Describe the GI bleeding as a complication.
Definition: the bleeding and/or hemorrhage of a peptic ulcer (either duodenal or gastric)
The most common complication of PUD
Can be a chronic, slow bleed or an overt, rapid, life-threatening hemorrhage
Posterior duodenal ulcers are more likely to bleed than anterior duodenal ulcers.
Gastric ulcers of the lesser curvature may cause bleeding from the left gastric artery.
Duodenal ulcers of the posterior wall may cause bleeding from the gastroduodenal artery.
Hematemesis (coffee-grounds emesis)
Hematochezia (less common; only seen in massive bleeding)
NPO, volume resuscitation, transfusion, endoscopy
Describe the peptic ulcer perforation.
Definition: full-thickness injury and loss of bowel wall integrity that results in leakage of gastrointestinal contents
The second most common complication of PUD
PUD is the most common cause of GI perforation.
Prepyloric gastric ulcers are the most common cause of perforation.
Duodenal ulcers of the anterior wall are more likely to perforate than ulcers of the posterior wall.
Sudden, diffuse abdominal pain and rigidity
Fever, tachycardia, tachypnea, hypotension
Shoulder pain (irritation of the phrenic nerve)
NPO, volume resuscitation, supportive care
Graham patch: surgical repair of a small, (generally < 5 mm) perforated duodenal ulcer using a piece of omentum to close the perforation
Describe the ulcer penetration and fistula formation.
Definition: Penetration of a peptic ulcer through the gastric/duodenal wall into adjacent organs (e.g., pancreas, biliary tree, colon) without leaking of gastric contents into the peritoneal cavity
Etiology: Duodenal ulcers are the most common cause of penetration.
Clinical features: a change in clinical symptoms that are related to the affected neighboring organs
Colon: Gastrocolic or duodenocolic fistulas may manifest with copremesis and postprandial diarrhea.
Liver, spleen, or diaphragm: Penetration may result in visceral abscesses (fever, abdominal tenderness, and sepsis).
Gastroduodenal artery or aorta: Vascular fistulas may result in severe hemorrhage.
Biliary tree: Choledochoduodenal fistulas may manifest with biliary tract obstruction (fever, jaundice, RUQ pain).
Pancreas: increased epigastric pain and peritonitis
Conservative management: indicated in all patients, as most fistulas close spontaneously
Surgical resection: in patients unresponsive to conservative management
Describe the gastric outlet obstruction (GOO).
GOO is more commonly due to malignancy in regions where the treatment of PUD and H. Pylori is prevalent (see “Gastric cancer” for details).
Acute PUD → inflammation and edema
Chronic PUD → scarring and fibrosis
Postprandial, nonbilious vomiting
Progressive gastric dilation
Imaging (e.g., barium swallow, CT abdomen)
EGD (confirmatory test)
Laboratory studies may show hypokalemic hypochloremic metabolic alkalosis.
Symptomatic: nasogastric suction, electrolyte and fluid replacement, and parenteral nutrition
Definitive: surgery or endoscopic dilation