COMPLICATIONSCOMPLICATIONS

GASTRO-DUODENAL PEPTIC GASTRO-DUODENAL PEPTIC ULCERSULCERS

COMPLICATIONS OF COMPLICATIONS OF GASTRODUODENAL GASTRODUODENAL ULCERSULCERS PERFORATIONPERFORATION- PERITONITIS- PERITONITIS

BLEEDINGBLEEDING- ANEMIA- ANEMIA

STENOSISSTENOSIS- GASTRIC OUTLET - GASTRIC OUTLET

OBSTRUCTIONOBSTRUCTION

PERFORATIONPERFORATION

PerforationPerforation- ulcer rupture into the - ulcer rupture into the peritoneal cavity with spillage of GD peritoneal cavity with spillage of GD contentscontents

PenetrationPenetration- erosion into a solid organ: liver - erosion into a solid organ: liver or pancreasor pancreas

Perforation of a chronic ulcerPerforation of a chronic ulcer- increasing - increasing dyspepsia prior to the perforationdyspepsia prior to the perforation

Perforation of an acute ulcerPerforation of an acute ulcer- no - no premonitory symptomspremonitory symptoms

PERFORATIONPERFORATION

Risk factors:Risk factors:

- drugs: steroids, NSAID- drugs: steroids, NSAID

- situations of stress: burns, - situations of stress: burns, multiple injuries, sepsis, multiple injuries, sepsis, chemotherapy, radiotherapychemotherapy, radiotherapy

CLINICAL FEATURES OF CLINICAL FEATURES OF PERFORATED ULCERPERFORATED ULCER The moment of perforation is identified The moment of perforation is identified

by the patient as an by the patient as an excruciating excruciating epigastric painepigastric pain

The intensity of sy. depend on The intensity of sy. depend on the the degree degree of peritoneal soiling and whether of peritoneal soiling and whether the perforation the perforation becomes sealedbecomes sealed

The spillage goes along the right The spillage goes along the right paracolic gutter- pain from epigastrium paracolic gutter- pain from epigastrium shifts to RIF , may mimick acute shifts to RIF , may mimick acute appendicitisappendicitis

Vomiting in delayed cases- Vomiting in delayed cases- ileus ileus

PHYSICAL SIGNS OF PHYSICAL SIGNS OF PERFORATED PEPTIC PERFORATED PEPTIC ULCERULCER Depend upon the Depend upon the degree and rate degree and rate of of

soiling within peritoneal cavitysoiling within peritoneal cavity Tenderness with guarding may vary from Tenderness with guarding may vary from

being localized to the upper abdo- to being localized to the upper abdo- to being generalizedbeing generalized

Typical signs for generalized peritonitis Typical signs for generalized peritonitis due to perforated ulcer are: due to perforated ulcer are: rigid rigid abdomenabdomen, no respiratory movements, , no respiratory movements, silent abdomen, silent abdomen,

As later features: progressive distension, As later features: progressive distension, hypotension, tachycardia, cold periphery, hypotension, tachycardia, cold periphery, decreased urinary outputdecreased urinary output

PHYSICAL SIGNS OF PHYSICAL SIGNS OF PERFORATED ULCERPERFORATED ULCER

Any deep inspiration, coughing- Any deep inspiration, coughing- increased painincreased pain

The patient The patient lies still lies still in the bed, any in the bed, any movement exacerbating the painmovement exacerbating the pain

INVESTIGATIONS IN INVESTIGATIONS IN PERFORATED ULCERPERFORATED ULCER Plain abdominal X Ray Plain abdominal X Ray in erect positionin erect position

– PneumoperitoneumPneumoperitoneum- air visible in the right - air visible in the right subdiaphragmatic spacesubdiaphragmatic space

– Gas/fluid levels Gas/fluid levels in advanced casesin advanced cases– If pneumoperitoneum is not seen, think to If pneumoperitoneum is not seen, think to

a sealed perforation or acute pancreatitisa sealed perforation or acute pancreatitis– Do not count on amylase, may be Do not count on amylase, may be

increased in any acute abdomenincreased in any acute abdomen USS of the abdomenUSS of the abdomen- fluid within - fluid within

peritoneal cavityperitoneal cavity

Plain rx. of the RUQ Plain rx. of the RUQ shows a tiny streak of air shows a tiny streak of air under the diaphragmunder the diaphragm

Pneumoperitoneum Pneumoperitoneum in perforated duodenal in perforated duodenal ulcerulcer

PneumoperitoneumPneumoperitoneum

PneumoperitoneumPneumoperitoneumperforated duodenal perforated duodenal ulcerulcer

Upright CXR shows Upright CXR shows a large collection of air under a large collection of air under both the diaphragmsboth the diaphragms

MANAGEMENT OF MANAGEMENT OF PERFORATED ULCERPERFORATED ULCER Correction of hypovolemia, electrolyte Correction of hypovolemia, electrolyte

disturbances, low urinary outputdisturbances, low urinary output Severe cases- monitoring CVP, hourly Severe cases- monitoring CVP, hourly

UOUO Colloids, cristaloids – effectiveColloids, cristaloids – effective Naso-gastric aspirationNaso-gastric aspiration Antisecretory drugsAntisecretory drugs Planning for operationPlanning for operation

OPERATIVE VS OPERATIVE VS CONSERVATIVE CONSERVATIVE TREATMENTTREATMENT Sealed perforated ulcer- Sealed perforated ulcer- Taylor’s Taylor’s

methodmethod Taylor’s method: NG aspiration, iv Taylor’s method: NG aspiration, iv

fluids, antibiotics, antisecretory fluids, antibiotics, antisecretory drugsdrugs

Indication: young patients with short Indication: young patients with short history of perforation of acute ulcer history of perforation of acute ulcer and with minimum of pneumo. and and with minimum of pneumo. and fluid under liverfluid under liver

Close clinical observationClose clinical observation

OPERATIVE OPERATIVE VS.CONSERVATIVE VS.CONSERVATIVE TREATMENTTREATMENT

If the patient is getting worse within 6-12 If the patient is getting worse within 6-12 hours, the operation is requiredhours, the operation is required

Operative procedure- Operative procedure- simple closure of simple closure of the perforation, omentoplasty, peritoneal the perforation, omentoplasty, peritoneal lavage and multiple drainageslavage and multiple drainages

Peritoneal fluid sent for bacteriological Peritoneal fluid sent for bacteriological cultureculture

Empiric antibiotherapy- broad spectrum Empiric antibiotherapy- broad spectrum antibiotics antibiotics

Perforated peptic duodenal ulcer. The Perforated peptic duodenal ulcer. The ulcer was found to be a typically punched ulcer was found to be a typically punched out peptic ulcer (arrows) with a diameter out peptic ulcer (arrows) with a diameter of 6 mmof 6 mm

Perforated peptic ulcerPerforated peptic ulcer

Perforated duodenal ulcerPerforated duodenal ulcer

A 49-year-old man was A 49-year-old man was admitted with sudden onset of admitted with sudden onset of severe pain in the epigastrium. severe pain in the epigastrium. Recently, he had taken a Recently, he had taken a course of a non-steroidal anti-course of a non-steroidal anti-inflammatory drug (NSAID).inflammatory drug (NSAID).

This had caused indigestion, This had caused indigestion, which had worsened in the two which had worsened in the two days prior to his presentation.days prior to his presentation.

On examination, the patient On examination, the patient was ill and had a rigid was ill and had a rigid abdomen. abdomen.

The operative photograph The operative photograph shows a perforated duodenal shows a perforated duodenal ulcer. This was oversewn. ulcer. This was oversewn.

Closure of perforated duodenal ulcer & Closure of perforated duodenal ulcer & omental patching.omental patching.  

PYLORIC STENOSISPYLORIC STENOSIS

Chronic scarring from ulceration in Chronic scarring from ulceration in the pyloric region- gastric outlet the pyloric region- gastric outlet obstruction or obstruction or pyloric stenosispyloric stenosis

Occurs in a patient with Occurs in a patient with longstanding ulcer disease ignored, longstanding ulcer disease ignored, neglected or bad treatedneglected or bad treated

Be aware that Be aware that pyloric stenosis pyloric stenosis might might be due to a be due to a malignant antral tumormalignant antral tumor

PYLORIC STENOSISPYLORIC STENOSISCLINICAL FEATURESCLINICAL FEATURES

PainPain in the upper abdomen, relieved by the in the upper abdomen, relieved by the vomitingvomiting

VomitingVomiting is efortless, projectile with is efortless, projectile with partially digested food and partially digested food and bile is absentbile is absent

Naso-gastric aspiration reveals only gastric Naso-gastric aspiration reveals only gastric fluid with thick partially digested foodfluid with thick partially digested food

For gastric decompresion- gastric lavage For gastric decompresion- gastric lavage and aspirationand aspiration

PYLORIC STENOSISPYLORIC STENOSISCLINICAL FEATURESCLINICAL FEATURES

Underweight patient, dehydrated Underweight patient, dehydrated with persistent skin fold, anemicwith persistent skin fold, anemic

Gastric stasis revealed by Gastric stasis revealed by succusion splash on percusionsuccusion splash on percusion

Visible peristalsisVisible peristalsis, passing across , passing across the upper abdomen from left to the upper abdomen from left to right right

PYLORIC STENOSISPYLORIC STENOSISMETABOLIC FEATURESMETABOLIC FEATURES Prolonged vomiting- electrolyte Prolonged vomiting- electrolyte

disturbances and renal failuredisturbances and renal failure Hypochloremic alkalosis Hypochloremic alkalosis due to due to

hydrogen and chloride ions losseshydrogen and chloride ions losses At a later stage- renal function At a later stage- renal function

disturbeddisturbed To compensate metabolic alkalosis, To compensate metabolic alkalosis,

the kidneys excret bicarbonates at the the kidneys excret bicarbonates at the expense of losing sodiumexpense of losing sodium

PYLORIC STENOSISPYLORIC STENOSISMETABOLIC FEATURESMETABOLIC FEATURES

The patient becomes progressively The patient becomes progressively more dehydrated and more dehydrated and hyponatremichyponatremic

In an attempt to conserve circulatory In an attempt to conserve circulatory volume, sodium is retained by the volume, sodium is retained by the kidneys and hydrogen plus potassium kidneys and hydrogen plus potassium is excreted preferentiallyis excreted preferentially

Hence alkalosis becomes more severe Hence alkalosis becomes more severe and and hypokalemiahypokalemia more marked more marked

HypocalcemiaHypocalcemia- disturbance of - disturbance of consciousness and tetanyconsciousness and tetany

PYLORIC STENOSISPYLORIC STENOSISMETABOLIC FEATURESMETABOLIC FEATURES These electrolyte disturbances in These electrolyte disturbances in

patients with severe pyloric stenosis patients with severe pyloric stenosis are termed are termed DARROW’S SYNDROMEDARROW’S SYNDROME

Lab.findings are:- base excess> Lab.findings are:- base excess> - high serum - high serum

urea, urea, - - hyponatremia, hyponatremia, - hypopotasemia, - hypopotasemia,

- hypocalcemia - hypocalcemia

X-ray after a barium meal will show X-ray after a barium meal will show delayed emptying of the stomach, and delayed emptying of the stomach, and often the contour of the stomach will be often the contour of the stomach will be seen deep in the pelvisseen deep in the pelvis

Draining the stomach with a naso-gastric Draining the stomach with a naso-gastric tube (NG tube) will produce thick muddy tube (NG tube) will produce thick muddy content (undigested food). content (undigested food).

Endoscopic viewEndoscopic viewof normal duodenumof normal duodenum

Endoscopic view of Endoscopic view of pyloric stenosispyloric stenosis

PYLORIC STENOSISPYLORIC STENOSISMANAGEMENTMANAGEMENT

The priority is correction of fluid and The priority is correction of fluid and electrolytes abnormalitieselectrolytes abnormalities

RehydrationRehydration- saline infusion with K - saline infusion with K supplementssupplements

Provision of adequate sodium allows Provision of adequate sodium allows excretion of alkaline urine so that the excretion of alkaline urine so that the alkalosis becomes correctablealkalosis becomes correctable

Clinical improvement: increased UO, a fall to Clinical improvement: increased UO, a fall to normal in blood urea and normal electrolytesnormal in blood urea and normal electrolytes

Gastric lavage until fluid is clearGastric lavage until fluid is clear

PYLORIC STENOSISPYLORIC STENOSISSURGICAL TREATMENTSURGICAL TREATMENT Partial gastric resection with gastro-Partial gastric resection with gastro-

duodenal anastomosis (PEAN-duodenal anastomosis (PEAN-BILLROTH I)BILLROTH I)

Partial gastric resection with gastro-Partial gastric resection with gastro-jejunal anastomosis (BILLROTH II)jejunal anastomosis (BILLROTH II)

For old, frail patients- by pass For old, frail patients- by pass operation like gastro-jejunostomyoperation like gastro-jejunostomy

BLEEDING PEPTIC BLEEDING PEPTIC ULCERULCER Acute bleeding is the commonest Acute bleeding is the commonest

complicationcomplication It carries the highest mortality It carries the highest mortality Bleeding results from erosion of the Bleeding results from erosion of the

ulcer into a blood vesselulcer into a blood vessel The most common sign is melena +/- The most common sign is melena +/-

hematemesishematemesis One of three pts. have no history of One of three pts. have no history of

ulcer ulcer In major bleeding- GI transit so rapid- In major bleeding- GI transit so rapid-

stool is bright red stool is bright red

BLEEDING PEPTIC BLEEDING PEPTIC ULCERULCER

Severity of acute bleeding assessed Severity of acute bleeding assessed by:by:

BP, PR, Hb., Ht. if sufficient time BP, PR, Hb., Ht. if sufficient time passed for compensatory passed for compensatory hemodilutionhemodilution

Systolic BP< 100, PR>100 with the Systolic BP< 100, PR>100 with the patient supine, suggest major blood patient supine, suggest major blood loss (>1 l.) loss (>1 l.)

BLEEDING PEPTIC BLEEDING PEPTIC ULCERULCER

Adverse clinical factors on outcome:Adverse clinical factors on outcome:– Severe, continuing bleedingSevere, continuing bleeding– Early rebleeding within 3-5 days of Early rebleeding within 3-5 days of

initial stabilizationinitial stabilization– Age greater than 60Age greater than 60– Associated diseases: cardio-vascular Associated diseases: cardio-vascular

and liver diseasesand liver diseases

BLEEDING PEPTIC BLEEDING PEPTIC ULCERULCER The differential diagnosis includes:The differential diagnosis includes:

– Rupture of esophago-gastric varicesRupture of esophago-gastric varices– Hemorrhagic gastritisHemorrhagic gastritis– Mallory-Weiss lacerationMallory-Weiss laceration– Ulcerated benign and malignant gastric Ulcerated benign and malignant gastric

tumorstumors– Vascular anomalies (angiodysplasia)Vascular anomalies (angiodysplasia)– Aorto-enteric fistula in pts. with a Aorto-enteric fistula in pts. with a

prosthetic aortic graftprosthetic aortic graft

BLEEDING PEPTIC ULCER-ENDOSCOPYBLEEDING PEPTIC ULCER-ENDOSCOPY

Forrest’s classification of bleeding Forrest’s classification of bleeding activityactivity

Forrest Ia- active bleeding- arterial Forrest Ia- active bleeding- arterial spurtingspurting

Forrest Ib- active bleeding- oozingForrest Ib- active bleeding- oozing

Forrest II-bleeding ceased- clot lying on Forrest II-bleeding ceased- clot lying on ulcer or visible vessel stumpulcer or visible vessel stump

Forrest III-bleeding ceased- no signs of Forrest III-bleeding ceased- no signs of recent bleedingrecent bleeding

MANAGEMENTMANAGEMENT

Three phases in the management Three phases in the management of the bleeding:of the bleeding:– ResuscitationResuscitation– DiagnosisDiagnosis– Definitive treatmentDefinitive treatment

Active bleeding gastric Active bleeding gastric ulcerulcer

Endoscopic view Endoscopic view of activ gastric of activ gastric bleedingbleeding

Endoscopic view Endoscopic view of erosive duodenitisof erosive duodenitis

Active bleeding- Active bleeding- duodenal ulcerduodenal ulcer

Bleeding duodenal Bleeding duodenal ulcerulcer

Bleeding erosive Bleeding erosive gastritisgastritis

RESUSCITATIONRESUSCITATION

Hemorrhagic shock- ICUHemorrhagic shock- ICU Do not sedate patient for Do not sedate patient for

endoscopyendoscopy Rapid transfusionRapid transfusion BP, PR, CVP, UO monitoringBP, PR, CVP, UO monitoring Confusion and restlessness demand Confusion and restlessness demand

attention for oxygenationattention for oxygenation

DIAGNOSISDIAGNOSIS

History- dyspepsia, liver disease, History- dyspepsia, liver disease, intake of alcohol, aspirin, NSAIDintake of alcohol, aspirin, NSAID

Endoscopic examination: the sourse Endoscopic examination: the sourse and the gravity of bleedingand the gravity of bleeding

Endoscopic criteria for early surgery:Endoscopic criteria for early surgery:– Arterial spurterArterial spurter– Visible vessel in base of ulcerVisible vessel in base of ulcer– Adherent clotAdherent clot

MANAGEMENTMANAGEMENT

Bed restBed rest Naso-gastric lavage with cold salineNaso-gastric lavage with cold saline IV antisecretory drugs (H proton IV antisecretory drugs (H proton

pump inhibitors, H2 receptor pump inhibitors, H2 receptor antagonists)antagonists)

Hemostatic drugsHemostatic drugs Endoscopic adrenaline injectionEndoscopic adrenaline injection

INDICATION FOR INDICATION FOR SURGERYSURGERY

Continuing bleedingContinuing bleeding Re-bleedingRe-bleeding The sourse of bleedingThe sourse of bleeding Fitness of the patientFitness of the patient

Check coagulation parametersCheck coagulation parameters

SURGERY IN BLEEDING SURGERY IN BLEEDING ULCERULCER

Partial gastrectomy but morbidity Partial gastrectomy but morbidity and mortality highand mortality high

Underrunning of the bleeding Underrunning of the bleeding ulcer, followed by the treatment ulcer, followed by the treatment with antiulcer drugswith antiulcer drugs

THE FAILURES THE FAILURES OF GASTRIC SURGERYOF GASTRIC SURGERY

Recurrent UlcerationRecurrent Ulceration– Incomplete vagotomyIncomplete vagotomy– Inadequate resectionInadequate resection– Retained gastric antrumRetained gastric antrum– Zollinger-Ellison syndromeZollinger-Ellison syndrome– HypercalcemiaHypercalcemia