PERFORATED AND BLEEDING PEPTIC ULCERS
Peptic Ulcer
Results from the corrosive action of acid gastric juice on a vulnerable epithelium
Evidence has implicated acid as the chief injurious agent
Due to the role of acid, emphasis on therapy with antacids and H2 blocking agents for the medical
therapy of ulcers and to operations that reduce acid secretion as the major surgical approach.
In the case of duodenal and gastric ulcers, Helicobactor Pylori, must colonize and weaken the
mucosa before acid is able to do the damage.
In general terms, ulcerative process can lead to four types of disability.
 Pain is most common
 Bleeding may occur
 Penetration of the ulcer through all layers of the gut results in perforation
 Obstruction may result from the inflammatory swelling
Bleeding Peptic Ulcer
Upper Gastrointestinal Haemorrhage
 May be mild or severe
 It is important to know that in 75% of cases the bleeding will stop spontaneously. The
remainder include those who will require surgery, experience complications or die
Definitions
Hematemesis – Bright red or dark blood indicates that the source is proximal to the ligament of
Treitz. It is more common from bleeding that originates in the stomach or esophagus.
Hematemesis denotes a more rapidly bleeding lesion, and a high percentage of patients who vomit
blood require surgery. Coffee ground vomitus is due to vomiting of blood that has been in the
stomach long enough for gastric acid to convert hemoglobin to methemoglobin.
Melena – is the passage of black or tarry stools. Melena can be produced by blood entering the
bowl at any point from the mouth to caecum.
Hematochezia – bleeding from the colon, rectum or anus can produce bright red rectal blood.
However, it can also indicate a brisk bleeding in the upper intestine where the blood may be
passed unchanged in the stool.
Initial Management
In the healthy patient, melena suggests that the bleeding is slow. The patient should be admitted to
the hospital and nonemergency workup is indicated.
Patients who present with hematemesis of melena of less than 12 hours duration should be
handled as if exsanguinations were imminent.
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Assess the status of the circulatory system and replace blood loss as necessary.
Determine the amount and rate of bleeding.
Slow or stop the bleeding by ice water lavage
Discover the lesion responsible for the episode
Make a correct diagnosis of the cause of bleeding.
The patient should be questioned about NSAID use and any history of bleeding tendancy.
Blood should be drawn for crossmatching, hematocrit, Hb, and liver function tests.
An intravenous infusion should be started and a large bore nasogastric tube inserted.
It is common practice to give H2 receptor antagonist or omeprazole. If bleeding continues or if
tachycardia and hypotension are present, the patient should be monitored and treated as for
hemorrhagic shock.
All of the above tests and procedures can be performed within 1 or 2 hours after admission. Once
the bleeding is under control, blood volume has been restored to normal and the patient is
adequately monitored additional diagnostic tests should be performed.
Once the patient is stabilized, endoscopy should be the first study, usually within 24 hours after
admission.
Peptic ulcer is the most common cause of massive upper gastrointestinal hemorrhage. Bleeding
ulcers in the duodenum are usually located on the posterior surface. As the ulcer penetrates, the
gastro duodenal artery is exposed and may become eroded. Since no major blood vessels lie on
the anterior surface of the duodenum, ulceration here is not prone to bleeding.
In some patients the bleeding is sudden and massive, manifested by hematemesis and shock. In
others, chronic anemia and weakness due to slow blood loss are the only findings.
Twice daily Hct readings should be ordered as a check on slow continued blood loss.
Rebleeding in the hospital has a mortality rate of about 30%. Patients over the age of 60, with
hematemesis actively bleeding at the time of endoscopy, or with an Hb < 8g/dl have a higher risk of
rebleeding.
Endoscopic Therapy
Treatments administered through the endoscope may stop active bleeding or prevent rebleeding.
Effective methods include
– injection in to the ulcer with epinephrine
– cautery using electrocautery.
Indications for treatment are:
- active bleeding at the time of endoscopy
- presence of a visible vessel in the base of the ulcer
Emergency Surgery
About 10% of patients bleeding from a peptic ulcer require emergency surgery.
During laparotomy, the first step is to make a pyloroplasty incision if the endoscopic diagnosis is a
bleeding duodenal ulcer. If the duodenal ulcer is found, the bleeding vessel is ligated and the
duodenum and antrum is inspected for additional ulcers.
Gastric ulcers can be handled by either gastrectomy or vagotomy and pyloroplasty.
Prognosis
The mortality rate for an acute massive hemorrhage is 15%.
Perforated Peptic Ulcer
Perforations usually occur anteriorly due to the absence of protective viscera and major blood
vessels on this surface. Immediately after the perforation, the peritoneal cavity is flooded with
gastric secretions and a chemical peritonitis develops.
A small percentage of cases, the perforation becomes sealed by adherence of the liver or
omentum. In such patients the process may be self limited but a subphrenic abscess may develop.
Clinical Findings
Symptoms and Signs :
 Sudden severe upper abdominal pain.
 Rarely nausea or vomiting.
 Shoulder pain, reflects diaphragmatic irritation
 Patient appears severely distressed, lying to minimize abdominal motion.
 Abdominal muscles are rigid with epigastric tenderness and boardlike rigidity.
 Peristaltic sounds are reduced or absent.
Laboratory findings
Mild leukocytosis – 12000/uL, after 12-24 hours may rise to 20000/uL
Imaging Studies
Plain X-rays of the abdomen reveal free sub diaphragmatic air in 85% of patients. Both supine and
upright plates should be taken. A left lateral decubitus position may be a more practical way to
demonstrate free air in the uncomfortable patient.
Differential Diagnosis
 Acute pancreatitis
- does not have such an sudden onset as perforated ulcer
- high serum amylase
 Acute cholecystitis
 Intestinal obstruction – pain more colic like
The simultaneous onset of pain and free air in the abdomen in the absence of trauma
usually means perforated peptic ulcer.
Treatment
Pass a nasogastric tube and empty the stomach to reduce further contamination of the peritoneal
cavity. The patient is kept nil per os. Blood for laboratory studies. Commence with intravenous
antibiotice – Cefazolin. Fluid resuscitation. X-Rays
The simplest surgical treatment is laparotomy with closure by securely pluggin the hole with
omentum sutured in place.
Remember the ulcer still exits and medical treatment for peptic ulcer disease should continue.
Prognosis:
15% of patients with perforated ulcers die.
Mr V.J. is a 51 yr old male. He has a chronic alcohol history. He complains of chronic lower back
pain for which he uses NSAIDS which he gets from his local pharmacy. Over the past week he
complains of pain progressively getting worse and his NSAID use more than what he usually takes.
He presents in casualty with sudden onset severe epigastric pain. He appears distressed and lying
down to minimize any abdominal movement.
On examination his vitals are :
BP = 100/60 Pulse = 110/min T=36.4
General examination shows patient to be slightly anaemic.
Abdominal examination : Severe epigastric tenderness, Rigid boardlike abdomen with rebound
guarding. Minimal bowl sounds.
PR : Faeces
Mrs L.R., is a 52yr female. She is a known patient with peptic ulcer disease. For the past few days
she complains of coffee ground vomiting. She is unsure of the amount. She presents in casualty as
the vomiting has become progressively worse and she is experiencing vague epigastric pain. An
endoscopy is done. During endoscopy, the stomach is completely filled with fresh blood and is
suggestive of active bleeding. Her BP= 90/50 Pulse = 120/min. She appears shocked.
Resussitation is started and she is taken to theatre.