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Complications of Peptic Ulcer Disease!

 COMPLICATIONS OF PEPTIC ULCER DISEASE

  1. Bleeding peptic ulcer
  2. Pyloric stenosis
  3. Zollinger-Ellison Disease
  4. Stress Ulcers


Bleeding peptic ulcer:

  • Peptic ulcer is the most common cause of non-variceal upper gastro-intestinal bleeding.
  • Most patients with bleeding peptic ulcer are clinically stable and stop bleeding without any intervention, whereas other outcomes include re-bleeding and mortality.
  • Endoscopy allows identification of the severity of disease.
  • Endoscopic hemostatic therapy which is successful in reducing mortality.
  • A number of pharmacological agents have been used for endoscopic injection therapy such as 1:10000 adrenaline (epinephrine), human thrombin and fibrin glue.
  • Mechanical endoscopic treatment options include Thermocoagulation using a heater probe or endoscopic clipping.
  • Combination therapies are superior to monotherapy and a combination of adrenaline 1:10000 with either thermal or mechanical treatment is recommended (SIGN,2008).



Pyloric Stenosis:

Malignancy is the most common cause of gastric outlet obstruction.
Peptic ulcer disease is the underlying cause in about 10% of cases.
Conventional treatment with acid-suppressive therapy may also help.
If medical therapy fails to relieve the obstruction, Endoscopic balloon dilation or surgery may be required.


Zollinger-Ellison Syndrome:

  • This is a rare syndrome that consists of a triad of non-beta cell tumors of the pancreas that contain and release gastrin, gastric acid hypersecretion and severe ulcer disease.
  • Extra-pancreatic gastrinomas are also common and may be frequently found in the duodenal wall.
  • A proportion of these patients have tumors of the pituitary gland and parathyroid gland.
  • Patients with idiopathic peptic ulcer disease should be investigated for Zollimger-Ellison Syndrome.
  • Medical management includes; greater than standard doses of Proton Pump Inhibitors. The somatostatin analogue OCTREOTIDE is also effective but has no clear advantage over PPIs.


Stress Ulcers:

  • Sever physiological stress such as Head Injury, Spinal cord injury, Burns, Multiple traumas or Sepsis may induce superficial mucosa erosions or gastroduodenal ulcerations. These may lead to hemorrhage or perforation.
  • Diminished blood flow to the gastric mucosa, decreased cell renewal, diminished prostaglandin production and hypertension are involved in causing stress ulceration.
  • Management involves: Intravenous acid-suppression therapy, Histamine H-receptor antagonists, PPIs and Nasogastric tube administration of SUCRALFATE (4-6g daily in divided doses) have been used to prevent stress ulceration in the intensive care unit until patient tolerates enteral feeding.
Most commonly used regimens are: IV Ranitidine 50mg every 8hr reducing to 25mg in severe renal impairment.
  • Patients at Mechanical ventilation and the presence of coagulopathies are at higher risks of stress-related mucosal bleeding and may require prophylactic treatment.


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