Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 15-24: Complications of Peptic Ulcer Disease + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ Laboratory Tests +++ UPPER GI HEMORRHAGE ++ Hematocrit may fall as a result of bleeding or expansion of the intravascular volume with intravenous fluids Blood urea nitrogen (BUN) may rise from absorption of blood nitrogen from the small intestine and from prerenal azotemia +++ ULCER PERFORATION ++ Leukocytosis Mildly elevated serum amylase +++ ULCER PENETRATION ++ Laboratory tests are nonspecific Elevated serum amylase +++ GASTRIC OUTLET OBSTRUCTION ++ Metabolic alkalosis Hypokalemia +++ Imaging Studies +++ ULCER PERFORATION, PENETRATION ++ Abdominal CT establishes diagnosis and excludes other causes of abdominal pain +++ GASTRIC OUTLET OBSTRUCTION ++ Endoscopy is preferred diagnostic study +++ Diagnostic Procedures +++ UPPER GI HEMORRHAGE ++ Nasogastric lavage demonstrates "coffee grounds" or bright red blood; lavage fluid negative for blood does not exclude active bleeding from a duodenal ulcer Endoscopy should be performed within 12–24 h in most cases It is possible to predict which patients are at a higher risk for rebleeding (see When to Admit) +++ ULCER PENETRATION ++ Endoscopy confirms the ulceration and penetration +++ GASTRIC OUTLET OBSTRUCTION ++ Nasogastric aspiration evacuation of a large amount (> 200 mL) of foul-smelling fluid establishes the diagnosis + Treatment Download Section PDF Listen +++ +++ Medications +++ UPPER GI HEMORRHAGE ++ Antisecretory agents: intravenous or oral proton pump inhibitors, with or without endoscopic therapy, reduce rebleeding, transfusions, and the need for further endoscopic therapy For ulcers documented at endoscopy to have active bleeding, adherent clot, or a visible vessel: After initial successful endoscopic treatment of ulcer hemorrhage, intravenous esomeprazole, pantoprazole, or omeprazole (80 mg bolus injection, followed by 8 mg/h continuous infusion for 72 hours) reduces the rebleeding rate from ~20% to < 10% However, intravenous omeprazole is not available in the United States Instead, administer high-dose oral therapy (omeprazole, 40 mg twice daily) +++ ULCER PERFORATION ++ Initial nonoperative management may be appropriate for selected patients, especially those Who are poor operative candidates Whose onset of symptoms is < 12 h Whose upper GI series or abdominal CT scan with water-soluble contrast medium does not demonstrate leakage Nonoperative management Fluids Nasogastric suction Intravenous proton pump inhibitor infusion (esomeprazole or pantoprazole 80 mg bolus, then 8 mg/h) Broad-spectrum antibiotics Up to 40% of ulcer perforations seal spontaneously For all others, emergency laparotomy or laparoscopy Postoperative treatment of Helicobacter pylori +++ ULCER PENETRATION ++ Patients should be given intravenous proton pump inhibitors and monitored closely +++ GASTRIC OUTLET OBSTRUCTION ++ Intravenous isotonic saline and KCl Intravenous esomeprazole or pantoprazole (80 mg bolus; 8 mg/h) continuous infusion Nasogastric decompression of the stomach +++ Surgery +++ UPPER GI HEMORRHAGE ++ Percutaneous radiologic embolization or surgery should be considered for patients in whom endoscopic therapy is unsuccessful The availability of newer, larger over-the-scope clips ("bear claw") has further reduced the risk of persistent bleeding requiring other more aggressive interventions +++ ULCER PERFORATION ++ Laparoscopic closure of perforation can be performed in many centers, significantly reducing operative morbidity compared with open laparotomy +++ GASTRIC OUTLET OBSTRUCTION ++ Vagotomy and either pyloroplasty or antrectomy +++ Therapeutic Procedures +++ UPPER GI HEMORRHAGE ++ Percutaneous arterial embolization is an alternative to surgery for patients in whom endoscopic therapy has failed +++ GASTRIC OUTLET OBSTRUCTION ++ Upper endoscopy with dilation by hydrostatic balloons achieves success in two-thirds of patients For those who do not respond, consider surgery + Outcome Download Section PDF Listen +++ +++ Prognosis +++ UPPER GI HEMORRHAGE ++ Surgical mortality for emergency ulcer bleeding is < 6% Prognosis is poorer for patients over age 60 years, those with serious underlying medical illnesses or chronic kidney disease, and those who require more than 10 units of blood transfusion +++ ULCER PERFORATION ++ Surgical mortality for emergency ulcer perforation is 5% +++ Prevention +++ UPPER GI HEMORRHAGE ++ Long-term prevention of rebleeding H pylori eradication In those with non–H pylori-associated ulcers, long-term therapy with H2-antagonist at bedtime or once daily dose of a proton pump inhibitor +++ When to Admit +++ UPPER GI HEMORRHAGE ++ Nonbleeding ulcers < 2 cm in size with a base that is clean have a < 5% chance of rebleeding Young (under age 60 years), otherwise healthy patients who are stable hemodynamically may be discharged from the hospital or emergency department after endoscopy Others may be observed for 24 h Ulcers that have only a flat red or black spot have a < 10% chance of significant rebleeding; hospitalization for 24–72 h usually recommended After endoscopic treatment, patients should remain hospitalized for at least 72 hours, when the risk of rebleeding falls to below 3%; rebleeding occurs in 10–20% + References Download Section PDF Listen +++ + +Abougergi MS et al. Thirty-day readmission among patients with non-variceal upper gastrointestinal hemorrhage and effects on outcomes. Gastroenterology. 2018 Jul;155(1):38–46. [PubMed: 29601829] + +Brandler J et al. Efficacy of over-the-scope clips in management of high-risk gastrointestinal bleeding. Clin Gastroenterol Hepatol. 2018 May;16(5):690–6. [PubMed: 28756055] + +Kochhar R et al. Etiological spectrum and response to endoscopic balloon dilation in patients with benign gastric outlet obstruction. Gastrointest Endosc. 2018 Dec;88(6):899–908. [PubMed: 30017869] + +Schmidt A et al. Over-the-scope clips are more effective than standard endoscopic therapy for patients with recurrent bleeding of peptic ulcers. Gastroenterology. 2018 Sep;155(3):674–86.e6. [PubMed: 29803838] + +Shimomura A et al. New predictive model for acute gastrointestinal bleeding in patients taking oral anticoagulants: a cohort study. J Gastroenterol Hepatol. 2018 Jan;33(1):164–71. [PubMed: 28544091] + +Stanley AJ et al. Management of acute upper gastrointestinal bleeding. BMJ. 2019 Mar 25;364:l536. [PubMed: 30910853]