Education

1. Complications of Peptic
Ulcer Disease

2. PRESENTED BY
ABDULLAH FAROOQI
GROUP
GM20-148

3. What is peptic Ulcer?
Peptic ulcer disease (PUD) is a condition characterized
by the formation of ulcers in the lining of the
stomach, duodenum, or sometimes in the esophagus.
These ulcers are typically caused by an imbalance
between the digestive fluids in the stomach and
duodenum, primarily stomach acid and the protective
mechanisms of the gastrointestinal lining.

4. The most common types of peptic ulcers are gastric
ulcers, which occur in the stomach, and duodenal
ulcers, which occur in the first part of the small
intestine known as the duodenum. Peptic ulcers can
range in size from small sores to larger craters, and
they can cause a variety of symptoms such as
abdominal pain, bloating, nausea, and vomiting.

6. Why complications are Important?
Complications of peptic ulcer disease refer to serious,
often life-threatening outcomes that can occur if the
ulcers are left untreated or if they become severe.
These complications are important to understand
because they can significantly impact a patient's
health and quality of life, and they may require urgent
medical intervention.

7. Types of Peptic Ulcer
Gastric ulcers are sores or erosions
that develop in the lining of the
stomach. They are typically found
in the antrum (lower part) of the
stomach or in the proximal portion
of the stomach near the pylorus.
Gastric ulcers are often associated
with conditions that disrupt the
balance between the protective
mechanisms of the stomach lining
and the corrosive effects of
gastric acid.
Duodenal ulcers are similar to
gastric ulcers but occur in the
first part of the small intestine
known as the duodenum. They are
most commonly found in the
duodenal bulb, which is the
portion of the duodenum closest
to the stomach. Duodenal ulcers
are more prevalent than gastric
ulcers and often present with
similar symptoms.

9. What is difference between the two?
The main difference between gastric ulcers and duodenal ulcers
lies in their location within the digestive tract. Gastric ulcers
occur in the stomach, whereas duodenal ulcers occur in the first
part of the small intestine, the duodenum.In terms of potential
causes, both types of ulcers can be caused by Helicobacter pylori
infection, NSAID use, and smoking. However, duodenal ulcers may
also be associated with conditions like Zollinger-Ellison syndrome,
which leads to excessive stomach acid production. Additionally,
there may be differences in the prevalence of certain risk factors
between gastric and duodenal ulcers.

10. Common Complications in
Peptic ulcer

11. Bleeding

13. Bleeding in Peptic Ulcer
Ulcers in the stomach or duodenum can cause bleeding
when they erode blood vessels within the
gastrointestinal tract. The corrosive effects of gastric
acid can damage the lining of the blood vessels, leading
to bleeding. Additionally, inflammation and tissue
damage associated with the ulcer can further weaken
blood vessels, making them more susceptible to rupture
and bleeding.

14. Symptoms of bleeding

15. Vomiting Blood (Hematemesis):
In severe cases of upper
gastrointestinal bleeding, blood
may be vomited up, leading to
hematemesis. Vomited blood
may appear bright red or have
a coffee-ground appearance due
to partial digestion.
Hematemesis is a serious
symptom that requires
immediate medical attention.
Black, Tarry Stools (Melena):
Blood from the upper
gastrointestinal tract, including
the stomach and duodenum,
undergoes partial digestion as it
travels through the digestive
system. This results in the
characteristic black, tarry
appearance of stools known as
melena. Melena is often a sign of
significant bleeding and should be
evaluated promptly.

16. Management and Treatment Options:
★ Fluid Resuscitation: Intravenous fluids may be administered to
maintain blood pressure and prevent dehydration in individuals with
significant bleeding.
★ Blood Transfusion: In cases of severe bleeding leading to anemia or
hemorrhagic shock, blood transfusion may be necessary to replace
lost blood volume and restore oxygen-carrying capacity.
★ Endoscopic Therapy: Endoscopy allows direct visualization of the
ulcer and provides the opportunity for therapeutic interventions to
stop bleeding. Techniques such as injection therapy, thermal
coagulation, and application of hemostatic clips or bands can be
employed to achieve hemostasis.

17. ★ Proton Pump Inhibitors (PPIs): Proton pump inhibitors are potent
acid-suppressing medications that can help promote ulcer healing
and reduce the risk of rebleeding by decreasing gastric acid
secretion. Intravenous PPIs may be administered initially, followed
by oral therapy.
★ Hemostatic Agents: Topical hemostatic agents, such as epinephrine
or fibrin sealants, may be applied during endoscopy to promote clot
formation and control bleeding.

18. ★ Helicobacter pylori Eradication: If H. pylori infection is identified as the
cause of the ulcer, eradication therapy with antibiotics may be indicated
to prevent recurrence and reduce the risk of rebleeding.

19. Perforation

21. How perforation Occur
Perforation typically occurs when an untreated or inadequately
treated peptic ulcer erodes through the entire thickness of the
stomach or duodenal wall. This erosion can be the result of
ongoing inflammation, tissue damage, and weakening of the
ulcerated area. Factors such as high gastric acid secretion,
persistent H. pylori infection, or NSAID use can exacerbate
ulcer formation and increase the risk of perforation.

22. What are the Symptoms of perforation
1. Sudden and Severe Abdominal Pain: Perforation often presents with
intense, sharp abdominal pain that may be localized or diffuse. The
pain is typically sudden in onset and may be described as stabbing
or tearing. Patients may find it difficult to find a comfortable position
due to the severity of the pain.
2. Signs of Shock: Perforation can lead to significant internal bleeding
and fluid loss into the abdominal cavity, resulting in hypovolemic
shock. Signs of shock may include rapid heartbeat (tachycardia), low
blood pressure (hypotension), pale or clammy skin, rapid breathing
(tachypnea), and altered mental status.

23. Diagnosis and Urgent Management:
★ Clinical Evaluation: A thorough history and physical examination are
essential for suspecting perforation. The presence of sudden, severe
abdominal pain, signs of shock, and a history of peptic ulcer disease or risk
factors for ulceration should raise suspicion.
★ Imaging Studies: Diagnostic imaging modalities such as abdominal X-rays
or computed tomography (CT) scans may be used to confirm the presence
of free air or fluid in the abdominal cavity, indicative of perforation
★ Laboratory Tests: Blood tests may reveal signs of infection, inflammation,
and anemia associated with perforation. Elevated white blood cell count
(leukocytosis) and metabolic acidosis may be observed.

24. ★ Urgent Surgical Consultation: Perforated peptic ulcer is a surgical
emergency that requires immediate intervention. Patients suspected
of having perforation should be promptly referred to a surgical team
for further evaluation and management
★ Fluid Resuscitation: Intravenous fluids should be administered to
restore intravascular volume and address hypovolemia associated
with shock.
★ Pain Management: Analgesia should be provided to alleviate severe
abdominal pain and discomfort, but caution should be exercised to
avoid masking symptoms of worsening peritonitis.

25. ★ Nasogastric Tube Insertion: Placement of a nasogastric tube
may be indicated to decompress the stomach and reduce
distension, which can help alleviate pain and prevent
aspiration.
★ Preoperative Stabilization: Patients with perforated peptic
ulcers may require stabilization with antibiotics, proton pump
inhibitors (PPIs), and other supportive measures before
undergoing definitive surgical repair.

26. Obstruction

28. How Scarring and Inflammation Lead to
Obstruction:
Chronic inflammation and tissue damage caused by peptic ulcers
can result in the formation of fibrous scar tissue within the walls
of the stomach or duodenum. As these scars accumulate and
thicken, they can gradually narrow the lumen of the
gastrointestinal tract, restricting the flow of contents through the
affected area. In some cases, the scarring may become so severe
that it completely obstructs the passage of food and fluids.

29. Symptoms of Obstruction:
Nausea: Patients may experience persistent feelings of nausea, especially after eating or drinking.
Nausea may be accompanied by a sensation of fullness or discomfort in the upper abdomen.
Vomiting: Obstruction can lead to episodes of vomiting, which may occur shortly after meals or
spontaneously throughout the day. Vomit may contain undigested food or bile, depending on the
location and severity of the obstruction.
Bloating: Patients may complain of abdominal bloating or distension, which can be caused by the
accumulation of gas and fluids upstream of the obstructed area. Bloating may worsen after eating and
may be associated with discomfort or pain
Inability to Pass Stool or Gas: Complete obstruction of the gastrointestinal tract can prevent the
passage of stool and gas, leading to constipation and abdominal discomfort. Patients may experience a
sense of urgency or straining with bowel movements, despite being unable to pass anything.

30. Diagnosis and Treatment
★ Nasogastric Decompression: Insertion of a nasogastric tube can help
decompress the stomach and relieve symptoms of obstruction by draining
gastric contents and reducing distension.
★ Prokinetic Agents: Medications such as metoclopramide or erythromycin
may be used to stimulate gastrointestinal motility and promote the
movement of contents through the obstructed area.
★ Fluid and Electrolyte Replacement: Intravenous fluids may be administered
to correct dehydration and electrolyte imbalances resulting from vomiting
and fluid loss.
★ Symptom Management: Antiemetics may be prescribed to alleviate nausea
and vomiting, while analgesics can help relieve abdominal pain or
discomfort.

31. ★ Endoscopic Therapy:Endoscopic procedures such as balloon dilation or
stent placement may be performed to mechanically widen the narrowed
segment of the gastrointestinal tract and restore patency.
★ Surgical Intervention:In cases of severe or refractory obstruction,
surgical intervention may be necessary to remove scar tissue, repair
strictures, or bypass the obstructed area through procedures such as
pyloroplasty or gastroduodenostomy.
★ Treatment of Underlying Cause:Addressing the underlying cause of
peptic ulcer disease, such as Helicobacter pylori infection or NSAID use,
is essential to prevent recurrence of obstruction.

32. Penetration

34. Penetration in peptic Ulcer
Penetration refers to the extension of a peptic ulcer through the
wall of the stomach or duodenum, leading to involvement of
adjacent organs or structures. This complication occurs when
chronic inflammation and tissue damage associated with the ulcer
erode through the wall and penetrate into nearby tissues.

35. Explanation of Penetration into Adjacent Organs
or Structures:
Peptic ulcers can penetrate into various adjacent organs or structures depending
on their location and the direction of tissue erosion. Common sites of
penetration include the pancreas, liver, gallbladder, and omentum. The ulcer may
create a communication between the gastrointestinal tract and the adjacent
organ, leading to complications such as abscess formation, fistula formation, or
localized inflammation.For example, if a duodenal ulcer penetrates posteriorly, it
may involve the pancreas, leading to the development of a peripancreatic
abscess or pancreatitis. Similarly, if a gastric ulcer penetrates into the liver, it
may result in the formation of a hepatic abscess.

36. Symptoms
Abdominal Pain: Patients may experience persistent or localized abdominal pain, which
can be dull, aching, or sharp in nature. The pain may worsen with movement or certain
activities and may be accompanied by tenderness upon palpation.
Fever: Fever may develop in response to localized inflammation or infection associated
with the penetrated organ. Fever may be low-grade or high-grade, depending on the
severity of the complication.
Localized Signs and Symptoms: Depending on the affected organ, patients may present
with specific signs and symptoms related to the site of penetration. For
example:Penetration into the pancreas may cause symptoms of pancreatitis, such as
epigastric pain radiating to the back, nausea, vomiting, and elevated pancreatic
enzymes.Penetration into the liver may result in right upper quadrant pain, jaundice, and
signs of liver dysfunction.

37. Diagnosis
Diagnostic Imaging: Imaging studies such as abdominal ultrasound, computed
tomography (CT) scan, or magnetic resonance imaging (MRI) may be used to
visualize the extent of tissue involvement and identify any associated complications
such as abscess formation or fistulae.
Laboratory Tests: Blood tests may reveal signs of inflammation, infection, or organ
dysfunction, depending on the site of penetration. Elevated white blood cell count
(leukocytosis), elevated liver enzymes, or abnormalities in pancreatic enzymes may
be observed.
Endoscopic Evaluation: Endoscopy may be performed to directly visualize the ulcer
and assess for signs of penetration or associated complications such as bleeding or
perforation.

38. Management
Management: Treatment of penetration involves addressing the
underlying ulcer and managing any associated complications.
This may include:Antibiotic therapy to treat infection or prevent
secondary infection.Surgical intervention to repair fistulae, drain
abscesses, or resect involved tissue.Supportive care to manage
pain, fever, and other symptoms.Treatment of underlying peptic
ulcer disease with acid-suppressing medications, antibiotics (if H.
pylori is present), and lifestyle modifications.

39. Gastric Outlet
Obstruction
(GOO)

41. Gastric outlet obstruction (GOO) refers to a condition where
there is partial or complete blockage of the passage from
the stomach to the small intestine, known as the pylorus.
This obstruction can impede the normal flow of food and
fluids out of the stomach, leading to symptoms of gastric
retention and delayed gastric emptying.

42. Symptoms
★ Early Satiety: Patients may feel full or satisfied shortly after
beginning a meal, even with small amounts of food.
★ Bloating: Abdominal distension and discomfort may occur due to the
accumulation of gas and fluids in the stomach
★ Nausea: Persistent feelings of nausea or discomfort may develop,
especially after eating.
★ Vomiting of Undigested Food: Incomplete gastric emptying may lead
to regurgitation or vomiting of undigested food, often several hours
after meals. Vomit may contain recognizable food particles and have
a sour or acidic odor.

43. Diagnosis
★ Diagnostic Imaging:Abdominal ultrasound, CT scan, or magnetic resonance
imaging (MRI) may be used to visualize the anatomy of the stomach and pylorus
and identify any structural abnormalities or masses causing obstruction.
★ Upper Endoscopy (Esophagogastroduodenoscopy, or EGD):Endoscopy allows
direct visualization of the pyloric region and can help identify the presence of
ulcers, tumors, or strictures causing obstruction. Biopsies may be taken for
histological analysis
★ Barium Swallow Study:A barium swallow study involves swallowing a contrast
agent (barium) that coats the lining of the stomach and intestines, allowing for
visualization of the anatomy and detection of any structural abnormalities or
obstructions.

44. Treatment
★ Endoscopic Therapy: Endoscopic techniques such as balloon dilation
or stent placement may be used to mechanically widen the pyloric
channel and relieve obstruction.
★ Surgical Intervention: In cases of severe or refractory obstruction,
surgical intervention may be necessary to bypass the obstructed
area (e.g., pyloroplasty) or remove the underlying cause (e.g., tumor
resection).
★ Symptomatic Management: Treatment may also focus on managing
symptoms such as nausea, vomiting, and pain with medications such
as antiemetics, prokinetic agents, and analgesics.

45. ★ Nutritional Support: Nutritional supplementation or enteral
feeding may be necessary for patients who are unable to tolerate
oral intake due to GOO
★ Treatment of Underlying Cause: Addressing the underlying cause
of GOO, such as treating H. pylori infection, managing cancer
with chemotherapy or radiation therapy, or addressing
inflammatory conditions, is essential to prevent recurrence and
optimize outcomes.

46. Less common
Complications

47. Perigastric Abscess:
A perigastric abscess is a collection of pus that forms in the
tissues surrounding the stomach, typically as a result of
perforation or penetration of a peptic ulcer. It may present with
symptoms such as fever, abdominal pain, and signs of
localized inflammation. Treatment usually involves antibiotics
and drainage of the abscess.

48. Fistula Formation:
Fistula formation refers to the abnormal connection between two
adjacent organs or between an organ and the skin surface. In peptic
ulcer disease, fistulae may develop between the stomach or
duodenum and neighboring structures such as the pancreas, liver, or
colon. This can lead to complications such as recurrent infections,
gastrointestinal bleeding, or fecal material in the urine or vice versa,
depending on the location of the fistula. Treatment often involves
surgical repair.

49. Malignancy (Ulcer-Associated Gastric Cancer):
Long-standing peptic ulcers, particularly those caused by chronic
Helicobacter pylori infection or associated with gastric mucosal
atrophy, may increase the risk of developing gastric cancer. Although
less common than other complications, ulcer-associated gastric
cancer can have serious consequences if not detected and treated
early. Regular surveillance endoscopy and biopsy may be
recommended for individuals with a history of peptic ulcers to detect
early signs of malignancy.

50. Conclusions

51. ★ In conclusion, peptic ulcer disease can lead to a range of complications
that significantly impact an individual's health and quality of life. These
complications include bleeding, perforation, obstruction, penetration
into adjacent organs, gastric outlet obstruction, and less common
complications such as perigastric abscess, fistula formation, and
malignancy
★ Early recognition and appropriate management of these complications
are crucial in preventing serious consequences and improving patient
outcomes. Prompt diagnosis and intervention can help minimize
morbidity and mortality associated with peptic ulcer disease.

52. ★ It's essential for individuals experiencing symptoms such as abdominal pain,
nausea, vomiting, or signs of gastrointestinal bleeding to seek medical attention
promptly. Timely evaluation by a healthcare provider, along with diagnostic
testing such as endoscopy or imaging studies, can facilitate early identification
of peptic ulcer complications and initiation of appropriate treatment.
★ By adopting lifestyle modifications, adhering to prescribed medications, and
following recommended treatment regimens, individuals with peptic ulcer
disease can effectively manage their condition and reduce the risk of
complications. Regular follow-up with healthcare providers and proactive
communication about symptoms are key components of successful
management.

53. Please Remember
Remember, early intervention saves lives. Don't hesitate to
seek medical attention if you or someone you know
experiences symptoms or complications of peptic ulcer
disease. Your health and well-being are paramount, and timely
medical care can make a significant difference in your
outcome.