COMPLICATIONS

GASTRO-DUODENAL PEPTIC
ULCERS
COMPLICATIONS OF
GASTRODUODENAL
ULCERS
 PERFORATION- PERITONITIS

 BLEEDING- ANEMIA

 STENOSIS- GASTRIC OUTLET

OBSTRUCTION
PERFORATION
 Perforation- ulcer rupture into the peritoneal
cavity with spillage of GD contents
 Penetration- erosion into a solid organ: liver
or pancreas

 Perforation of a chronic ulcer- increasing

dyspepsia prior to the perforation
 Perforation of an acute ulcer- no premonitory
symptoms
PERFORATION
 Risk factors:

- drugs: steroids, NSAID

- situations of stress: burns,

multiple injuries, sepsis,
chemotherapy, radiotherapy
CLINICAL FEATURES OF
PERFORATED ULCER
 The moment of perforation is identified by
the patient as an excruciating epigastric
pain
 The intensity of sy. depend on the degree
of peritoneal soiling and whether the
perforation becomes sealed
 The spillage goes along the right paracolic
gutter- pain from epigastrium shifts to
RIF , may mimick acute appendicitis
 Vomiting in delayed cases- ileus
PHYSICAL SIGNS OF
PERFORATED PEPTIC
ULCER
 Depend upon the degree and rate of soiling within
peritoneal cavity
 Tenderness with guarding may vary from being
localized to the upper abdo- to being generalized
 Typical signs for generalized peritonitis due to
perforated ulcer are: rigid abdomen, no
respiratory movements, silent abdomen,
 As later features: progressive distension,
hypotension, tachycardia, cold periphery,
decreased urinary output
PHYSICAL SIGNS OF
PERFORATED ULCER

Any deep inspiration, coughing-

increased pain

The patient lies still in the bed, any

movement exacerbating the pain
INVESTIGATIONS IN
PERFORATED ULCER
 Plain abdominal X Ray in erect position
– Pneumoperitoneum- air visible in the right
subdiaphragmatic space
– Gas/fluid levels in advanced cases
– If pneumoperitoneum is not seen, think to
a sealed perforation or acute pancreatitis
– Do not count on amylase, may be
increased in any acute abdomen
 USS of the abdomen- fluid within
peritoneal cavity
Plain rx. of the RUQ
shows a tiny streak of air
under the diaphragm
Pneumoperitoneum
in perforated duodenal
ulcer
Pneumoperitoneum
Pneumoperitoneum
perforated duodenal
ulcer
 Upright CXR shows
a large collection of air under
both the diaphragms
MANAGEMENT OF
PERFORATED ULCER
 Correction of hypovolemia, electrolyte
disturbances, low urinary output
 Severe cases- monitoring CVP, hourly UO
 Colloids, cristaloids – effective
 Naso-gastric aspiration
 Antisecretory drugs
 Planning for operation
OPERATIVE VS
CONSERVATIVE
TREATMENT
 Sealed perforated ulcer- Taylor’s
method
 Taylor’s method: NG aspiration, iv
fluids, antibiotics, antisecretory drugs
 Indication: young patients with short
history of perforation of acute ulcer
and with minimum of pneumo. and
fluid under liver
 Close clinical observation
OPERATIVE
VS.CONSERVATIVE
TREATMENT
 If the patient is getting worse within 6-12
hours, the operation is required
 Operative procedure- simple closure of the
perforation, omentoplasty, peritoneal lavage
and multiple drainages
 Peritoneal fluid sent for bacteriological
culture
 Empiric antibiotherapy- broad spectrum
antibiotics
Perforated peptic duodenal ulcer. The
ulcer was found to be a typically punched
out peptic ulcer (arrows) with a diameter
of 6 mm
Perforated peptic ulcer
Perforated duodenal ulcer

A 49-year-old man was admitted with

sudden onset of severe pain in the
epigastrium. Recently, he had taken
a course of a non-steroidal anti-
inflammatory drug (NSAID).
 This had caused indigestion, which
had worsened in the two days prior
to his presentation.
 On examination, the patient was ill
and had a rigid abdomen.
 The operative photograph shows a
perforated duodenal ulcer. This was
oversewn.
Closure of perforated duodenal ulcer &
omental patching.
 
PYLORIC STENOSIS
 Chronic scarring from ulceration in the
pyloric region- gastric outlet obstruction or
pyloric stenosis
 Occurs in a patient with longstanding ulcer
disease ignored, neglected or bad treated
 Be aware that pyloric stenosis might be due
to a malignant antral tumor
PYLORIC STENOSIS
CLINICAL FEATURES

 Pain in the upper abdomen, relieved by the

vomiting
 Vomiting is efortless, projectile with partially
digested food and bile is absent
 Naso-gastric aspiration reveals only gastric
fluid with thick partially digested food
 For gastric decompresion- gastric lavage and
aspiration
PYLORIC STENOSIS
CLINICAL FEATURES

 Underweight patient, dehydrated

with persistent skin fold, anemic
 Gastric stasis revealed by succusion
splash on percusion
 Visible peristalsis, passing across
the upper abdomen from left to
right
PYLORIC STENOSIS
METABOLIC FEATURES
 Prolonged vomiting- electrolyte
disturbances and renal failure
 Hypochloremic alkalosis due to
hydrogen and chloride ions losses
 At a later stage- renal function disturbed
 To compensate metabolic alkalosis, the
kidneys excret bicarbonates at the
expense of losing sodium
PYLORIC STENOSIS
METABOLIC FEATURES
 The patient becomes progressively
more dehydrated and hyponatremic
 In an attempt to conserve circulatory
volume, sodium is retained by the
kidneys and hydrogen plus potassium
is excreted preferentially
 Hence alkalosis becomes more severe
and hypokalemia more marked
 Hypocalcemia- disturbance of
consciousness and tetany
PYLORIC STENOSIS
METABOLIC FEATURES
 These electrolyte disturbances in patients
with severe pyloric stenosis are termed
DARROW’S SYNDROME
 Lab.findings are:- base excess>
- high serum urea, -
hyponatremia, - hypopotasemia,
- hypocalcemia
X-ray after a barium meal will show
delayed emptying of the stomach, and
often the contour of the stomach will be
seen deep in the pelvis
Draining the stomach with a naso-gastric
tube (NG tube) will produce thick muddy
content (undigested food).
Endoscopic view
of normal duodenum
Endoscopic view of
pyloric stenosis
PYLORIC STENOSIS
MANAGEMENT
 The priority is correction of fluid and
electrolytes abnormalities
 Rehydration- saline infusion with K
supplements
 Provision of adequate sodium allows
excretion of alkaline urine so that the
alkalosis becomes correctable
 Clinical improvement: increased UO, a fall to
normal in blood urea and normal electrolytes
 Gastric lavage until fluid is clear
PYLORIC STENOSIS
SURGICAL TREATMENT
 Partial gastric resection with gastro-
duodenal anastomosis (PEAN-
BILLROTH I)

 Partial gastric resection with gastro-

jejunal anastomosis (BILLROTH II)
 For old, frail patients- by pass
operation like gastro-jejunostomy
BLEEDING PEPTIC
ULCER
 Acute bleeding is the commonest
complication
 It carries the highest mortality
 Bleeding results from erosion of the
ulcer into a blood vessel
 The most common sign is melena +/-
hematemesis
 One of three pts. have no history of ulcer
 In major bleeding- GI transit so rapid-
stool is bright red
BLEEDING PEPTIC
ULCER
Severity of acute bleeding assessed by:
BP, PR, Hb., Ht. if sufficient time passed
for compensatory hemodilution

Systolic BP< 100, PR>100 with the

patient supine, suggest major blood loss
(>1 l.)
BLEEDING PEPTIC
ULCER

 Adverse clinical factors on outcome:

– Severe, continuing bleeding
– Early rebleeding within 3-5 days of initial
stabilization
– Age greater than 60
– Associated diseases: cardio-vascular and
liver diseases
BLEEDING PEPTIC
ULCER
 The differential diagnosis includes:
– Rupture of esophago-gastric varices
– Hemorrhagic gastritis
– Mallory-Weiss laceration
– Ulcerated benign and malignant gastric
tumors
– Vascular anomalies (angiodysplasia)
– Aorto-enteric fistula in pts. with a
prosthetic aortic graft
BLEEDING PEPTIC ULCER-ENDOSCOPY

Forrest’s classification of bleeding activity

Forrest Ia- active bleeding- arterial spurting

Forrest Ib- active bleeding- oozing
Forrest II-bleeding ceased- clot lying on ulcer
or visible vessel stump
Forrest III-bleeding ceased- no signs of recent
bleeding
MANAGEMENT

 Three phases in the management

of the bleeding:
– Resuscitation
– Diagnosis
– Definitive treatment
Active bleeding gastric
ulcer
Endoscopic view
of activ gastric
bleeding
Endoscopic view
of erosive duodenitis
Active bleeding-
duodenal ulcer
Bleeding duodenal
ulcer
Bleeding erosive
gastritis
RESUSCITATION

 Hemorrhagic shock- ICU

 Do not sedate patient for endoscopy
 Rapid transfusion
 BP, PR, CVP, UO monitoring
 Confusion and restlessness demand
attention for oxygenation
DIAGNOSIS

 History- dyspepsia, liver disease,

intake of alcohol, aspirin, NSAID
 Endoscopic examination: the sourse
and the gravity of bleeding
 Endoscopic criteria for early surgery:
– Arterial spurter
– Visible vessel in base of ulcer
– Adherent clot
MANAGEMENT

 Bed rest
 Naso-gastric lavage with cold saline
 IV antisecretory drugs (H proton pump
inhibitors, H2 receptor antagonists)
 Hemostatic drugs
 Endoscopic adrenaline injection
INDICATION FOR
SURGERY

 Continuing bleeding
 Re-bleeding

 The sourse of bleeding

 Fitness of the patient

Check coagulation parameters

SURGERY IN BLEEDING
ULCER

 Partial gastrectomy but morbidity

and mortality high
 Underrunning of the bleeding
ulcer, followed by the treatment
with antiulcer drugs
 THE FAILURES
OF GASTRIC SURGERY

 Recurrent Ulceration
– Incomplete vagotomy
– Inadequate resection
– Retained gastric antrum
– Zollinger-Ellison syndrome
– Hypercalcemia