COMLLICATIONS OF CHRONIC PEPTIC ULCER By AMGAD FOUAD Professor Of Surgery Gastroenterology Center Mansoura University.

Perforation Bleeding Stenosis Malignanacy - Acute - Subacute - Chronic - Hematemsis - Melena - Both Stenosis - pyloric stenosis - Hourglass -Tea-pot Malignanacy

ACUTE PERFORATION Incidence Etiology Ppt alcohol Path 10 – 15 % DU>GU 10 times Etiology Ppt alcohol Irritant foods nervousness Path Ant >post wall Stages : Stage of perforation stage of reaction stage of peritonitis

C/P Hist : +ve in 80 % Manifestations : 3 stages STAGE OF ONSET Sudden severe agonising pain Shock LUCID INTERVAL: 3 – 6 h Patient feels & looks better Tenderness & rigidity remain. SEPTIC PERITONITIS: 6 hours Abdomen distended & silent 36 – 48 hours → Toxemia

INVESTIGATIONS Clinical Hist → Diagnostic Doubtful Cases Plain X ray (70 %) GIT series with water-soluble contrast TREATMENT Resuscitation Urgent surgical intervention (Graham patch). Definitive surgery

Subacute Perforation A small leaking ulcer allow the body to wall off leaking material from the general cavity by omentum or by the liver with development of Subphrenic abcess

Chronic perforation (penetrating ulcer) The ulcer base penetrates a nearby organ Liver Pancreas Transverse colon

BLEEDING PEPTIC ULCER Incidence : Pathology : 65% DU > GU Hematemsis → GU Melena → DU Pathology : Mild : Granulation tissue Severe: Vs at floor Fatal : Penetration of large extragastric artery

Investigations: Clinical picture: Long history Massive bleeding Hypovolemic shock Hematemsis Melena Unless bleeding stops within 48 h → irreversible shock Investigations: Fiberoptic endoscopy Selective celiac angiography.

TREATMENT Conservative: Resuscitation Diagnosis Subsequent management Surgical: Indication: Profuse bleeding age > 45 years. Associated pathology procedure : Aim→ stop bleeding DU → vagotomy & drainage & under – running GU → Partial gastrectomy Endoscopic: Laser Sclerotherapy V.C agents

PYLORIC STENOSIS (GASTRIC OUTLET OBSTRUCTION) Pathology: Duod bulb → Cicatrized & stenosed Stomach → Hypertrophied → Dilated Intestine →Normal & Collapsed Complications: Metabolic Alkalosis Fluid & electrolyte imbalance Dehydration Antral Stasis Respiratory complications

CLINICAL PICTURE Long history: Symptoms: Distention Pain Vomiting Lost periodicity Progressive constipation Picture of complications Signs: General → Dehydration → Tetany → Mental confusion Abdominal → Epigastric fullness → Visible peristaltic waves → Succussion splash → Food residue

INVESTIGATIONS Blood chemistry Gastric function tests Ba Meal (soup dish appearance) Endoscopy.

TREATMENT Pre-operative preparation: Surgery: Gastric lavage IV fluid Abx Surgery: The only method of cure Vagotomy & drainage Gastrectomy

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