**Question:** A 30 Yr old male presents to emergency department with symptoms of epigastric pain radiating to back that wakes him up at night and is relieved by consuming food. He gives history of similar pain in the past which was diagnosed as perforated duodenal ulcer and treatment with omental patch surgery on two occasions. Pain before and after surgery has been controlled with proton pump inhibitors and analgesics. The likely diagnosis on this occasion is:

A. Gastric ulcer
B. Esophageal reflux disease
C. Gastric cancer
D. Cholecystitis

**Core Concept:**

Perforated duodenal ulcer is a condition characterized by the rupture or perforation of a peptic ulcer in the duodenum, usually resulting from the prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs) or H. pylori infection. Acid suppression therapy, such as proton pump inhibitors (PPIs), reduces stomach acid production and helps manage the symptoms of the ulcer and its complications.

**Core Concept (Revised):**

Perforated duodenal ulcer is a condition characterized by the rupture or perforation of a peptic ulcer in the duodenum, resulting from the prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs) or H. pylori infection. Acid suppression therapy, such as proton pump inhibitors (PPIs), reduces stomach acid production and helps manage the symptoms of the ulcer and its complications.

**Why the Correct Answer is C:**

In this scenario, the patient's symptoms, history of previous perforated duodenal ulcer, and successful management with acid suppression therapy suggest that the likely diagnosis is:

C. Gastric ulcer

**Why the Wrong Answers are Incorrect:**

A. Gastric ulcer: Although the patient has a history of perforated duodenal ulcer, the pain relief achieved with acid suppression therapy points towards a gastric ulcer as the correct diagnosis.

B. Esophageal reflux disease: The patient's symptoms and response to acid suppression therapy do not align with the typical presentation and treatment of esophageal reflux disease.

D. Cholecystitis: The patient's symptoms and response to acid suppression therapy do not align with the typical presentation and treatment of cholecystitis (gallstone-related pain).

**Core Concept (Revised):**

Perforated duodenal ulcer is a condition characterized by the rupture or perforation of a peptic ulcer in the duodenum, usually resulting from the prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs) or H. pylori infection. Acid suppression therapy, such as proton pump inhibitors (PPIs), reduces stomach acid production and helps manage the symptoms of the ulcer and its complications.

**Why the Correct Answer is C:**

The patient's symptoms, history of previous perforated duodenal ulcer, and successful management with acid suppression therapy point towards a gastric ulcer as