Complications of Peptic Ulcer Disease

Hemorrhage is the leading cause of death associated with peptic ulcer disease. Lifetime risk of bleeding for those without treatment is approximately 35%. Spontaneous, and often temporary, cessation of bleeding occurs in about 70% of patients. EGD is appropriate in the acute setting. This is successful in identifying the cause of bleeding in the majority of cases. Sometimes bleeding can be controlled with thermal coagulation via a heater probe. Stigmata of recent bleeding include the presence of an adherent clot or the presence of a visible vessel in the ulcer base. In general, approximately 30% of those with stigmata of recent bleeding will rebleed and a large proportion of these will require emergent operation. Operative strategy is that of duodenotomy with oversewing of the bleeder combined with a definitive acid-reducing procedure. Operative intervention is necessary when there is ongoing massive hemorrhage leading to shock or cardiovascular instability, prolonged blood loss requiring transfusion, or recurrent bleeding despite medical or endoscopic therapy.

Perforation. The lifetime risk of perforation in untreated peptic ulcer disease is approximately 10%. Perforation is unusual if ulcer healing has been accomplished with medical therapy. Clinically, patients demonstrate sudden onset of severe diffuse abdominal pain, which quickly reaches peak intensity and remains constant. Free air is often noted on plain, upright chest X-ray. However, free air may not be seen in as many as 20% of cases. The site of perforation is closed with an omental patch (Graham patch) and irrigation of the peritoneal cavity. Simple omental patching is associated with an 80% chance of recurrent ulceration and a 10% rate of repeat perforation. This is not ideal and often definitive antiulcer therapy is necessary eventually. The timing of a definitive procedure is dictated by the physiologic status of the patient and is not performed if the patient has preoperative shock, life-threatening coexistent medical illness, or if there is a significant delay in diagnosis. In these situations, an omental patch and peritoneal wash-out is performed and the patient is brought back to the operating room at another time when he or she has had an opportunity to recover.

Obstruction can occur acutely as a result of edema and inflammation or chronically as a result of scarring. Obstruction is associated with ulcers of the pyloric channel or bulb of the duodenum. Acute obstruction can, in general, be treated conservatively with rehydration, correction of electrolyte abnormalities, and nasogastric tube decompression. Chronic obstruction occurs after repeated ulceration followed by healing. With untreated ulcer disease the lifetime risk of obstruction is approximately 10%. EGD is indicated to confirm the diagnosis and to exclude malignancy. Approximately 85% of cases of chronic obstruction are amenable to hydrostatic balloon dilatation. About 80% of these patients will experience immediate relief. About 40% will still be unobstructed at 3 months. Repeated dilation is sometimes necessary. Operative management consists of relief of the obstruction with additional definitive antiulcer surgery.

References

1. Nyhus LM, Baker RJ, Fischer JE. Mastery of Surgery. 3rd ed. Boston: Little, Brown and Co., 1997.

2. Greenfield LJ, Mulholland M, Oldham KT et al. Surgery Scientific Principals and Practice. 2nd ed. Philadelphia: Lippincott-Raven, 1997.

3. Sabiston DC, Lyerly HK. Textbook of Surgery. 15th ed. Philadelphia: WB. Saunders Co., 1997.

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