What are the most common complications of peptic ulcer?

Some people always think that peptic ulcer is just a common stomach disease and does not require any further treatment. If this continues for a long time, complications such as massive bleeding, pyloric obstruction, perforation, and cancer may suddenly occur, seriously endangering physical and mental health.

1. Heavy bleeding

It is the most common complication of peptic ulcer. Bleeding volume > 1000 ml occurs in approximately 10-25% of patients. Ulcer bleeding is the most common cause of acute upper gastrointestinal bleeding.

The main clinical manifestations are hematemesis and black stools. If an ulcer bleeds more than 60 ml at a time, black stools may appear, and vomiting blood is related to the bleeding site, amount of bleeding and bleeding rate. When gastric ulcer bleeds a lot at one time (250~300ml), vomiting blood may occur. If the bleeding rate is slow or the amount of bleeding is small, there may be only black stool. Bulbous ulcer accompanied by vomiting blood is generally rare, but if the amount of bleeding is large or the bleeding rate is fast, causing blood to reflux into the stomach, vomiting blood may also occur. In short, most patients only have black stools but no hematemesis, while those with hematemesis generally have black stools.

Systemic symptoms depend on the amount and rate of bleeding and the patient's responsiveness. If the bleeding is 60~100ml at a time, only black stool will appear, but there will be no systemic symptoms. The amount of bleeding is <500ml. Due to circulatory compensation, there may be mild dizziness, slightly pale complexion, normal or slightly faster pulse, and no change in blood pressure. If bleeding continues, syncope or shock may occur. Red blood cells, hemoglobin, hematocrit, etc. often remain unchanged within a few hours after bleeding, but decrease due to blood dilution after about 6 to 12 hours. After hemorrhagic shock is controlled, low fever (below 38.5℃) may occur, which lasts for 3-5 days or returns to normal after the stool turns yellow. When the amount of bleeding is large, mild intestinal azotemia may occur and the blood urea nitrogen increases, but most of the time it does not exceed 140mmol/L.

The diagnosis of ulcer bleeding is generally not difficult. For patients with a clear history of ulcers or difficult to establish a diagnosis, if the condition permits, emergency fiber gastroscopy should be performed within 24 to 48 hours to ensure a clear diagnosis and determine treatment measures.

2. Pyloric obstruction

Duodenal bulb or pyloric ulcers can cause reflex pyloric spasm or edema and inflammation of the tissues around the ulcer, which can lead to temporary pyloric obstruction of varying degrees. If the ulcer disappears as it improves after medical treatment, it is called functional (medical) pyloric obstruction. If the ulcer repeatedly recurs and leaves scars or adhesions after healing, causing persistent pyloric stenosis, it is called organic (surgical) pyloric obstruction.

Most patients have a history of long-term ulcer attacks. After complications of pyloric obstruction, the upper abdominal pain loses its rhythmicity and worsens after meals, sometimes presenting as colic or bloating, belching and acid reflux, and vomiting are the most prominent, more obvious after dinner. The vomit is large in volume, has a sour and smelly smell, and contains fermented overnight food. The upper abdominal pain is relieved after vomiting. Physical signs include upper abdominal distension, gastric shape, peristaltic waves and gurgling sounds. There may be malnutrition, dehydration, electrolyte imbalance (large loss of H+CI-K+ ions), and metabolic alkali poisoning. In severe cases, prerenal azotemia may be present.

The diagnosis of pyloric obstruction is not difficult, but it needs to be differentiated from pyloric obstruction caused by gastric cancer, etc. Barium meal examination after gastric lavage and fiber gastroscopy can be used for differentiation.

3. Perforation

Acute perforation is one of the most serious complications of peptic ulcer, with an incidence rate generally around 1-2%. According to statistics of hospitalized patients, acute perforation accounts for 18% of hospitalized patients with ulcer.

When the ulcer reaches deep into the serosa, it may suddenly penetrate and cause acute perforation, which is more common in ulcers of the lesser curvature of the gastric antrum and the anterior wall of the duodenal bulb. Some patients have factors such as full meals, rough food, and increased abdominal pressure. After acute perforation of the ulcer, the contents of the stomach and duodenum flow into the abdominal cavity, causing acute diffuse peritonitis. The clinical manifestations are sudden onset of severe abdominal pain, which begins in the upper abdomen and gradually extends to the umbilicus. Sometimes the gastrointestinal contents flow along the root of the mesentery to the right lower abdomen, causing right lower abdominal pain that resembles acute appendicitis perforation. Peritoneal irritation occurs several hours later, most patients have pneumoperitoneum, and some patients have symptoms of shock. It needs to be differentiated from other acute abdomens, and emergency surgical treatment is often required after diagnosis.

4. Canceration

A small number of gastric ulcers may become cancerous, but the incidence is generally believed to be very low, not exceeding 2 to 3%. The following points should be noted with caution: ① Symptoms do not improve after active medical treatment, or the ulcer persists; ② The rhythmic pain disappears without complications, and the original effective drugs are ineffective; ③ Weight loss; ④ The fecal occult blood test is continuously positive. If there are the above situations, further X-ray barium gas double contrast, gastroscopy review and mucosal biopsy should be performed to rule out early cancer. If no conclusion can be drawn, close follow-up and observation should be carried out until the ulcer heals.