37. Stomach and duodenal ulcers: complications

Gastric and duodenal ulcers: complications

Bleeding is the most common serious PUD complication and may present with haematemesis, coffee-ground vomiting, melaena, syncope or shock.
Assess ABCDE, haemodynamic status, comorbidities, medication use and anticoagulation. Obtain IV access, blood count, coagulation profile, renal function, group and crossmatch.
Resuscitate with fluids and blood products as indicated; use a restrictive transfusion strategy in many patients while individualising for cardiovascular disease and active shock.
Urgent endoscopy provides diagnosis and haemostasis using clips, thermal therapy or combination techniques. High-dose PPI is given after endoscopic treatment of high-risk lesions.
Rebleeding may require repeat endoscopy, transcatheter arterial embolisation or surgery.

Perforation allows gastric/duodenal contents into the peritoneal cavity, causing chemical then bacterial peritonitis and sepsis.
Presentation is sudden severe epigastric pain, rigid abdomen, guarding, rebound tenderness and reduced bowel sounds; older or immunosuppressed patients may have subtle signs.
Erect chest radiograph may show free subdiaphragmatic air; CT is more sensitive and helps localise the perforation. Do not delay surgery in a clinically unstable patient with clear peritonitis.
Management: nil by mouth, IV fluids, broad-spectrum antibiotics, PPI, analgesia, nasogastric decompression when indicated and urgent surgical assessment. Laparoscopic or open closure with omental patch is commonly used for perforated duodenal ulcer, depending on patient and defect.
Postoperative care includes H. pylori eradication, NSAID review and acid suppression. Complications include abscess, leak, sepsis and recurrent ulcer.

An ulcer may penetrate an adjacent organ without free perforation; posterior duodenal ulcers may penetrate the pancreas, causing persistent back-radiating pain.
Other sites include liver and biliary structures. CT and endoscopy help assess the anatomy and exclude alternative causes.
Treat with acid suppression and H. pylori eradication; surgery is considered for uncontrolled symptoms, complications or diagnostic uncertainty.

Chronic ulceration near the pylorus/duodenal bulb can cause oedema and fibrosis, narrowing the gastric outlet.
Symptoms include early satiety, postprandial non-bilious vomiting, weight loss, dehydration and metabolic alkalosis with hypochloraemia/hypokalaemia.
Investigate with endoscopy and biopsy to exclude gastric cancer; CT may define wall thickening or mass.
Initial management includes IV fluid/electrolyte correction, gastric decompression and PPI. Endoscopic balloon dilation may be used for selected benign strictures; surgery is considered for refractory obstruction or malignancy.