Introduction
The complications related to PUD (peptic ulcer disease) include bleeding, penetration, perforation, and gastric outlet obstruction. Although recent medical innovations aim at reducing the disease frequency, complications related to peptic ulcers are not resolved.
What Are PUD-Related Complications?
Peptic ulcer complications are rare but of serious concern if they occur. PUD-related complications can include the following:
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Internal bleeding
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Penetration
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Perforation
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Malignancy
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Recurrent disease
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Post-surgical complications
What Are the Risk Factors for PUD Complications?
Risk factors for PUD complications include:
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Over-use of certain drugs: In most cases, peptic ulcer complications occur due to the overuse of drugs like NSAID (nonsteroidal anti-inflammatory drugs) and ASA (acetylsalicylic acid). It is dose-related, and using them for a prolonged time can cause internal bleeding.
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H-pylori (helicobacter-pylori) infections: Complications associated with a peptic ulcer are also more in patients with H.pylori infections. The role of H.pylori in giving rise to complications is still under research and debate.
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Age: Chances of a peptic ulcer developing into other complications depend on age. People older than 60 years are more prone to complications.
What Is Internal Bleeding?
Internal bleeding is the most common complication associated with peptic ulcers. It occurs when an ulcer evolves adjacent to a blood vessel. The bleeding can be long-term and slow, resulting in anemia, fatigue, shortness of breath, pale skin, and palpitations (fast heart rate). It can also be rapid and severe bleeding like vomiting blood or blood in the stool occurs.
Other symptoms include orthostasis (low blood pressure while standing), syncope (fainting), and sweating due to blood loss. In severe conditions, severe internal hemorrhage can lead to hypovolemic shock. The patient must be subjected to immediate resuscitation therapy, and the cause and location of the bleeding should be identified. The diagnosis must be confirmed using endoscopy to rule out any underlying pathology.
The current therapeutic approach includes fluid resuscitation, intravenous supply of proton pump inhibitors, blood transfusion if required, and endoscopic management. The ulcer heals and recovers in most cases. However, surgical procedures should be considered if this does not resolve the problem.
What Is Penetration?
Penetration is when a peptic ulcer invades the stomach wall. There will be severe persistent pain in the abdomen. There can be referred pain (pain in one part of the body due to an injury in another part) to the other sites and may change depending upon body positions. Penetration can be confirmed using an MRI or CT scan. If medical therapy does not work, surgery might be required.
What Is Perforation?
Perforation is a spontaneous clinical event. It is characterized by sudden abdominal pain.
Around 2 to 10 percent of peptic ulcer cases are complicated to cause perforation. It is most common in duodenal ulcers. The pain shoots up in time and spreads over the entire abdomen. The pain then predominates over the lower left quadrant. There can be referred pain in one or both shoulders. Even deep breathing can cause pain, so the patient prefers to lie still.
A few more important observations on perforation are listed below:
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Palpation of the abdomen is painful, and the abdominal muscles become rigid.
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Rebound tenderness (pain is present when the pressure applied is removed) is prominent.
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Bowel sounds are less or absent.
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There can also be an increase in the pulse rate and reduced blood pressure.
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An X-ray or CT scan can be used to confirm the diagnosis.
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Free air under the diaphragm or peritoneal cavity is seen in a plain X-ray.
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Immediate surgery is required.
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The prognosis becomes poor as the time delay increases.
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An intravenous supply of antibiotics should be given.
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Usually, a nasogastric tube is inserted for suction.
What Is Gastric Outlet Obstruction?
It is a lesser frequent complication and is associated with scarring, inflammation, or edema of a peptic ulcer. Recurrent vomiting in large volume, usually about six hours post-meal, is observed. Loss of appetite, bloating, or feeling of fullness can also be symptoms to be considered. Frequent vomiting can cause dehydration, weight loss, and electrolyte imbalance. Decreased efficacy of antacids is yet another typical symptom. The condition can be diagnosed by endoscopy, biopsy, and imaging techniques. The initial management is restoring the lost electrolyte balance and dehydration. Then, gastric decompression (done to reduce inner GI tract) by nasogastric tube is done. The condition usually resolves within 25 days of treatment. Surgery might be necessary in severe cases.
What Is Malignancy?
An increased risk of gastric cancer is associated with peptic ulcer disease. Other risk factors for malignancy include age, sex, location of the ulcer, H.pylori infection, and the use of NSAIDs. A biopsy should be done if a malignancy is suspected.
What Are the Recurrent Diseases Associated With PUD?
Recurrence is usually related to H.pylori infection, use of NSAIDs, and smoking. These factors should be avoided as much as possible. The risk of recurrence can be reduced from 50 % to around 10 % by eradicating the chance of H.pylori infection. Proton pump therapy can be started in patients who develop a peptic ulcer on long-term NSAID therapy. Ulcers not associated with NSAIDs and H.pylori infections have a greater chance of recurring. After a gastric resection, the recurrence rate is 2 to 5%, and after highly selective vagotomy is 5 to 12 percent. Patients are usually given proton pump inhibitors or H2 antagonists in these cases.
What Are the Post Surgical Complications?
There can be symptoms like weight loss, anemia, malnutrition, dumping syndrome (a condition where food moves very quickly from the stomach to the small intestine after a meal), gastroparesis (reduced movements of the stomach), and ulcer recurrence after a surgical procedure. The symptoms shown can vary, depending upon the procedure performed. For example, a gastrojejunostomy (a procedure that connects a part of the stomach to the jejunum, a part of the small intestine) can cause malabsorption and malnutrition. In addition, the feeling of not being well, like postprandial sweating, nausea, vomiting, palpitations, etc., of a dumping syndrome patient can make them avoid food, leading to malnutrition. To prevent this, patients should be encouraged to have small frequent meals.
Conclusion
Peptic ulcer-related complications are still of concern though they are rare. Although recent medical innovations aim at reducing the disease frequency, complications related to peptic ulcers are not resolved. Bleeding, perforation, and gastric outlet obstruction are still being reported.
