A male patient who has previously undergone an antrectomy with loop gastrojejunostomy reconstruction (Billroth II) is diagnosed with alkaline reflux gastritis that is not well managed with nonoperative therapy. Which of the following is a reasonable operative approach?

A 70-year-old man returns for a postoperative visit after undergoing antrectomy and vagotomy with a Billroth II reconstruction for gastric outlet obstruction related to ulcer disease. He complains of frequent nausea, epigastric fullness, vomiting, cramping abdominal pain, and diarrhea within 15 minutes of eating. Less frequently, he has noticed tachycardia and diaphoresis after meals. The most appropriate initial intervention is:

A 65-year-old diabetic female undergoes an antrectomy and truncal vagotomy with Billroth II reconstruction for gastric outlet obstruction due to peptic ulcer disease. She has had post-prandial nausea with inability to tolerate food for 12 months and has lost 10% of her body weight. She has been on prokinetic agents without benefit. Her blood glucose has been under good control. What is the best management?

A 72-year-old woman with a known history of duodenal ulcer disease presents to her primary care physician with progressive abdominal pain, nausea, daily vomiting, and weight loss over the past 6 months. She has had vomiting and intolerance of all solid food for the past 4 days. Her abdominal x-rays show a massively distended stomach without evidence of small or large bowel distention. What pattern of electrolyte and acid-base disturbance is most likely to be seen?

A 54-year-old man admitted with hematemesis undergoes EGD after fluid resuscitation. A 1-cm posterior duodenal bulbar ulcer is observed with a visible vessel in its base. There is a small adherent clot, but no bleeding is observed. What should be done at this point?

A 50-year-old man who has been taking naproxen long term for bilateral knee osteoarthritis is found to have a gastric antral ulcer. Biopsies are negative for neoplasm. Which best describes the mechanism by which ulceration has most likely occurred?

A 53-year-old man with anemia undergoes EGD and is found to have an adenocarcinoma of the gastric cardia. EUS shows tumor invasion through the serosa without invasion into surrounding structures and three enlarged lymph nodes. CT of the chest, abdomen, and pelvis demonstrates gastric thickening in the proximal stomach and enlarged regional lymph nodes with no evidence of distant metastases. Diagnostic laparoscopy is negative. What is the best next step in his care?

A 43-year-old woman who had gastric surgery for refractory ulcers 5 years ago presents to the clinic reporting a racing heart, sweating, and diarrhea 30 minutes after a meal. An oral glucose challenge confirms the diagnosis of dumping syndrome. Which gastric procedure did this patient most likely have?

You are consulted by the emergency department regarding a 4-year-old girl who, according to her mother, swallowed a nickel 2 hours ago. She is asymptomatic with vital signs that are within normal limits. Which of the following is an appropriate next step in management?

A 46-year-old man who had previous gastric surgery undergoes a routine EGD. Biopsies reveal foveolar hyperplasia, glandular cystic degeneration, and edema of lamina propria without evidence of inflammatory cell infiltration. Which procedure is most commonly associated with these histologic findings? 

A 53-year-old man underwent an endoscopic ultrasound and was found to have a 6-cm submucosal gastric mass that was biopsied. It stained positive for c-kit with 8 mitoses/hpf. His tumor has most likely to spread to the

A 23-year-old man is evaluated in the emergency department for early satiety and epigastric pain. He has a history of obsessive-compulsive disorder and no surgical history. On examination, his abdomen is benign, but you notice a tuft of hair at his bedside. What condition are you most concerned for?

An 82-year-old woman in hemorrhagic shock presents to the ED with hematemesis and epigastric pain. A nasogastric tube is placed, and a warm saline lavage is performed. Bright red and dark blood is aspirated. After resuscitation, an emergent EGD reveals a 3-cm posterior duodenal ulcer that has active, pulsatile bleeding. The hemorrhage is controlled with epinephrine injection and heater probe. Which of the following best describes when surgery is indicated?