Gastrointestinal Surgery — MCQs

Q: Based on the image shown, a patient has been diagnosed with a gastric ulcer. According to the Modified Johnson classification, what type of gastric ulcer is present?

Type 1. ***Type 1*** - The image shows a gastric ulcer located in the **gastric body along the lesser curvature**, which is characteristic of a **Type 1 ulcer** (most common type, ~55% of gastric ulcers). - Type 1 ulcers are typically associated with **normal or decreased acid secretion** and occur in patients with **chronic gastritis** and decreased mucosal resistance. - These ulcers are **not associated with duodenal ulcers** and have the **highest risk of malignancy** among gastric ulcer types. *Type 2* - A Type 2 ulcer involves **two concurrent ulcers**: one in the gastric body and a **concomitant active duodenal ulcer**. - Associated with **increased acid secretion** (similar to duodenal ulcer pathophysiology). - The image shows only a **single gastric ulcer** without evidence of duodenal involvement. *Type 3* - A Type 3 ulcer is located in the **prepyloric region** (within 3 cm of the pylorus). - Associated with **high acid secretion** and often occurs in younger patients. - The ulcer shown is in the **body/lesser curvature**, not the prepyloric area. *Type 4* - A Type 4 ulcer is a **high lesser curvature ulcer** located near the **gastroesophageal junction** (proximal stomach/cardia). - Associated with **low acid secretion** and has high malignant potential. - The image clearly shows the ulcer in the **mid-body region**, distal to the cardia. *Type 5* - Type 5 ulcers can occur **anywhere in the stomach** and are specifically associated with **chronic NSAID use**. - These are medication-induced ulcers rather than location-specific. - The image shows a typical Type 1 location without clinical information suggesting NSAID etiology.

Q: Which subtype of gastric ulcer is shown in the image?

Lesser curvature at incisura. ***Lesser curvature at incisura*** - The image clearly labels the **incisura angularis (Incision)**, which is a notch on the lesser curvature of the stomach. Gastric ulcers frequently occur at this location. - Ulcers at the incisura are often associated with **Type I gastric ulcers**, which are typically found on the lesser curvature. *High on lesser curvature* - While ulcers can occur high on the lesser curvature (Type II or III, depending on whether there's an associated duodenal ulcer), the label in the image specifically points to the **incisura**. - High lesser curvature ulcers are distinct from those precisely at the incisura, which is a more distal point on the lesser curvature. *Greater curvature* - Ulcers on the **greater curvature** are relatively rare and often raise suspicion for malignancy. - The image explicitly shows a potential ulcer location along the lesser curvature, not the greater curvature. *Pre-pyloric* - **Pre-pyloric ulcers** are located in the region immediately before the pylorus, in the antrum. - The label in the image is proximal to the pylorus, but specifically points to the incisura, which is generally considered part of the gastric body/antrum junction rather than solely pre-pyloric. *Cardia* - **Type IV gastric ulcers** occur at the cardia, near the gastroesophageal junction. - The image shows the incisura angularis on the lesser curvature, which is significantly distal to the cardia.

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