Peptic ulcers and stomach cancer: Clinical

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Peptic ulcers and stomach cancer: Clinical

USMLE® Step 2 questions

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A 56-year-old woman presents to the primary care physician with a chief complaint of post-prandial abdominal pain and dyspepsia. The patient reports the symptoms started approximately 3-4 weeks ago and have been worsening in intensity. The patient’s only other medical problem is osteoarthritis, for which she occasionally receives corticosteroid injections and recently started taking diclofenac daily. Current temperature is  37 °C (98.6 °F), pulse is 86/min, respirations are 16/min and blood pressure is 142/62 mmHg. Physical examination shows epigastric tenderness on palpation. Which of the following is the best initial management for this patient’s condition?  


Peptic ulcers are deep erosions in the lining of the stomach or duodenum that lead to inflammation in the gastric or duodenal wall.

Sometimes, peptic ulcers develop acutely like after a toxic ingestion or ischemia, but more often the erosions are chronic, developing slowly over time.

Chronic ulcers are mostly benign, but they can sometimes develop into a malignant ulcer, termed stomach cancer, which is why an upper endoscopy with biopsy is essential to the diagnosis.

Chronic ulcers sometimes don’t cause any symptoms. When they do, the most common symptom is dyspepsia.

Dyspepsia includes epigastric pain related to eating food, early satiety, postprandial belching, and nausea.

With gastric ulcers, epigastric pain worsens when eating a meal because of the hydrochloric acid that’s produced in response to food.

With duodenal ulcers, epigastric pain is relieved while eating a meal, but it typically recurs 2 to 5 hours later or it can appear at night. That’s because with duodenal ulcers, Helicobacter pylori is involved in most cases and it increases the hydrochloric acid production by indirectly increasing gastrin production and when there’s no food to act as a buffer, the pain worsens.

Sometimes peptic ulcers can erode deep into the gastric and duodenal wall resulting in complications.

If an ulcer erodes into a blood vessel, then it can cause hematemesis or melena.

If there’s an ulcer in the pyloric antrum or in the duodenum, then it can cause gastric outlet obstruction. That can worsen the symptoms and even cause the individual to lose weight.


A peptic ulcer is an erosion or a break in gastric or/and duodenal mucosa. The most common causes of peptic ulcers are infection with a bacterium called Helicobacter pylori (H. pylori) and long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen. Symptoms of peptic ulcers include upper left abdominal pain, bloating, vomiting, nausea, and loss of appetite. Treatment involves a combination of medications, and sometimes surgery.

Moving on to stomach cancer, also known as gastric cancer, it is a type of cancer that begins in the lining of the stomach. Risk factors for stomach cancer include H. pylori infection, a diet high in smoked or salty foods, and a family history of stomach cancer. Symptoms of stomach cancer usually appear in advanced stages and include nausea, vomiting, unintended weight loss, diffuse abdominal pain, hematemesis or melena, and a sense of fullness in the upper abdomen after eating a small meal. Treatment of stomach cancer may involve surgery, chemotherapy, and/or radiation therapy.


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