A 50-year-old man with a long history of duodenal ulcer presents with progressive vomiting of partially digested food eaten hours earlier, visible gastric peristalsis, and a succussion splash. Serum electrolytes show sodium 138 mEq/L, potassium 2.8 mEq/L, chloride 88 mEq/L, bicarbonate 38 mEq/L. The immediate priority before any definitive surgery is:
- A Urgent truncal vagotomy with antrectomy
- B Nasogastric decompression and correction of the hypochloremic hypokalemic metabolic alkalosis with isotonic saline and potassium replacement ✓
- C Gastrojejunostomy as an emergency procedure
- D Endoscopic balloon dilatation under conscious sedation on arrival
Explanation
Benign gastric outlet obstruction from chronic duodenal ulcer produces loss of hydrogen and chloride ions in vomited gastric juice, causing hypochloremic hypokalemic metabolic alkalosis with paradoxical aciduria. Operating on an unresuscitated patient carries high risk. Initial management is nasogastric tube decompression, correction of volume and electrolyte deficits with normal saline and potassium, nutritional support, and endoscopic assessment once the stomach is empty. Definitive treatment, whether endoscopic dilatation or surgery such as vagotomy with drainage or antrectomy, is undertaken only after metabolic correction.
Reference: Sabiston Textbook of Surgery, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.