gastrointestinal disorders
Peptic Ulcer Disease
Complications of Peptic Ulcer Disease
Mild to severe Overview of Gastrointestinal Bleeding is the most common complication of peptic ulcer disease. Symptoms include hematemesis (vomiting of fresh blood or coffee-ground material), passage of bloody stools (hematochezia) or black tarry stools (melena), and weakness, orthostasis, syncope, thirst, and sweating caused by blood loss. A peptic ulcer may penetrate the wall of the stomach or duodenum. If adhesions prevent leakage into the peritoneal cavity, free penetration is avoided and confined perforation occurs. The ulcer may penetrate into the adjacent confined space (lesser sac) or another organ (eg, pancreas, liver). Pain may be intense, persistent, referred to sites other than the abdomen (usually the back when caused by penetration of a posterior duodenal ulcer into the pancreas), and modified by body position. CT or MRI is usually needed to confirm the diagnosis. When therapy does not result in healing, surgery is required. Ulcers that perforate into the peritoneal cavity unchecked by adhesions are usually located in the anterior wall of the duodenum or, less commonly, in the stomach. The patient presents with an acute abdomen. There is sudden, intense, continuous epigastric pain that spreads rapidly throughout the abdomen, often becoming prominent in the right lower quadrant and at times referred to one or both shoulders. The patient usually lies still because even deep breathing worsens the pain. Palpation of the abdomen is painful, rebound tenderness is prominent, abdominal muscles are rigid (boardlike), and bowel sounds are diminished or absent. Shock may ensue, heralded by increased pulse rate and decreased blood pressure and urine output. Symptoms may be less striking in older or moribund patients and in those receiving corticosteroids or immunosuppressants. Diagnosis is confirmed if an x-ray or CT shows free air under the diaphragm or in the peritoneal cavity. Upright views of the chest and abdomen are preferred. The most sensitive view is the lateral x-ray of the chest. Severely ill patients may be unable to sit upright and should have a lateral decubitus x-ray of the abdomen. Failure to detect free air does not exclude the diagnosis. Immediate surgery is required. The longer the delay, the poorer is the prognosis. IV antibiotics effective against intestinal flora (eg,cefotetan, oramikacinplusclindamycin) should be given. Usually, a nasogastric tube is inserted to do continuous nasogastric suction. In the rare cases when surgery cannot be done, prognosis is poor. Obstruction may be caused by scarring, spasm, or inflammation resulting from an ulcer. Symptoms include recurrent, large-volume vomiting, occurring more frequently at the end of the day and often as late as 6 hours after the last meal. Loss of appetite with persistent bloating or fullness after eating also suggests gastric outlet obstruction. Prolonged vomiting may cause weight loss, dehydration, and alkalosis. If the patient’s history suggests obstruction, physical examination, gastric aspiration, or x-rays may provide evidence of retained gastric contents. A succussion splash heard>6 hours after a meal or aspiration of fluid or food residue>200 mL after an overnight fast suggests gastric retention. If gastric aspiration shows marked retention, the stomach should be emptied and endoscopy or cross-sectional imaging with CT should be done to determine site, cause, and degree of obstruction. Edema or spasm caused by an active pyloric channel ulcer is treated with gastric decompression by nasogastric suction and acid suppression (eg, IV H2 blocker or IV proton pump inhibitor). Dehydration and electrolyte imbalances resulting from protracted vomiting or continued nasogastric suctioning should be vigorously sought and corrected. Prokinetic agents are not indicated. Generally, obstruction resolves within 2 to 5 days of treatment. Prolonged obstruction may result from peptic scarring and may respond to endoscopic pyloric balloon dilation. Surgery is necessary to relieve obstruction in selected cases. 50% when it is not. Thus, a patient with recurrent disease should be Treatment and treated again if the tests are positive. Although long-term treatment with H2 blockers, proton pump inhibitors, ormisoprostolreduces the risk of recurrence, their routine use for this purpose is not recommended. However, patients who require NSAIDs after having had a peptic ulcer are candidates for long-term therapy, as are those with a marginal ulcer or prior perforation or bleeding. –associated ulcers have a 3- to 6-fold increased risk of Stomach Cancer later in life. There is no increased risk of cancer with ulcers of other etiology. 