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1
Peptic ulcer
complications
Mohammed Emad Witwit Ali Salim Rasheed
2
1. Bleeding . 2. Perforation . 3. Gastric outlet obstruction .
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1 - Bleeding peptic ulcers
About 20 % of patients (especially elderly) with ulcer disease would suffer from bleeding episodes .
It is commonly associated with the ingestion of NSAIDs.
The most common site of bleeding from a peptic ulcer is the duodenum .
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Causes of upper GI bleeding
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Pathology
Mild : Bleeding from the granulation tissue.
Moderate : Due to erosion of small vessels.
Severe : Due to erosion of a large vessel as gastroduodenal .
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Clinical features symptoms 1. Hematemesis : Coffee ground blood . Fresh blood in severe cases .2. Melena in mild cases.3. Hematochezia in severe cases.
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Clinical features signs General 1. Anemia in case of repeated minor bleeding. 2. Hypovolemic shock (sweating, pallor, weak rapid pulse) in severe bleeding .
Local Epigastric tenderness
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Investigations (Urgent investigations after resuscitation ) 1. OGD ( within 24 hrs ) For diagnosis and exclusion of other causes of
hematemesis.
2. Selective mesenteric angioaphy lf endoscope fails to localize the source.
3. Laboratory : CBC , Electrolytes , KFTs.
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Investigations OGD SMA
???
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Treatment Initial assessment ( ABC ) Resuscitation ( IV fluids ,
blood , O2 , etc ….) Monitoring ( vital signs ,UOP )
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Treatment Medical PPI , H2-antagonist . Limited efficacy . Prevent rebleeding after
endoscopy .
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Treatment Therapeutic endoscopy Achieve haemostasis in
~70 - 90 % of cases . Combination of adrenaline
injection with heater probe +/or clips.
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Treatment Surgery
What are the indications of surgery ?
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2- Perforated peptic ulcer Perforation occurs in as many as 10%
of patients with PUD . Most common in elderly female
patients ( use of NSAIDs ) . The most common site of perforation
is the anterior aspect of the duodenum. However, the anterior or incisural gastric ulcer may perforate .
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Pathology Stage ( I )
Sudden Rapture of ulcer base
Gastric or
duodenal content
in peritoneal cavity
Chemical peritonitis
Stage of Chemical peritonitis
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Clinical features Stage ( I )
Symptoms ( usually short and the patient not seen in it ) . Sudden severe epigastric pain which become generalized . Signs General Pallor, sweating, subnormal temperature, rapid weak pulse.
Local Board like rigidity, guarding, epigastric tenderness . Decreased liver dullness (air under the diaphragm). Shifting dullness (fluid in the peritoneal cavity). Decresed intestinal sounds (paralytic ileus occurs late ).
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Pathology Stage ( II )
Reaction of
peritoneum
Production of large amount of alkaline fluid and bringing
antibodies.
Stage of illusion
3-6 hours after perforation
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Clinical features Stage ( II )
Symptoms Pain decreases. Signs General The patient has more tachycardia.Local Like the previous stage with less rigidity
and increased shifting dullness.
3-6 hours after perforation
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Pathology Stage ( III)
Bacteria (flourish as a
result of HCI and loss
of its antiseptic
effect)
Pus formatio
n Septic
peritonitis
Stage of Septic peritonitis
6-12 hours after perforation
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Clinical features Stage ( III )
Symptoms Pain increases with fever, anorexia,
headache, malaise, repeated vomiting and distension .
Signs General Fever, toxemia, More tachycardia , deterioration of
the general condition of the patient,Local Generalized rigidity, tenderness, progressive
abdominal distension.
6- 12 hours after perforation
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Investigations 1. Upright Plane CXR / AXR : air under diaphragm
in 80 % of cases .
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Investigations 2. U/S: shows fluid in the peritoneum.3. Gastroqrafin meal: ensure escape of the dye
through the perforation (especially if no air under diaphragm is seen by X-ray ).
4. CT imaging : is more accurate and diagnostic . Can we
use barium ??
?
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Barium meal Leakage of barium into the
peritoneal cavity may lead to endotoxic shock which is often fatal.
As a result, the use of barium as a contrast agent is contraindicated when there is a suspicion or possibility of compromise of GI wall integrity.
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Investigations 5. Lab. CBC: PNL in septic peritonitis. KFTs : prerenal failure. Electrolytes : disturbances . Serum amylase : moderate increase .
( highly increased in acute pancreatitis )
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Treatment 1. Resuscitation .2. Analgesia.3. Surgery : Laparoscopy. Laparotomy . 4. Thorough peritoneal lavage.5. Systemic antibiotics 6. Following operation : Nasogastric suction . Gastric antisecretory agents .
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3- Gastric outlet obstruction
The two common causes of gastric outlet obstruction are :
1. Gastric cancer .2. Pyloric stenosis secondary to peptic
ulceration. Nowadays , gastric outlet obstruction
should be considered malignant until proven otherwise, at least in the West.
It occurs in ~ 5% of patients with PUD . It is usually due to duodenal or prepyloric
ulcer disease .
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Pathology Chronic
inflammation
Repair and scarring
Fibrosis and
stenosis
Hypertrophic Stomach dilatation
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Clinical features symptoms 1. Vomiting
Projectile, food content , not bile stained , foul odour from fermentation , characteristically in the evening .
2. Pain History of periodic pain, which is lost at presentation becoming continuous with no relation to food.
3. Progressive weigh loss & constipation.
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Clinical features signs General Dehydration . Weight loss .
Local Inspection : Epigastric fullness . Outlines of enlarged stomach may be seen . Auscultation:Succussion splash (the stomach full with water & solid) .
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Metabolic effectsVomiting of
HCL
Hypochloremic
alkalosis +dehydration
Renal dysfunction
( HCo3- ) +Na loss
Hyponatraemia +profound
dehydration
Na retention+
K & H excretion
Paradoxically acidic urine +
hypokalaemia
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Metabolic effectsVomiting of
HCL
Hypochloremic
alkalosis
Low circulating ionised Ca
Tetany
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Investigations Lab. (assess general condition of the
patient) CBC : anemia,
hemoconcentration. KFTs : prerenal failure. Serum electrolytes : decreased (
Na, K & Cl ) & paradoxical aciduria.
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Investigations Barium meal :a. Dilated stomach (often reaching the pelvis) .b. Soup Dish appearances or inverted hat appearance .
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Investigations OGD Main value: to exclude malignancy + biopsy Dilated stomach with atrophic gastritis &
failure of passage through pylorus.
???
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Treatment Conservative measures IV isotonic saline with potassium supplementation. Tx of anemia . large nasogastric / orogastric tube and lavage of
the stomach . Medical gastric antisecretory agent, initially given IV to
ensure absorption.Surgical Truncal vagotomy & gastrojejunostomy is the
standard treatment . ln the elderly or unfit patients: Gastrojejunostomy
alone or endoscopic balloon dilatation
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Treatment
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Thanks for
listening