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View Full Version : Bleeding Peptic Ulcer (COMPLICATIONS OF PEPTIC ULCER)



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04-24-2008, 08:45 AM
m Incidence: 15-20% of cases of peptic ulcer
m Types:
1- Mild ® from vascular granulation tissue in the floor.
2- Moderate ® errosion of a small vessel (branch of left gastric or gastrodudenal artery)
3- Severe ® extragastric vessel e.g. Splenic ® fatal.
mClinical Picture:
It varies from unexplained anaemia to severe shock due to haematemesis. If the bleeding was moderate melaena may occur without haematemesis.
m D.D. of haematemesis: "Causes of upper G.I.T Bleeding"
1) Oesophageal and gastric varices " the commonest in Egypt"
2) Peptic ulcer "the second common"
3) Stress ulceration and gastric erosions.
4) Mallory Weiss syndrome: cardio-oesophageal longitudinal lacerations due to recurrent forcible vomiting and retching ® tears in mucosa ® bleeding. It is difficult to diagnose by endoscope for the inexperienced endoscopist. Surgical treatment may be necessary.
5) Cancer oesophagus and cancer stomach "rare"
6) Blood disease e.g. Hemophilia.
7) Dieulafoy’s disease, (Gastric arterio-venous malformations).
m Investigations:
1) Gastroscopy: Can detect oesophageal and gastric causes but gastric wash with cold saline should be done before.
2) Selective coeliac angiography: The dye will be more apparent in the bleeding vessel and amount of extravasated blood can be detected.
m Factors affect prognosis in bleeding peptic ulcer
1- Age: young age is better than old age. WHY?
Young patient has better cardiac reserve.
Old age ® Atherosclerosis in vessels ® hge.
2- Amount: when bleeding is massive i.e. big vessel is suspected to be torn e.g. in gastric ulcer the prognosis will be worse.
More than 7 units of blood needed = serious condition
3- The time factor: Big amount in long duration is better than moderate amount in short duration.
4- Frequency: first attack is not serious, second attack is serious, third attack is fatal.
m Treatment:
I. Medical: usually succeed to control bleeding.
Blood transfusion, antacids, coagulants.
Morphia "not given in bl. varices"
Gastric wash through nasogastric tube by cold saline.
Oral feeding by iced citrated milk [why oral feeding is better than TPN?]
(i) Psychologically better. (ii) Neutralize the acidity.
(iii) Increase gastric tone ® decrease bleeding.
II. Minimal intervention techniques: Through the recent endoscopic devices haemostasis can be achieved either by expensive laser devices or inexpensive different injectant materials. These techniques are less useful in cases with bleeding from large vessels.

III. Surgical management:
q Indications:
Recurrence after medical control.
Severe hemorrhage from the start (More than 7 units in less than
12 hours).
Old age.
q Operation: Depends on general condition of the patient:
If good ® Do vagotomy & drainage operation with ligation of vessels at ulcer base, or partial gastrectomy including the ulcer area.
If the general condition is bad ® Do ligation of vessels at the base of the ulcer.
Occasionally, ulcer site cann't be detected even after gastrotomy (Hemorrhagic gastritis). In these cases blind gastrectomy may safe the patient's life.
SOURCE: DR. AYMAN SALEM'S BOOK
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