Peptic Ulcer & its Complications

Prof. Dr. Faisal Ghani SiddiquiFCPS; 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.pylori13C and 14C breath tests

CLO testHistpathology

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 Pyloric Outlet ObstructionObstruction

PerforationPerforation

BleedingBleeding

• Long history of Long history of peptic ulcer peptic ulcer

diseasedisease• VomitingVomiting• Weight lossWeight loss• Dehydration Dehydration

• Succussion splashSuccussion splash• PeristalsisPeristalsis• TetanyTetany

Hypochloraemic alkalosis&

paradoxical alkalosis

Investigations

Laboratory Laboratory investigationsinvestigations

Hypochloraemic alkalosis; Hypochloraemic alkalosis;

hyponatremia; hyponatremia;

hypokalaemiahypokalaemia

Investigations

ImagingPlain 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

Treatment

•Correction of fluid & electrolyte imbalance

Rehydration with isotonic saline and potassium supplements

Treatment

• Medical treatmentGastric lavage and suction (5-7 days)

• Surgical treatmentTruncal vagotomy with gastrojejunostomy

• Endoscopic treatmentBalloon 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 ulcerPerforation of peptic ulcer

Most perforated ulcers are Most perforated ulcers are located anteriorlylocated anteriorlyabsence of protective viscera | major absence of protective viscera | major blood vesselsblood vessels

Pain•PainPain

•DistressedDistressed•Shallow breath Shallow breath

•RigidityRigidity•Absent gut Absent gut

soundssounds•Tympanitic Tympanitic

note over livernote over liver

Investigations

Laboratory investigationsLeucocytosis ; raised serum amylase

High levels of amylase in aspirated fluid

ImagingGas under diaphragm

Escape of contrast material from the lumen

Tretament

• Nasogastric tube

• IV fluids

• Antibiotics

• Graham-Steele patch

Bleeding peptic ulcerBleeding peptic ulcer

Hematemesis & Shock

Hematemesis with shock

• Initial management

• Definitive management

Initial Management

Causes of Upper GI Bleeding

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

InjectionEpinephrine | ethanol

CauteryHeat probe | electorcautry

Nd:YAG laser

Emergency Surgery

Hypotensionon admission

4 units of bloodto achieve circulatory stability

Continuous bleeding Subsequent transfusion requirements

exceed 1 unit every 8 hours