Investigations:
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)
D. Repeat the gastroscopy after six weeks high-dose proton pump inhibitor (PPI) therapy
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?
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.
Investigations:
| Gastroscopy | Severe peptic ulcer disease. Predominant ulceration in distal duodenum with multiple small ulcers. Large gastric folds. |
What is the next appropriate investigation?
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?
16.A 69-year-old retired builder was recently diagnosed with a diffuse T2N gastric adenocarcinoma. Imaging and laparoscopy excluded occult and distant metastatic disease. He had no significant past medical history of note.
Which is the most appropriate treatment option?
Investigations:
| Haemoglobin | 130 g/L |
| Creatinine | 67 µmol/L |
| Thyroid stimulating hormone | 1.16 munit/L |
| Fasting glucose | 4.5 mmol/L |
| Gastroscopy | Normal |
| MR enterography | Normal |
What is the most appropriate investigation to make a diagnosis?
18.A 68-year-old man with Parkinson’s disease on levodopa was admitted with vomiting and abdominal pain.
19.A 45-year-old woman attended her general practitioner with recurrent nausea and vomiting associated with travel. She had tried cyclizine to no effect.
What is the next choice of medication for her motion sickness?
Investigations:
| Gastroscopy | Fig. 3.6 |
| Urease breath test | Negative |
Fig. 3.6 Endoscopic image of stomach. See also Plate 8
Image courtesy of Dr Tim Ambrose, Oxford University Hospitals NHS Foundation Trust
What is the most likely diagnosis?
Investigations:
| Haemoglobin | 130 g/L |
| White cell count | 9.0 × 109/L |
| Platelet count | 387 × 109/L |
| Albumin | 28 g/L |
| C-reactive protein | 9 mg/L |
| Gastroscopy | Markedly thickened gastric folds primarily of the body and fundus. Gastric biopsies taken. |
| Histology | Foveolar hyperplasia |
What is the most likely diagnosis?
22.A patient had undergone a gastroscopy to investigate iron-deficiency anaemia. Their GP had received the duodenal histology result showing ‘intraepithelial lymphocytosis and normal villous architecture’, and asked whether this meant that the patient had coeliac disease.
In which other condition can duodenal intraepithelial lymphocytosis be present?
Investigations:
| Gastroscopy | A mass was seen in the second part of the duodenum (Fig. 3.7) |
| Histology (duodenal mass) | |
| Colonoscopy | Sigmoid diverticulae only |
Fig. 3.7 Endoscopic image of second part of duodenum. See also Plate 9
Image courtesy of Dr Tim Ambrose, Oxford University Hospitals NHS Foundation Trust
What is the most likely diagnosis?
Which of the following is a key performance measure for gastroscopy?
A. Accurate documentation of indications after therapeutic upper gastrointestinal (UGI) endoscopy
B. Accurate photo documentation of anatomical landmarks and abnormal findings
C. Documentation of distance from incisors to gastro oesophageal junction (GOJ), in centimetres
D. Documentation of patient comfort score
E. Minimum seven-minute procedure time for index gastroscopy
25.A 57-year-old taxi driver with pancreatic cancer attended the emergency department with profuse vomiting and metabolic alkalosis. A succussion splash was elicited on examination.
Investigations:
| CT abdomen and pelvis | Distended stomach with evidence of gastric outlet obstruction secondary to duodenal obstruction from locally advanced pancreatic cancer |
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