Key facts:
Authors: Alex Tan, Richard Lin, Anil Ghosh, Asif Haq
Top Tip: Atypical presentations are well recognised
Key Differential Diagnoses
- Non-perforated PU
- Gastritis, duodenitis, oesophagitis
- Pancreatitis
- Perforated intra-abdominal viscus
Key Investigations
- FBC, CRP, Clotting
- U&E, LFTs, Glucose, Amylase
- Blood cultures
- G&S
- Erect CXR, AXR
Key Treatment
- NBM
- Regular clinical assessment
- IV fluid & blood products
- Analgesia (IV MORPHINE 5-10mg) and anti-emetic (IV CYCLIZINE 10mg)
- Emergency surgery (laparotomy/ laparoscopic surgery)
Key Management Decision
- Surgery
Background
50% have no history of peptic ulcer
Introduction
- Most commonly affects 1st part of duodenum (90% of DU occur there, 2cm or less from the pylorus), the pylorus and lesser curve of the stomach; but may also affect the oesophagus and rarely the jejunum (associated with gastrojejunostomy and the ileum adjacent to a Meckel’s diverticulum)
- It is a clinical diagnosis which classically presents with a sudden onset of generalised abdominal pain, radiating to shoulder tip; and signs of peritonitis on examination
- Adjunct signs and symptoms include haematemesis and melaena
- If a chronic peptic ulcer (PU) is left untreated, it can lead to life-threatening gastrointestinal bleeding and perforation
- Duodenal ulcer (DU) perforation often involves the anterior wall of the first part of duodenum (the posterior perforation usually affects the pancreas or erodes into the gastroduodenal artery leading to severe haemorrhage)
- Gastric ulcers (GU) usually occur on the greater curve, fundus and antrum are more commonly malignant
Note: diagnosis can be difficult as there may be no history of PU, and atypical presentations occur (see below)
Definition
Peptic ulcer disease
- Ulceration of areas of the gastrointestinal tract due to exposure to gastric acid and pepsin. An ulcer is a breach in the epithelium that penetrates the muscularis mucosae
Perforation of a peptic ulcer
- Perforation of the wall of the gastrointestinal tract with spillage of gastric and small bowel contents
Etymology
- 'Peptic' means relating to or promoting digestion
- Derived from Latin pepticus, from Greek peptikos, from peptos 'cooked', from peptein, pessein 'to cook, digest'
Epidemiology
Peptic ulcer disease
- Annual incidence is approximately 1-4/1000; overall lifetime risk of PU disease is 10%
- DU usually affects patients <40y
- DU is more common in men, and are four times more common than GU
- Incidence of DU is decreasing in the UK and USA most likely due to early detection and effective medical management of Helicobacter pylori in the community
- GU occurs with a peak age between 55-65y
Perforation of a peptic ulcer - Approximately 50% of affected patients have no history of PU
- 79% male
- Older age group affected due to early use of anti-ulcer treatment and the use of NSAIDs and aspirin
- Decreasing incidence of DU perforation
- DU perforation is more common than GU perforation (67% vs 17%)
- GU perforation strongly associated with NSAIDs (e.g ibuprofen, diclofenac and naproxen)
- GU perforation peaks in the elderly, with associated high morbidity and mortality
Causes / Risk Factors
Peptic ulcer disease
- Usually due to an imbalance between damaging action of acid and pepsin and mucosal protective mechanisms
- Helicobacter pylori antritis: is present in more than 95% of non-drug related DU, leading to hypergastrinaemia, high acid secretion and gastric metaplasia in the duodenal cap, which is, in turn, colonised by H. pylori
- H. pylori is present in 70-80% of GU
- Ulcerogenic drugs: including NSAIDs, aspirin and steroids
- Genetic susceptibility - 20-50% of patients with DU have a positive family history of DU
- Blood group O (relative risk 1:25) and non-secretion of blood group substances in the saliva (weak association)
- Smoking - can reduce time of healing and increase the likelihood of relapse
- Alcohol consumption
- Environmental stress
Perforation
- Undiagnosed and untreated risk factors in the community before the acute presentation
- Failure of medical therapy of peptic ulcer disease
Types
- Duodenal
- Gastric
- Oesophageal
- Jejunum (in Zollinger-Ellison syndrome)
- Meckel’s diverticulum
- Occasionally at the site of previous gastroenterostomy
Symptoms
Perforated peptic ulcer disease
- Sudden onset of generalised abdominal pain, radiating to shoulder tip
- Vomiting (including haematemesis)
- May present with melaena
- May prefer to lie very still and avoid abdominal movement, or be writhing in pain
Atypical presentations
- Sealed perforations (or perforations contained by adhesions or omentum) may present with upper abdominal signs only
- PU that perforate posteriorly into the lesser sac may present with minimal abdominal signs
- Localised RIF peritonitis may occur if gastroduodenal contents track down the right paracolic gutter, mimicking appendicitis
Key questions
- “Where is the tummy pain? Does the pain become better with antacids?”
- “Do you take any aspirin, steroids or painkillers such as Ibuprofen, Diclofenac or Naproxen?”
- “Have you lost your appetite?”
- “Do you feel sick? Have you vomited? Have you noticed any blood in your vomit? Have you noticed any blood in your stools, or black stools? ”
- “Does your tummy hurt when you cough/move around/stand? Are you most comfortable lying still?”
Signs
Perforated peptic ulcer disease
- Generalised tender, rigid abdomen; with rebound and percussion tenderness, and guarding (a characteristic ‘drum-like’ tender abdomen); all suggesting peritonitis
- Haematemesis (coffee ground granules) and melaena
- Tachycardia, Hypotension, Tachypnoea
- May be pyrexial (> 37.5oC)
- Anorexia
- Cold peripheries
- Lying still - indicative of peritonitis; coughing or movement worsens the pain
- Absent or reduced bowel sounds
- Melaena, on PR
Investigation
Amylase is vital to exclude pancreatitis
Blood
- FBC (WC ↑↑, can be ↓ in advanced cases), CRP, Clotting, ± ABG, if unwell
- U&E (ARF?), LFTs, Glucose, Amylase (may be slightly ↑)
- Blood cultures
- G&S
Other
- AXR and erect CXR (obtain left lateral decubitus, if not fit enough for erect CXR)
- ECG
Erect CXR
Key investigation
- Erect CXR: gas under diaphragm in 70-85%
- Remember there are other causes of gas including: recent surgery, peritoneal dialysis, gas-forming infection, vaginal gas insufflation during water-skiing or oral sex)
Specialist investigation
- Consider CT abdomen, if there is generalised or localised peritonitis, with no free gas on erect CXR, and amylase↑
- If patient very unwell, do not delay laparotomy to do CT
Differential diagnoses
Principle
- Non-perforated PU
- Gastritis, duodenitis, oesophagitis
- Pancreatitis
- Perforated intra-abdominal viscus (e.g. distal oesophagus, gallbladder, small intestine, colon
Other
- Gastric carcinoma
- Abdominal aortic aneurysm (symptomatic)
- Intestinal obstruction
Medical
- Myocardial infarction
- Spontaneous bacterial peritonitis
Treatment
Regular clinical reassessment is important
Treatment (first line, definitive)
- For patients who are suspected to have a perforated viscus and are fit for surgery
- For those whose gastrointestinal bleeding failed to be controlled by gastroscopy or noted to have a perforation visualised on endoscopy:
- Laparotomy/laparoscopy should be performed without delay. A laparotomy and peritoneal lavage (irrigation with 2-10 Litres of warm saline) is usually performed, with the perforation being closed and an omental patch being placed over the ulcer. Any active bleeding is located and controlled by suturing the affected vessels
- Gastric ulcers: Antrectomy with vagotomy. A Bilroth I partial gastrectomy with gastroduodenal anastomosis is performed. The distal half of the stomach is removed, with a combined with a vagotomy. The stomach is then re-anastomosed directly to the duodenum. The GU should be biopsied (4 quadrant and frozen section) to exclude carcinoma
- Duodenal ulcers: A truncal or selective vagotomy with a combination of a drainage procedure (pyloroplasty or a gastroenterostomy) is performed. As the vagus nerve regulates the release of gastric acid, the division of these nerves can reduce the amount of acid generated. Otherwise, a Bilroth II partial gastrectomy used to be considered, but it is currently no longer performed. In this procedure, unlike Bilroth I procedure, the stomach is reanastomosed to a small bowel loop, leaving the duodenal stump being closed
- Postoperatively, if H. pylori positive, it needs to be eradicated with the appropriate medical therapy
Open vs laparoscopic repair
- There is no consensus on which method is the better approach
- Boey’s classification may act be a useful guide in the decision-making; whereas others may consider the age of the patient (>70 years) and size of the perforation (>10 mm) as relative contraindications for laparoscopic surgery
- Boey’s score has a maximum score of 3 (1 point for shock on admission; 1 for grade III-V of the American Society of Anaesthesiologists (ASA) comorbidity score; and 1 for more than 24 hour duration of symptoms). This would indicate high risk for laparoscopic surgery, thereby favouring the open approach
- In general, the advantage of performing laparoscopic surgery is the ability to make accurate diagnosis in the patient (up to 98% cases). The disadvantages of laparoscopy include longer operating time, cost - and it may be unsafe in a haemodynamically unstable patient
- Based on the Bertleff's review in 2010, the mortality of the patients was 3.6% in the laparoscopic surgery group and 6.4% in the open surgery group
Supportive measures
Drugs
Supportive Management
- NBM
- Emergency resuscitation, if necessary
- Maintenance of airway, breathing and circulation in a surgical emergency
- Oxygen, if hypoxic
- IV access, fluid resuscitation (e.g. crystalloids, colloids, blood)
- Consider NG tube, for aspiration of gastric contents
- Urinary catheter
Nursing
- Regular observations - temperature, respiratory rate, pulse, O2 saturation & blood pressure
Post-operative drugs
- IV PPI (eg IV OMEPRAZOLE 40mg od)
- Once eating, give oral 'triple therapy' (PO OMEPRAZOLE 20mg id + PO AMOXYCILLIN 1g bd + PO CLARITHROMYCIN 500mg bd) for one week
Key Management Decision
- Surgery
Treatment (alternative, conservative)
For high-risk patients (or where diagnosis is uncertain, but patient stable) consider a conservative approach:
- It is imperative to discuss this decision with the lead consultant ASAP
- Continue to re-examine the patient and re-assess the vital signs every hour to confirm/exclude the diagnosis
- Establish IV access and prescribe IV fluid (e.g. 0.9% Normal saline, colloids) if patient is dehydrated
- Prescribe adequate analgesia and anti-emetic (e.g. IV morphine and IV cyclizine)
- Keep the patient NBM and insert NG tube to facilitate aspirating gastric contents
- Give IV antibiotics (check hospital policy)
- If suspect causes other than perforated viscus, proceed to other investigations (eg US or CT scan) as long as patient is kept comfortable and is haemodynamically stable
- Admit the patient into the general surgical ward if unable to exclude the diagnosis
Prescribing issues
- Avoid metoclopramide if you suspect any intestinal obstruction
Stop
- Ulcerogenic drugs (NSAIDs, aspirin, steroids and clopidogrel)
Admit?
- Absolutely! Do not discharge the patient home until you (and your consultant) have ruled out any underlying perforated viscus and stopped any active gastrointestinal bleeding
Bed plan
- General surgical ward
- ± ITU (if needed for elderly patients who are not fit and well)
Referrals
- General surgery
- ± ITU
The Rest
Patients with a GU require an endoscopy in 6-8 weeks
Maxim
- "Treat peptic ulcer disease before gastrointestinal bleeding and perforation occurs"
Complications
Peptic ulcer surgery (Bertleff's review 2010)
- Postoperative scar (up to 9.9%)
- Postoperative mortality (5.8%)
- Intra-abdominal collection (5.7%)
- Wound infection (4.9%)
- Sepsis (4.6%)
- Re-surgery (4.5%)
- Prolonged ileus (4.1%)
- Leakage of suture (3.8%)
- Ulcer recurrence (3.1%)
- Haemorrhage (2%)
Risk stratification (Boey's Classification)
- In Boeys 1987 study, major medical illness, preoperative shock, and longstanding perforation (>24h) predicted outcome
- Mortality rate increased progressively with increasing numbers of risk factors: 0%, 10%, 45.5%, and 100% in patients with none, one, two, and all three risk factors, respectively
Prognosis
- Mortality 15-25%
- Higher mortality and morbidity in perforated GU > DU
2° Prevention + Health promotion
- Stop smoking, moderate alcohol consumption, environmental stress control
- Eradication therapy of H. pylori
Don't forget
- To keep monitoring and re-examining the patients managed conservatively
- To rule out perforated gastric carcinoma among elderly patients managed conservatively
- GU require repeat endoscopy in 6-8 weeks
Red flags
- Haematemesis, melaena
- Shock (hypotension, tachycardia, tachypnoea)
- Tender, rigid abdomen with rebound tenderness
Synonyms: peptic ulcer
