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Peptic ulcer

complications

Mohammed Emad Witwit Ali Salim Rasheed

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1. Bleeding . 2. Perforation . 3. Gastric outlet obstruction .

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1 - Bleeding peptic ulcers

About 20 % of patients (especially elderly) with ulcer disease would suffer from bleeding episodes .

It is commonly associated with the ingestion of NSAIDs.

The most common site of bleeding from a peptic ulcer is the duodenum .

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Causes of upper GI bleeding

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Pathology

Mild : Bleeding from the granulation tissue.

Moderate : Due to erosion of small vessels.

Severe : Due to erosion of a large vessel as gastroduodenal .

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Clinical features symptoms 1. Hematemesis : Coffee ground blood . Fresh blood in severe cases .2. Melena in mild cases.3. Hematochezia in severe cases.

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Clinical features signs General 1. Anemia in case of repeated minor bleeding. 2. Hypovolemic shock (sweating, pallor, weak rapid pulse) in severe bleeding .

Local Epigastric tenderness

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Investigations (Urgent investigations after resuscitation ) 1. OGD ( within 24 hrs ) For diagnosis and exclusion of other causes of

hematemesis.

2. Selective mesenteric angioaphy lf endoscope fails to localize the source.

3. Laboratory : CBC , Electrolytes , KFTs.

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Investigations OGD SMA

???

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Treatment Initial assessment ( ABC ) Resuscitation ( IV fluids ,

blood , O2 , etc ….) Monitoring ( vital signs ,UOP )

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Treatment Medical PPI , H2-antagonist . Limited efficacy . Prevent rebleeding after

endoscopy .

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Treatment Therapeutic endoscopy Achieve haemostasis in

~70 - 90 % of cases . Combination of adrenaline

injection with heater probe +/or clips.

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Treatment Surgery

What are the indications of surgery ?

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2- Perforated peptic ulcer Perforation occurs in as many as 10%

of patients with PUD . Most common in elderly female

patients ( use of NSAIDs ) . The most common site of perforation

is the anterior aspect of the duodenum. However, the anterior or incisural gastric ulcer may perforate .

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Pathology Stage ( I )

Sudden Rapture of ulcer base

Gastric or

duodenal content

in peritoneal cavity

Chemical peritonitis

Stage of Chemical peritonitis

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Clinical features Stage ( I )

Symptoms ( usually short and the patient not seen in it ) . Sudden severe epigastric pain which become generalized . Signs General Pallor, sweating, subnormal temperature, rapid weak pulse.

Local Board like rigidity, guarding, epigastric tenderness . Decreased liver dullness (air under the diaphragm). Shifting dullness (fluid in the peritoneal cavity). Decresed intestinal sounds (paralytic ileus occurs late ).

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Pathology Stage ( II )

Reaction of

peritoneum

Production of large amount of alkaline fluid and bringing

antibodies.

Stage of illusion

3-6 hours after perforation

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Clinical features Stage ( II )

Symptoms Pain decreases. Signs General The patient has more tachycardia.Local Like the previous stage with less rigidity

and increased shifting dullness.

3-6 hours after perforation

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Pathology Stage ( III)

Bacteria (flourish as a

result of HCI and loss

of its antiseptic

effect)

Pus formatio

n Septic

peritonitis

Stage of Septic peritonitis

6-12 hours after perforation

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Clinical features Stage ( III )

Symptoms Pain increases with fever, anorexia,

headache, malaise, repeated vomiting and distension .

Signs General Fever, toxemia, More tachycardia , deterioration of

the general condition of the patient,Local Generalized rigidity, tenderness, progressive

abdominal distension.

6- 12 hours after perforation

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Investigations 1. Upright Plane CXR / AXR : air under diaphragm

in 80 % of cases .

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Investigations 2. U/S: shows fluid in the peritoneum.3. Gastroqrafin meal: ensure escape of the dye

through the perforation (especially if no air under diaphragm is seen by X-ray ).

4. CT imaging : is more accurate and diagnostic . Can we

use barium ??

?

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Barium meal Leakage of barium into the

peritoneal cavity may lead to endotoxic shock which is often fatal.

As a result, the use of barium as a contrast agent is contraindicated when there is a suspicion or possibility of compromise of GI wall integrity.

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Investigations 5. Lab. CBC: PNL in septic peritonitis. KFTs : prerenal failure. Electrolytes : disturbances . Serum amylase : moderate increase .

( highly increased in acute pancreatitis )

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Treatment 1. Resuscitation .2. Analgesia.3. Surgery : Laparoscopy. Laparotomy . 4. Thorough peritoneal lavage.5. Systemic antibiotics 6. Following operation : Nasogastric suction . Gastric antisecretory agents .

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3- Gastric outlet obstruction

The two common causes of gastric outlet obstruction are :

1. Gastric cancer .2. Pyloric stenosis secondary to peptic

ulceration. Nowadays , gastric outlet obstruction

should be considered malignant until proven otherwise, at least in the West.

It occurs in ~ 5% of patients with PUD . It is usually due to duodenal or prepyloric

ulcer disease .

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Pathology Chronic

inflammation

Repair and scarring

Fibrosis and

stenosis

Hypertrophic Stomach dilatation

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Clinical features symptoms 1. Vomiting

Projectile, food content , not bile stained , foul odour from fermentation , characteristically in the evening .

2. Pain History of periodic pain, which is lost at presentation becoming continuous with no relation to food.

3. Progressive weigh loss & constipation.

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Clinical features signs General Dehydration . Weight loss .

Local Inspection : Epigastric fullness . Outlines of enlarged stomach may be seen . Auscultation:Succussion splash (the stomach full with water & solid) .

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Metabolic effectsVomiting of

HCL

Hypochloremic

alkalosis +dehydration

Renal dysfunction

( HCo3- ) +Na loss

Hyponatraemia +profound

dehydration

Na retention+

K & H excretion

Paradoxically acidic urine +

hypokalaemia

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Metabolic effectsVomiting of

HCL

Hypochloremic

alkalosis

Low circulating ionised Ca

Tetany

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Investigations Lab. (assess general condition of the

patient) CBC : anemia,

hemoconcentration. KFTs : prerenal failure. Serum electrolytes : decreased (

Na, K & Cl ) & paradoxical aciduria.

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Investigations Barium meal :a. Dilated stomach (often reaching the pelvis) .b. Soup Dish appearances or inverted hat appearance .

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Investigations OGD Main value: to exclude malignancy + biopsy Dilated stomach with atrophic gastritis &

failure of passage through pylorus.

???

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Treatment Conservative measures IV isotonic saline with potassium supplementation. Tx of anemia . large nasogastric / orogastric tube and lavage of

the stomach . Medical gastric antisecretory agent, initially given IV to

ensure absorption.Surgical Truncal vagotomy & gastrojejunostomy is the

standard treatment . ln the elderly or unfit patients: Gastrojejunostomy

alone or endoscopic balloon dilatation

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Treatment

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Thanks for

listening