LECTURE NR.

2
Complications of Peptic Ulcer Disease
I. HEMORRHAGE
The most common cause of upper GI hemorrhage is peptic ulcer. Approximately 20% of
patients with peptic ulcer will bleed. It is likely that with !. pylori eradication and proton pump
inhibitor therapy the incidence of bleeding will decrease. To date howe"er no con"incing data
support this contention.
#ot all bleeding from ulcer is acute or massi"e. Indeed some patients present with iron$
deficiency anemia from occult blood loss.%hen acute hemorrhage occurs patients present with
hematemesis and&or melena. Infre'uently massi"e bleeding from a duodenal ulcer presents as
lower gastrointestinal hemorrhage without hematemesis. If the bleeding is rapid the blood
issuing rectally may be red rather than black.
(ome )0% of patients admitted with upper GI hemorrhage from an ulcer stop bleeding
spontaneously within * hours of admission to a hospital. +f the remainder about half are
successfully treated endoscopically with in,ection therapy or with heater$probe or laser
coagulation. The rare patient has such an exsanguinating hemorrhage that immediate operation
and control of bleeding is necessary before "olume resuscitation can be ade'uately accomplished.
Resscitation
Initial resuscitation should be accomplished 'uickly. If there is any 'uestion about the
patient-s le"el of consciousness the airway must be protected with endotracheal intubation. In
most circumstances such drastic action is unnecessary. In the initial sur"ey the patient should
also be carefully examined for any stigmata of chronic li"er disease and oral mucosal
hemangiomas.
.uickly two large$bore intra"enous catheters should be inserted as well as a nasogastric
tube and a /oley catheter. A blood sample is obtained for complete blood count 01213 blood
urea nitrogen 024#3 electrolyte le"els and for a crossmatch of 5 to 6 units. The speed and type
of fluid resuscitation depends on the hemodynamic status of the patient. 7ost patients are
moderately hypotensi"e and the initial resuscitation can be successfully accomplished with
crystalloids 0saline or lactated 8inger-s solution3.%hen hypotension is extreme howe"er
immediate blood transfusion should be gi"en using either group specific 8h$negati"e or +$
negati"e blood. (ome se"erely hypotensi"e patients can be successfully resuscitated 'uickly with
colloids 0plasma albumin or !espan3 until fully crossmatched blood is a"ailable. %hen the
patient is hemodynamically compromised central "enous pressure monitoring or preferably
pulmonary artery pressure monitoring is necessary. The goal of resuscitation is to rapidly restore
circulating "olume and ade'uate urine output 09:0 m;&h3 and to establish monitoring of "ital
signs urine output and central "enous or pulmonary arterial wedge pressure measurements.
Aspiration should be pre"ented by insertion of either a large nasogastric tube or an <wald
tube. The stomach is e"acuated and la"aged with water or saline.
=
%hen large amounts of blood are transfused it is necessary to monitor coagulation factors
0e.g. platelets prothrombin time3 and "itamin > administration may be necessary.
Dia!nosis
<arly detection of the source of bleeding is a key step in management. The best way to
identify the source is with upper GI endoscopy.
The ideal time to perform this examination is
0=3 when the patient is hemodynamically stable and
023 when the nasogastric aspirate following irrigation is pink.
<ndoscopy identifies the site of bleeding in about )0% of patients with upper GI bleeding.
The esophagus is easily ruled out as the site of bleeding. ;esions in the stomach may be obscured
by blood clot but e"en then with persistence and expertise the entire stomach can be examined
satisfactorily.
2leeding from duodenal ulcer may be e"idenced by the presence of
0=3acti"e bleeding from a posterior ulcer crater?
023 a "isible bleeding "essel?
0@3 a "isible nonbleeding "essel with clot?or
053 an adherent fresh clot at ulcer base.
In 2 and @ the "isible "essel is the gastroduodenal artery or one of its ma,or branches
Angiography has a role but not a fre'uent one in the early detection of the site of
hemorrhage. 2leeding has to occur at the rate of 2m;&min or more for the test to succeed. It is
most useful when endoscopy has failed to identify the cause of bleeding. +n occasion when
bleeding is massi"e and a nonsurgical treatment approach is chosen angiography can be useful
not only in identifying the bleeding "essel but also in controlling bleeding by selecti"e
emboliAation.
Control of "lee#in!
As indicated earlier )0% of patients stop bleeding spontaneously within * hours of
admission to a hospital and can be managed conser"ati"ely.
If bleeding persists control with the aid of endoscopy can be achie"ed with coagulation
0e.g. heater probe laser3 endoscopic sclerotherapy or by endoscopic in,ection of alcohol or
adrenaline.
$r!ical In#ications
The following indications for surgery for the patient with a bleeding ulcer are generally acceptedB
=. <xsanguinating hemorrhage when 'uick resuscitation is difficult.
2. /ailure of control of hemorrhage with endoscopicbased methods.
@. 8ebleeding that begins again while the patient is under treatment in a hospital after initial
cessation. 0This circumstance nearly always suggests bleeding from a gastroduodenal artery.3
<"en here it is reasonable to attempt endoscopic control before surgery if the patient is stable
and&or at high risk for surgery.
5. ;oss of 6 units of blood or more where endoscopic therapy is una"ailable or cannot be
performed.
2
The principles of surgery in a bleeding peptic ulcer are to control bleeding and perform a
definiti"e ulcer operation. Creferred options are a"ailable when the site of bleeding can be
identified as either a duodenal or a gastric ulcer. %hen the site of bleeding is uncertain a distal
gastrotomy is first performed so that it can be extended into the duodenum if necessary.
$r!er% for "lee#in! Do#enal Ulcer
If a duodenal ulcer is identified as the cause of bleeding the two surgical options are
0=3 truncal "agotomy pyloroplasty and suture control of bleeding or
023 duodenotomy suture control of bleeding and CGD.
In the elderly or unstable patient the first option is more appropriate? the author prefers the
second option in the young and stable patient.
The techni'ue of controlling a bleeding duodenal ulcer with sutures $ nonabsorbable 00 sutures
on a stout needle are used. Interrupted sutures are placed at the proximal and distal parts of the
ulcer and tied. This may control all or most of the bleeding. Then a 4$stitch is used to ligate
branches of the gastroduodenal artery. Additional sutures including figure$* sutures may be
needed to arrest the bleeding completely. If these techni'ues fail to completely control the
bleeding the gastroduodenal artery must be dissected outside the duodenum as it branches off the
hepatic artery and ligated in continuity using 0$silk suture.
In se"ere chronic duodenal ulcer disease with ad"anced scarring and foreshortening of the
first part of the duodenum the application of sutures to control bleeding from the ulcer bed poses
a potential risk to the common bile duct. If the risk is considered high it is prudent to perform
choledochotomy and lea"e a red rubber catheter in the 12E until after the hemostatic sutures are
tied. At this point the surgeon can ascertain whether the catheter is freely mo"able indicating
that no ligation of the duct has occurred. The choledochotomy is then closed o"er a T$tube.
$r!er% for "lee#in! Gastric Ulcer
Although a bleeding gastric ulcer can be treated by underrunning the bleeding point and
performing truncal "agotomy and pyloroplasty the preferred surgical approach is to perform a
distal gastrectomy that remo"es the ulcer.
%hen the ulcer is higher up on the lesser cur"ature of the stomach a slee"e resection of
the lesser cur"ature may be performed encompassing the ulcer.%hen the ulcer is "ery high and
near the gastroesophageal ,unction the 7adlener procedure may be used. This procedure which
has been successfully utiliAed in the past in"ol"es underrunning with sutures to control bleeding
a four$'uadrant biopsy to rule out carcinoma and a distal gastrectomy to treat the ulcer diathesis.
If the surgeon can ascertain intraoperati"ely that the ulcer is !. pyloriFassociated the
gastrectomy may be a"oided and eradication therapy administered postoperati"ely. At the present
time because no data are a"ailable to support this theoretical approach it is not recommended.
@
Mana!ement of peptic lcer &emorr&a!e
Essentials: Management of Peptic
Ulcer Hemorrha
geManagement
(uture control of bleeding ulcer re'uires the
ligature of se"eral branches of the gastroduodenal artery in
the base of the ulcer. +ne techni'ue uses the 4$shaped suture
as shown in the diagram.
5
II. PER'ORATION
Cerforation still occurs commonly and continues to be a lethal complication of peptic
ulcer disease particularly in elderly patients or when treatment is delayed. Its incidence in elderly
patients is rising because of increased use of #(AIEs.
Cerforated duodenal ulcer is ten times more common than perforated gastric ulcer.
In all abdominal crises as in multiple trauma it is helpful to use a consistent approach that
includes resuscitation diagnosis and treatment.
Resscitation( Initial an# $econ#ar% Assessments
The patient is in ob"ious pain and is anxious. Dery 'uickly the airway and "ital signs are
assessed. The breathing is shallow and rapid as diaphragmatic mo"ement is restricted but airway
is not usually a problem. A mild tachycardia is present but during the early phases of perforation
hypotension should not be present. If hypotension is present other diagnoses should be
suspected. These include ruptured abdominal aortic aneurysm se"ere acute pancreatitis and
mesenteric "ascular accident. The initial sur"ey also re"eals the presence of an acute abdomen or
peritonitis with board$like abdominal rigidity tenderness and rebound tenderness and hypoacti"e
or absent bowel sounds. The patient lies perfectly still often in the fetal position.
+nce the initial examination is completed 0it should take no more than = or 2 minutes3
resuscitation is started with institution of intra"enous fluid administration and insertion of a
nasogastric tube to decompress the stomach and pre"ent aspiration.
(econdary assessment should include obtaining a full history and performing a thorough
physical examination. A history of pre"iously diagnosed peptic ulcer or peptic ulcerFtype
symptoms may or may not be present. /lorid presentation of an acute abdomen may be absent in
a number of patients with special circumstances. These includeB
=. the "ery old or "ery young patient?
2. any patient who is recei"ing high$dose steroid therapy which blunts the peritoneal response?
@. the paraplegic patient in whom the only symptom may be tip of shoulder pain?
5. the comatose patient in whom systemic manifestation of sepsis is often the first clue? and
:. the patient reco"ering from an abdominal operation where the diagnosis is often delayed as
signs and symptoms are assigned to causes related to the recent operation.
.
Dia!nosis
A patient-s diagnosis is often established with his or her medical history and the classic
findings from the physical examination. The patient may ha"e a slight leukocytosis with some
shift to the left and a normal urinalysis which often suffice in the typical case. +ften howe"er
plain abdominal "iews 0supine upright and right decubitus3 and a chest x$ray are also obtained.
/ree gas in the peritoneal ca"ity is seen in about G:% of patients
%hen perforation is suspected but no free air is seen in the peritoneal ca"ity a
Gastrografin swallow may be useful. <ndoscopy howe"er should be a"oided.
%hen the presentation is not as clear$cut as described abo"e other conditions must be
included in the differential diagnosis particularly acute pancreatitis acute cholecystitis acute
:
appendicitis and e"en acute myocardial infarction. If the serum amylase le"el is ele"ated because
of a perforated peptic ulcer the ele"ation is usually lower than three times the normal le"el.
;eukocytosis tends to be greater in acute pancreatitis.
An abdominal ultrasound when indicated is useful in ruling out acute cholecystitis. An
electrocardiogram and serum enAymes may be necessary to exclude the diagnosis of acute
myocardial infarction.
+nce it is decided that an operation will be performed analgesia and perioperati"e broad$
spectrum antibiotics should be administered.
$r!ical Mana!ement
+perati"e closure of the perforation is the definiti"e treatment. This operation can be done
laparoscopically or through a limited epigastric incision depending on the surgeon-s experience.
A classic approach to closing a perforated duodenal ulcer is the
Graham patch techni'ue. Alternati"ely the ulcer can be closed primarily and an omental patch
applied o"er the suture line.
A secondary approach is to perform an additional ulcer$reducing procedure. (e"eral
prospecti"e randomiAed clinical trials ha"e documented that the addition of proximal gastric
"agotomy to closure of perforation does not increase the mortality or morbidity of surgical
therapy but reduces postoperati"e ulcer recurrence from 50% to :0% to approximately *%.
The following conditions must be confirmed before CGD is added to the closure procedure.
=. The perforation must be less than 25 hours old?
2. The patient must be hemodynamically stable and free of any serious cardiac pulmonary or
renal disease?
@. There must be e"idence of ulcer chronicity in either the history or the operati"e findings of
scarring and distortion of the duodenal bulb.
It must be mentioned howe"er that the studies demonstrating the usefulness of CGD were
done before the recognition of H. pylori as a cause of ulcer and the de"elopment of effecti"e
eradication therapy to pre"ent recurrence. Crospecti"e randomiAed studies are needed to
determine whether CGD is necessary in the era of H. pylori eradication.
Dela%e# Perforation
A patient with a perforation of 5* hours duration or longer may be treated conser"ati"ely
with nasogastric suction intra"enous antibiotics and parenteral nutrition as long as peritonitis is
absent and Gastrografin swallow shows that the perforation is sealed.
If a conser"ati"e management approach is decided upon careful follow$up is necessary to
detect early de"elopment of any abdominal abscess. If an abdominal abscess does de"elop
diagnosis and treatment by percutaneous catheter can be accomplished with the aid of an
abdominal 1T scan.
Nonsr!ical Mana!ement of Perforation
/rom time to time published clinical studies claim that nonsurgical management is
effecti"e. %hen carefully scrutiniAed howe"er these studies show flaws that make it difficult to
accept their recommendations. /or example at the 4ni"ersity of (outhern 1alifornia the
Gastrografin swallow test has been used to determine whether the perforation is sealed or not. If
the perforation is sealed and peritonitis is not present conser"ati"e management of these selected
6
patients has been used successfully. %hile this approach may be necessary when operating room
capacity is in short supply it is not recommended for general use.
)*issin! Ulcer+ Pro,lem
Infre'uently a patient who presents with a perforated duodenal ulcer is found to ha"e
blood in the stomach when nasogastric suction is performed. In these circumstances the old
adage appliesB HAnterior ulcers perforate and posterior ones bleed.I A patient with une'ui"ocal
findings of a perforated duodenal ulcer and concomitant bloody nasogastric aspirate must be
suspected of ha"ing a Hkissing ulcerI that is a perforated anterior ulcer and a bleeding posterior
ulcer.
At the time of operation the posterior wall of the first part of the duodenum must be
examined by extending the hole from the perforation. In the presence of a bleeding duodenal
ulcer suture control of the bleeding must be accomplished. A definiti"e ulcer operation is also
re'uired. The choices are to close the perforation and duodenotomy with an omental patch and
perform proximal gastric "agotomy? or to extend the duodenotomy incision across the pylorus
into the stomach close this with pyloroplasty and perform truncal "agotomy.
Perforate# Gastric Ulcer
The abo"e discussion on perforated duodenal ulcer applies e'ually well to perforated
gastric ulcer with one difference. 7alignancy which has an incidence of =:% must always be
ruled out in a perforated gastric ulcer. This can be accomplished by completely excising the ulcer
or alternati"ely by four$'uadrant biopsy if excision cannot be accomplished successfully.
1onser"ati"e distal gastrectomy encompassing the ulcer is the initial therapy of choice. If
the ulcer is malignant a more radical type of gastrectomy will be needed.
Mana!ement of perforate# peptic lcer
G
Graham patch techni'ue. 0A and 23 This techni'ue pro"ides a safe and established
method of closure of perforated duodenal ulcer. The ulcer is closed by sutures
applied o"er a piece of
omentum.
*