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For further information, see CMDT Part 15-24: Complications of Peptic Ulcer Disease

Key Features

Essentials of Diagnosis

  • Upper gastrointestinal (GI) hemorrhage, with “coffee grounds” emesis, hematemesis, melena, or hematochezia

  • Perforation, with severe pain and peritonitis

  • Penetration, with severe pain and pancreatitis

  • Gastric outlet obstruction, with vomiting

  • Emergent upper endoscopy is usually diagnostic and sometimes therapeutic

General Considerations

UPPER GI HEMORRHAGE

  • ∼50% of upper GI bleeding is due to peptic ulcer disease

  • Bleeding occurs in 10% of patients with an ulcer

  • Bleeding stops spontaneously in about 80% of patients; the remainder have severe bleeding

  • Overall mortality rate for ulcer bleeding is 7%

  • Mortality rate is higher in

    • The elderly

    • Those with comorbid medical problems

    • Those with hospital-associated bleeding, persistent hypotension, or shock

    • Those with bright red blood in the vomitus or nasogastric lavage fluid

    • Those with severe coagulopathy

ULCER PERFORATION

  • Perforations develop in < 5%

  • May be increasing in incidence due to use of nonsteroidal anti-inflammatory drugs and cocaine

ULCER PENETRATION

  • Penetration occurs into contiguous structures such as the pancreas, liver, or biliary tree

GASTRIC OUTLET OBSTRUCTION

  • Occurs in 2% of patients with ulcer disease causing obstruction of pylorus or duodenum by inflammation and scarring

Clinical Findings

Symptoms and Signs

UPPER GI HEMORRHAGE

  • Up to 20% have no antecedent pain

  • Presents with “coffee grounds” emesis, hematemesis, melena, or hematochezia

ULCER PERFORATION

  • May present with sudden, severe abdominal pain

  • Elderly or debilitated patients and those receiving long-term corticosteroid therapy may have minimal initial symptoms; bacterial peritonitis, sepsis, and shock may present later and then patients appear ill, with a rigid, quiet abdomen and rebound tenderness, hypotension

ULCER PENETRATION

  • Pain is severe and constant, may radiate to the back, and is unresponsive to antacids or food

  • Physical examination is nonspecific

GASTRIC OUTLET OBSTRUCTION

  • Causes symptoms of early satiety, vomiting, and weight loss

  • Early symptoms: epigastric fullness or heaviness after meals

  • Later symptoms: after eating, vomiting of partially digested food contents

  • Chronic obstruction: a grossly dilated, atonic stomach, severe weight loss, and malnutrition, dehydration

  • Succussion splash in the epigastrium

Differential Diagnosis

  • Upper GI bleeding

    • Bleeding esophageal varices

    • Mallory-Weiss tear

    • Vascular ectasias

    • Dieulafoy lesion

    • Malignancy

    • Aortoenteric fistula

    • Hepatic or pancreatic lesions bleeding into pancreatobiliary system

  • Severe epigastric pain

    • Esophageal rupture

    • Gastric volvulus

    • Cholecystitis

    • Acute pancreatitis

    • Small bowel obstruction

    • Appendicitis

    • Ureteral colic

    • Splenic rupture

Clinical Findings

Laboratory Tests

UPPER GI HEMORRHAGE

  • Hematocrit may fall as a result of bleeding or expansion of the intravascular ...

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