Peptic Ulcer Disease, Complications

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 ...