Peptic Ulcer & its
Complications
Prof. Dr. Faisal Ghani Siddiqui
FCPS; MCPS-HPE; PGDip-bioethics
Preamble
• Peptic ulcer and its treatment
• Complications of peptic ulcer disease
Peptic Ulcer -Sites
• Duodenum
• Stomach
• Stomas
• Oesophagus
• Meckel’s diverticulum
Peptic Ulcer -Aetiology
• Acid
• Familial
• Stress
• NSAIDs
• Cigarette smoking
• H.pylori
Peptic Ulcer -Investigations
• Endoscopy
• Tests for H.pylori
13C and 14C breath
tests
CLO test
Histpathology
Serology
Peptic Ulcer -Treatment
• Medical treatment
(H2-receptor antagonists / PPI)
• Eradication treatment
(PPI + Metronidazole + Amoxycillin / clarothromycin)
• Surgery
Peptic Ulcer -Complications
• Pyloric outlet obstruction
• Perforation
• Bleeding
Pyloric Outlet Obstruction
Perforation
Bleeding
• Long history of
peptic ulcer disease
• Vomiting
• Weight loss
• Dehydration
• Succussion splash
• Peristalsis
• Tetany
Hypochloraemic alkalosis
&
paradoxical alkalosis
Vomiting –loss of HCl,
HYPOCHLORAEMIC ALKALOSIS
Renal Excretion of HCO3 with Na+ deficit
Aldosterone secretion & Na+ conservation
Renal loss of K+ and H+
PARADOXICAL ACIDURIA
Investigations
Laboratory investigations
Hypochloraemic alkalosis;
hyponatremia;
hypokalaemia
Investigations
Imaging
Plain X-ray ; Barium meal
Investigations
Saline load test
• 700 ml normal saline infused over 3-4 minutes
• Tube clamped for 30 minutes
• Stomach aspirated
• Recovery of >350 ml indicates obstruction
Treatment
Correction of
metabolic
abnormalities
Dealing with
the
mechanical
problem
Treatment
• Correction of fluid & electrolyte
imbalance
Rehydration with isotonic saline and
potassium supplements
Treatment
• Medical treatment
Gastric lavage and suction (5-7 days)
• Surgical treatment
Truncal vagotomy with gastrojejunostomy
• Endoscopic treatment
Balloon dilatation
… in summary
• Most commonly associated with PUD and
carcinoma stomach
• Hypochloraemic alkalosis & paradoxical
aciduria
• Medical / endoscopic dilatation effective in less
severe cases
• Operation with a drainage procedure usually
required
Perforation of peptic ulcer
Most perforated ulcers are located
anteriorly
absence of protective viscera | major blood vessels
Pain
•Pain
•Distressed
•Shallow breath
•Rigidity
•Absent gut sounds
•Tympanitic note
over liver
Investigations
Laboratory investigations
Leucocytosis ; raised serum amylase
High levels of amylase in aspirated fluid
Imaging
Gas under diaphragm
Escape of contrast material from the lumen
Tretament
• Nasogastric tube
• IV fluids
• Antibiotics
• Graham-Steele patch
Bleeding peptic ulcer
Hematemesis & Shock
Hematemesis with shock
• Initial management
• Definitive management
Initial Management
Assess shock & replace blood loss
Pulse | BP | Urine output | Haematocrit | Blood aspirated
Stop bleeding by ice-water lavage
History & physical examination
Upper GI Endoscopy
(within 1-2 hours of admission)
Causes of Upper GI Bleeding
Peptic ulcer
Acute gastritis
Oesophageal varices
Oesophagitis
Mallory-Weiss syndrome
Bleeding Peptic Ulcer -Treatment
• Endoscopic treatment
• Emergency Surgery
Endoscopic Treatment -Indications
Active bleeding
at the time of endoscopy
Visible vessel
at the base of the ulcer
Endoscopic Treatment
Injection
Epinephrine | ethanol
Cautery
Heat probe | electorcautry
Nd:YAG laser
Emergency Surgery
Hypotension
on admission
4 units of blood
to achieve circulatory stability
Continuous bleeding
Subsequent transfusion requirements
exceed 1 unit every 8 hours