0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Image of the Month—Quiz Case FREE

Tomonori Iida, MD; Haruyuki Akita, MD, PhD; Masasi Sasaki, MD, PhD; Nobuyoshi Hanyu, MD, PhD; Katsuhiko Yanaga, MD, PhD
[+] Author Affiliations

Author Affiliations:Departments of Surgery, The Jikei University School of Medicine, Tokyo (Drs Iida, Hanyu, and Yanaga), and Sasaki Private Hospital, Saitama (Drs Akita and Sasaki), Japan.


Section Editor: Grace S. Rozycki, MD, MBA


Arch Surg. 2008;143(6):609. doi:10.1001/archsurg.143.6.609.
Text Size: A A A
Published online

A 62-year-old man was admitted to the hospital with epigastric pain, nausea, anorexia, and abdominal distention. He had a history of duodenal ulcer with pyloric stenosis 10 years earlier and recent multiple gastric ulcers mainly in the gastric angle. The findings of a physical examination revealed anemia, emaciation, and epigastric tenderness without peritoneal signs. Peripheral blood cell counts and biochemical test results showed anemia (hemoglobin level, 10.9 g/dL [to convert to grams per liter, multiply by 10.0]), nutritional impairment (serum total protein level, 5.7 g/dL [to convert to grams per liter, multiply by 10.0]; albumin level, 3.1 g/dL [to convert to grams per liter, multiply by 10.0]; and total cholesterol level, 112 mg/dL [to convert to millimoles per liter, multiply by 0.0259]), and mild inflammation (C-reactive protein level, 18.1 mg/L [to convert to nanomoles per liter, multiply by 9.524]). Gastrointestinal fiberscopy (Figure 1) and barium enema (Figure 2) were performed.

Place holder to copy figure label and caption
Figure 1.

Gastrointestinal endoscopy indicated a giant gastric ulcer at the gastric angle. At the bottom of the ulcer, what appears as the intestine with 2 openings (arrows) was identified.

Graphic Jump Location

Place holder to copy figure label and caption
Figure 2.

Barium enema showed backward flow of barium from the transverse colon into the stomach (arrows).

Graphic Jump Location

WHAT IS THE DIAGNOSIS?

A. Large peptic ulcer

B. Gastric adenocarcinoma type 2

C. Gastrocolic fistula associated with a gastric ulcer

D. Gastric submucosal tumor

Figures

Place holder to copy figure label and caption
Figure 1.

Gastrointestinal endoscopy indicated a giant gastric ulcer at the gastric angle. At the bottom of the ulcer, what appears as the intestine with 2 openings (arrows) was identified.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Barium enema showed backward flow of barium from the transverse colon into the stomach (arrows).

Graphic Jump Location

Tables

References

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
JAMAevidence.com