A 52-year-old man is brought to the emergency department due to repeated vomiting that began 2 hours ago. His vomit is dark brown and has a granular consistency. The patient has a history of dyspepsia, for which he takes over-the-counter antacids as needed and degenerative knee arthritis, for which he takes naproxen regularly. He drinks 2-3 beers daily. Temperature is 36.7 C (98 F), blood pressure is 114/62 mm Hg, pulse is 102/min, and respirations are 14/min. Physical examination reveals mild epigastric tenderness with no rebound or guarding. Hemoglobin is 9 g/dL. Endoscopy shows a deep, bleeding ulcer on the posterior wall of the duodenal bulb. This patient's ulcer has most likely penetrated which of the following arteries?

Question

A 52-year-old man is brought to the emergency department due to repeated vomiting that began 2 hours ago.  His vomit is dark brown and has a granular consistency.  The patient has a history of dyspepsia, for which he takes over-the-counter antacids as needed and degenerative knee arthritis, for which he takes naproxen regularly.  He drinks 2-3 beers daily.  Temperature is 36.7 C (98 F), blood pressure is 114/62 mm Hg, pulse is 102/min, and respirations are 14/min.  Physical examination reveals mild epigastric tenderness with no rebound or guarding.  Hemoglobin is 9 g/dL.  Endoscopy shows a deep, bleeding ulcer on the posterior wall of the duodenal bulb.  This patient's ulcer has most likely penetrated which of the following arteries?

Quizplus · Accepted Answer

11ec160b_3587_6608_9249_d5c0fd3acb6b_MD0001_00 Bleeding peptic ulcer disease should be considered in patients who develop acute epigastric pain, unstable vital signs, or hematemesis, particularly in the setting of prior dyspepsia. Most peptic ulcers are caused by Helicobacter pylori infection or nonsteroidal anti-inflammatory drug use; other risk factors include smoking, older age, and glucocorticoid use. Duodenal ulcers are more common than gastric ulcers and tend to occur anteriorly. Ulcers located on the anterior wall of the duodenal bulb are more prone to perforation; those on the posterior wall are more likely to cause hemorrhage. These complications are explained by the relationship of the duodenal bulb to adjacent organs. The duodenal bulb is approximately 5 cm long, beginning at the pylorus and ending at the neck of the gallbladder. The gallbladder and liver lie anterior to the duodenal bulb within the intraperitoneal space; the gastroduodenal artery, common biliary duct, and portal vein are posterior to the bulb; and the head of the pancreas is located inferiorly. When an ulcer penetrates the posterior duodenal wall, it is likely to erode into the gastroduodenal artery, which perfuses both the pylorus and the proximal part of the duodenum. Damage to the gastroduodenal artery can cause significant upper gastrointestinal bleeding. (Choice A) The common hepatic artery arises from the celiac trunk and bifurcates into the proper hepatic and gastroduodenal arteries. It passes superior to the duodenal bulb. (Choice C) The inferior pancreaticoduodenal artery is a branch of the superior mesenteric artery. It supplies blood to the lower duodenum and to the head of the pancreas. This artery has no close relation to the duodenal bulb. (Choices D, E, and F) The left gastroepiploic and right gastric arteries supply blood to the greater and lesser curves of the stomach, respectively. The short gastric arteries arise off the splenic artery and supply the upper portions of the greater curvature. These vessels do not lie in close proximity to the duodenal bulb. (Choice G) The superior mesenteric artery lies anterior to the transverse part of the duodenum. It arises from the anterior surface of the abdominal aorta and supplies the intestine from the duodenum to the proximal two-thirds of the transverse colon. Educational objective: The gastroduodenal artery lies along the posterior wall of the duodenal bulb and is likely to be eroded by posterior duodenal ulcers. Ulceration into the gastroduodenal artery can be a source of life-threatening hemorrhage.

A 52-Year-Old Man Is Brought to the Emergency Department Due