A 75-year-old man is brought to the emergency department due to acute-onset profuse vomiting of large amounts of bright red blood. He has had intermittent, dull epigastric pain for the last 3 months. Medical history is significant for chronic obstructive pulmonary disease with multiple exacerbations and lumbar spinal stenosis. The patient has smoked 1 pack of cigarettes daily for 40 years. Blood pressure is 70/40 mm Hg and pulse is 120/min. Examination shows epigastric tenderness. The patient dies an hour after admission despite resuscitation efforts. Autopsy shows a deep peptic ulcer localized proximally on the lesser curvature of the stomach. The ulcer most likely penetrated which of the following arteries?

Question

A 75-year-old man is brought to the emergency department due to acute-onset profuse vomiting of large amounts of bright red blood.  He has had intermittent, dull epigastric pain for the last 3 months.  Medical history is significant for chronic obstructive pulmonary disease with multiple exacerbations and lumbar spinal stenosis.  The patient has smoked 1 pack of cigarettes daily for 40 years.  Blood pressure is 70/40 mm Hg and pulse is 120/min.  Examination shows epigastric tenderness.  The patient dies an hour after admission despite resuscitation efforts.  Autopsy shows a deep peptic ulcer localized proximally on the lesser curvature of the stomach.  The ulcer most likely penetrated which of the following arteries?

Quizplus · Accepted Answer

11ec160b_358a_4c39_9249_9f5fecac24ca_MD0001_00 Massive hemorrhage with hypovolemic shock is a potential life-threatening complication of peptic ulcer disease (PUD). Most cases of PUD are due to Helicobacter pylori infection or nonsteroidal anti-inflammatory drug use. Other risk factors include smoking, glucocorticoid use, and older age. Most gastric ulcers arise along the lesser curvature of the stomach, usually at the transitional zone between the gastric corpus (body) and antrum. Glands in the corpus contain parietal cells that produce hydrochloric acid and intrinsic factor; mucosal glands in the antrum contain G cells that secrete gastrin. This transitional zone provides the optimal microenvironment (eg, pH, host immune factors) for H pylori proliferation. The resultant inflammation leads to mucosal atrophy and ulcer formation. The left and right gastric arteries run along and perfuse the lesser curvature of the stomach, and are a common source of hemorrhage from penetrating gastric ulcers. Other potential complications of PUD include penetration into other adjacent structures (eg, biliary tract, colon), gastric outlet obstruction, and free wall perforation with peritonitis. (Choices A and B) The common hepatic artery perfuses the liver, gallbladder, pylorus, duodenum, and pancreas. It arises from the celiac trunk and ends when it bifurcates into the proper hepatic and gastroduodenal arteries. The gastroduodenal artery supplies blood to the pylorus and proximal duodenum. Ulcers in the posterior duodenal bulb can erode into the gastroduodenal artery, but a gastric ulcer at the lesser curvature would not involve these arteries. (Choices C and G) The superior mesenteric and inferior pancreaticoduodenal arteries do not perfuse the stomach. (Choice E) The right gastroepiploic artery arises from the gastroduodenal artery and perfuses the distal greater curvature of the stomach. Gastric ulcers do not commonly occur in the greater curvature. (Choice F) The splenic artery arises from the celiac trunk and supplies blood to the spleen. It is separated from the posterior wall of the stomach by the pancreas and is only rarely penetrated by gastric ulcers. Educational objective: Most gastric ulcers arise along the lesser curvature of the stomach, usually at the transitional zone between the gastric corpus (body) and antrum. The left and right gastric arteries run along the lesser curvature and are likely to be penetrated by ulcers, causing gastric bleeding.

A 75-Year-Old Man Is Brought to the Emergency Department Due