UNIVERSITY iOVIDIUS iOF iCONSTANTA [611369]

UNIVERSITY i“OVIDIUS” iOF iCONSTANTA
FACULTY iOF iMEDICINE
GENERAL iMEDICINE

GASTRIC iULCER
COMPLICATIONS

Scientific icoordinator:
M.D.Ph.D. iNicoara iAlina -Doina

i i i i i i i i i i i i i i i i i i Undergraduate:
SIWAR

i i i i
i i i iConstanta
i i i i i i i i2020

I iwould ireally ilike ito ithank iscientific icoordinator idoctor iNicoara iAlina -Doina i ifor igiving
ime ithe iopportunity ito iwork ion imy ithesis iunder iher iobservation, iallowing ime ito
iparticipate iin iher iclinical idepartment iof iinternal imedicine -gastroenterology , iknowing ihow
iimportant ithis isubject imeans ito ime.

Table iof icontents
SECTION iI:
iINTRODUCTION…………………………………………………………………………………………..5
1. ANATOMY iAND iPHYSIOLOGY iOF iPEPTIC iULCERS……………………………..10
2. EPIDEMIOLOGY iAND iETIOPATHOGENESIS ……………. ………………………………12
3. i i i i i i i i i CLASSIFICATION iOF iPEPTIC iULCERS i…………………………………………………..
4. CLINICAL iFEATURES iOF iGASTRIC
iULCERS………. ………………. ……………………22
5. DIAGNOSIS: iPARACLINICAL iINVESTIGATIONS iAND iPHYSICAL
iEXAMINATIONS…………………………………………………………………………………………………26
5.1. iLABORATORY iFINDINGS……………………………………….. …………………………………..26
5.2. iGASTROESOPHAGEAL iFIBROSCOPY
6. DIFFERENTIAL iDIAGNOSIS………………………………………………………………51
7. PROGNOSIS iAND iEVOLUTION …………. ………………………………………………53
8. COMPLICATIONS iOF iGASTRIC iULCERS ………………………………. ……………….54
9. TREATMENT iOF iGASTRIC iULCERS i…………………………………………………………
9.1. iMEDICAL iMANAGEMENT………………………………………………………………………….55
9.2. iSURGICAL iTREATMENT…………………………………………………………………………….60

SECTION iII: iPERSONAL
iCONTRIBUTION……… ……………………………………………………… ……………………. …..61
a. PURPOSE………………………………………………………………………………………….61
b. MATERIALS iAND iMETH ODS…………………………………………………………………..62
c. RESULTS…………………………………………………………………………………………….64
1. iCases idistribution iaccording ito iage iand isex
2. iCases idistribution iaccording ito iregion
3. iCases idistribution iaccording ito icomplications
4. iCases idistribution iaccording ito icomorbidities
5. iCases idistribution iaccording ito ibehaviors i– ismoking, ialcohol iconsumption
6. iCases ianalyses iaccording ito iclinical iand iparaclinical iaspects
d. ABBREVIATIONS………………………………………………………………………………..71
e. REFERENCES…………………………………………………………………………. ……………73

i i i i i i i i i i i SECTION iI
i i i i i i i i i INTRODUCTION

Gastroi ntestinal ipathology iis ihighly ivaried. iThat iis ithe ireason iwhy iit iis ialmost
iimposible ito ipresent iit iexhaustively. iThe ipurpose iof ithis ithesis iis ito ideepen ia iserious
igastric iproblem i– igastric iulcer i– iwith iit’s icomplications, ithat ican icause ieven iexitus iif inot
itreated iproperly iand ito idiscuss ithe ilatest itreatment ioptions iavailable.
The ithesis iis istructured iin itwo imain iparts: ia igeneral ipart iand ia ispecial, ipersonal
icontribution.
The igeneral ipart icontains idata iabout ianatomy, iphysiology iof ithe igastrointestinal
itract, iwith ithe iprincipal iepidemiological, ietiopathogen etic, ipathophysiological, iclinical iand
iparaclinical icharacteristics. iIt iis ialso idiscussed ithe imedical iand isurgical itreatment iof
igastric iulcers. i
I itried ito imention icomplications iof ithe ipeptic iulcers, iinsisting iupon igastric iulcer
iand iit`s imost ifeared icomplication. iMoreover, iI ifollowed iand idiscussed ithe inewest
imethods iof idiagnostic iand ialso ithe imedical itreatment iversus ithe isurgical ione. i
I iwrote iabout iadvantages iand idisadvantages iof isurgical iand inon-surgical imethods,
iinsisting iupon ithe itherapeutic isuperiority iof…..
The ispecial ipart irepresents ia iclinical iand iparaclinical iretrospective istudy, iwhich
ihighlights ithe iclinical ifeatures, idiagnostic iand itherapeutic iof igastric iulcer. iFurthermore,
iemphasizes ithe ievolution iof ithe idisease iwith iit`s icomplications. i
To isum iup, iI imade ithis iretrospective istudy ion i50 ipatients iwith ithis idiagnosis i–
igastric iulcer i– ion iadmission i(between i2015 -2020), ifrom ithe iConstanta iCounty iEmergency
iHospital. iI iwrote ithe iresults , istatistically ianalyzed iand iprocessed iaccording ito iage, isex,
irace, iassociated icustoms, i icomorbidities, icomplications iand itherapeutic isuccess. i
At ithe iend iof imy ithesis, iI ioutlined isome iconclusions iresulted ifrom imy istudy iand
ithose iare ithat ithe igastric iulcer iis imore ifrequently imet iin ipatients ithat i…… iand
icomplications iappear imore ion i….. iThe imedical itreatment ishould istart iimmediat ely iafter
idiagnosis iand isurgical itreatment ishould ibe ipostponed iif…… i

I. GENERAL iPART
ANATOMY iAND iPHYSIOLOGY

Peptic iulcer idisease i(PUD) irefers ithe ifinding iof iat ileast ione iulcerative ilesion iin ithe
istomach ior ilining iof ithe iduodenum. iSharp -burning ipain ithat iis iusually i ilocalized iin ithe
iepigastric isite iexacerbated iby ithe ilack iof ifood iingestion iand iimproved i iby ifood iintake
ican ibe ithe isymptom i ithat icould imake ithe iclinician ithink iof i ithis idisease.
These iulcers iare iusually ichronic iin inature iand ithe imain itypes iare igastric iand
iduodenal iulcers. iThese iulcers iare ioften irelated ito iHelicobacter ipylori, iwhich iis ialso ian
iimportant irisk ifactor ifor igastric ilymphoma iand iother imalignan idiseases. iOther icauses iare
idaily iaspirin iintake iand iother i inonsteroidal ianti-inflammatory imedication ifor ivarious
iresons ; ithe iulcer iassociated iwith iZollinger iEllison isyndrome i(SZE) iwhich iis ibeing icaused
iby itumours iof ithe ipancreatic iislet icells iwho isecrete igastrin i ishould ibe ialso iconsidered . i
Although iactual iknowledge iabout ithe ireal icauses iof ipeptic iulcers iis iincomplete,
iwhat iwe iknow ifor isure iis ithat ithe imain irole iis ibeing iplayed iby ibacterial ipresence iof
iHelicobacter iPylori iand ialso ithe inecessary irole iof ihydrochloric iacid iand ipepsin. iIf ithe
iulcer iappears ior ino idepends ion isome ifactors ias: iif ithe icorrosive ieffects iof ipepsin iand
iacid iexceed ithe idefending imechanisms iof ithe igastric iand iduodenal imucosae. i i

Notions iof iGastric iAnatomy i

The istomach i iis ia icavitary iorgan, ibeing ithe ifirst iabdominal isegment iof ithe
idigestive, itract. iIt iis imuscular iand ihighly ivascular iorgan , iand ihas ithe iability ito idisten d
itaking ivarious ishapes, idepending ion iits ifullness ior ion ithe iposture iof ia iperso. iIt iis
ilocalized iin ithe ileft iupper iquadrant ior ileft ihypochondrium.

i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i Fig. i1 iThe ianatomy iof ithe istomach

The iesophagus i– ithe ithoracic ipart i– igoes iinto ithe iabdomen ithrough ithe iesophageal
ihiatus iof ithe idiaphragm iat ithe itenth ivertebrae. iThe iabdominal iesophageal isegment ihas ia
ilittle iabdominal ilength iof i2 ior i3 icm. iThe iesophagogastric ijunction , inamed icardia, istands
iin ithe iabdomen iunder ithe idiaphragm iat ithe ieleventh ivertebrae ilevel.
The i“incisura icardiaca igastri” iis ithe iangle ithat icomes ibetween ithe ifundus iof ithe
istomach iand ithe ileft iborder iof ithe iabdominal iesophagus. iThis iis ithe igastric isegment ithat
iis iover ia ihorizontal iline iif iit iis idrawn istarting ifrom ithe icardia. iThe icorpus iof ithe istomach
icontinues iafter iat iincisura iangularis iwith ithe ipylor ic iantrum . iThe ipylor ic iantrum istraitens
ito ithe iright iand isoon ibecomes ithe ihomologous icanal ibeing isurrounded iby ia isphincter
He ithen iconnects iwith ithe iduodenum i(transpyloric iplane) ito ithe iright iof ithe
imidline , iat ithe iL1 ilevel. i
The igastric ianterior isurface iis iclose ito ithe iabdominal iwall, itransverse icolon iand
inext ito ithe ihepatic ileft ilobe i– isegments iII, iIII iand iIV. iThe iposterior iplane iis iclose ito ileft
ihemidiaphragm iand iother iintra-abdominal iorgans isuch ias ispleen, ipancreas, ileft ikidney,
iadrenal.

The iomental ibursa iis isituated iposteriorly ito ithe istomach iand ianterior ito ithe
ipancreas; . iThe iconnection iof ithe ilesser isac iwith ithe igreater isac iis imade ithrough ithe
iepiploic iforam en, ibeing ibehind ito ithe ihepatoduodenal iligament .
The iconvex igastric icurvature ibegins iat ileft iof icardia , igoes istraight idown ifrom ithe
ifundus ithrough ithe ileft igastric imargin iand ithe iinferior iedging iof ithe ipylorus. iThe igastric
iconcave icurvature , inamed ilesser, ibegins iin ithe iright iside iof icardia , ibeing icontinued ifrom
ithe iabdominal iesophageal ipart. iIt igoes ia ishort idistance ialong ithe iright iborder iof ithe ibody
iof ithe istomach iand ithe isuperior iborder iof ithe ipylorus. iThe ijunction iof ivertical iand
ihorizontal iparts iof ithe iconcave icurvature iis inamed iincisura iangularis. iLesser icurvature iis
imuch ismaller icompared ito ithe igreat , iconvex, icurvature.
The istomach iand ithe ifirst ipart iof ithe iduodenum iare iattached ito ithe iliver iby ithe
ihepatogastric iligament i(the ileft iportion iof ithe ilesser iomentum) icontaining iright iand ileft
igastric ivessels, ito ithe ileft ihemidiaphragm iby ithe igastrophrenic iligament, ito ithe ispleen iby
ithe igastrosplenic/gastrolienal iligament icontaining ishort igastric ivessels, iand ito ithe
itransverse icolon iby ithe igastrocolic iligament i(part iof ithe igreater iomentum) icontaining
iepiploic ivessels. iFew iperitoneal ibands imay ibe ipresent ibetween ithe iposterior isurface iof
ithe istomach iand ithe ianterior isurface iof ithe ipancreas. iPart iof ithe igreater iomentum ihangs
ilike ian iapron ifrom ithe itransverse icolon, iwith i4 ilayers iof ithe iperitoneum: itwo ilayers igo
idownward ifrom ithe istomach iand ithen irun iupward ito ibe iattached ito ithe itransverse icolon.
Vascular isupply
The iceliac iaxis iarises ifrom ithe ianterior isurface iof ithe iabdominal iaorta iat ithe ilevel
iof iL1. iIt ihas ia ishort ilength i(about i1 icm) iand itrifurcates iinto ithe icommon ihepatic iartery
i(CHA), ithe isplenic iartery, iand ithe ileft igastric iartery i(LGA).

The iLGA iruns itoward ithe ilesser icurvature iof ithe istomach iand idivides iinto ian
iascending ibranch i(supplying ithe iabdominal iesophagus) iand ia idescending ibranch
i(supplying ithe iproximal istomach). iThe iCHA iruns itoward ithe iright ion ithe isuperior iborder
iof ithe ipancreas iand igives ioff ithe igastroduodenal iartery i(GDA), iwhich iruns idown ibehind
ithe ifirst ipart iof ithe iduodenum. iAfter igiving ioff ithe iGDA, ithe iCHA icontinues ias ithe
iproper ihepatic iartery.

The iright igastric iartery i(RGA), ia ibranch ifrom ithe iproper ior icommon ihepatic
iartery, iruns ialong ithe ilesser icurvature ifrom iright ito ileft iand ijoins ithe idescending ibranch
iof ithe iLGA ito iform ian iarcade ialong ithe ilesser icurvature ibetween ithe i2 ileaves iof
iperitoneum iof ithe ilesser iomentum. iThis iarcade igives ioff imultiple ismall iarteries ito ithe
ibody iof ithe istomach. iThe iGDA igives ioff ithe iPSPDA iand ithen idivides iinto ithe iright
igastro -omental i(gastroepiploic) iartery i(RGEA) iand ithe ianterior isuperior
ipancreaticoduodenal iartery i(ASPDA); iit ialso igives ioff ithe ismall isupraduodenal iartery i(of
iWilkie). iThe iright igastro -omental iartery iruns ialong ithe igreater icurvature ifrom iright ito
ileft.
The isplenic iartery iruns itoward ithe ileft ion ithe isuperior iborder iof ithe idistal ibody
iand itail iof ipancreas iand igives ioff ithe ileft igastro -epiploic i(gastro -omental) iartery i(LGEA),
iwhich iruns ifrom ileft ito iright ialong ithe igreater icurvature iand ijoins ithe iRGEA ito iform ian
iarcade ialong ithe igreater icurvature ibetween ithe itwo ileaves iof iperitoneum iof ithe igreater
iomentum. iThis iarcade igives ioff imultiple ismall iarteries ito ithe ibody iof ithe istomach.
The igreater icurvature iarcade iformed iby ithe iright igastro -omental iartery iand ithe ileft
igastro -omental iartery iprovides iseveral iomental i(epiploic) ibranches ito isupply ithe ihighly
ivascular igreater iomentum. iThe isplenic iartery ialso igives ioff i3-5 ishort igastric iarteries ithat
irun iin ithe igastro -splenic i(gastro -lienal) iligament iand isupply ithe iupper ipart iof ithe igreate r
icurvature iand ithe igastric ifundus. iFew ismall iposterior igastric iarteries imay iarise ifrom ithe
isplenic iartery. iThe istomach ihas ia irich inetwork iof ivessels iin iits isubmucosa.
The ileft igastric i(coronary) ivein idrains iinto ithe iportal ivein iat iits iformation i(by ithe
iunion iof ithe isplenic iand isuperior imesenteric iveins). iThe iright igastric iand iright igastro –
omental iveins idrain iinto ithe iportal ivein. iThe ileft igastro -omental ivein idrains iinto ithe
isplenic ivein, ias ido ithe ishort igastric iveins.
The ipylorus iis imarked iby ia iprepyloric ivein i(names ialso i- iof iMayo), iwhich ilies ion
iits ianterior isurface. iThe igastrocolic itrunk i(GCT) iof iHenle iis ipresent iin ia ilarge inumber iof
icases iand ilies iat ithe ijunction iof ithe ismall ibowel imesentery iand ithe itransverse imesocolon.
iIt imay idrain ibranches ifrom ithe imiddle icolic, iand iASPDV iand iright igastro -omental iveins.
The ishort igastric iarteries iand iveins iare isometimes icollectively ireferred ito ias ithe
ivasa ibrevia.
Lymphatic idrainage

Lymph inodes idraining ithe istomach iare inumbered iand idivided iinto i4 ilevels, ias
ifollows:
Level iI i(perigastric ilymph inodes) i- iRight iparacardiac i(1), ileft iparacardiac i(2),
ialong ilesser icurvature i(3) ialong igreater icurvature i(4), isuprapyloric i(5), iinfrapyloric i(6)
Level i2 i- iAlong iLGA i(7), ialong iCHA i(8), ialong iceliac iaxis i(9), iat isplenic ihilum
i(10), ialong isplenic iartery i(11)
Level i3 i- iIn ihepato -duodenal iligament i(12), ibehind iduodenum iand ipancreas ihead
i(13), iat ithe iroot iof ismall ibowel imesentery i(14)
Level i4 i- iMesocolic i(15), iparaaortic i(16)
Nerve isupply
The iesophageal iplexus iof ivagus i(para -sympathetic) inerves ilies iin ithe iposterior
imediastinum ibelow ithe ihila iof ithe ilungs. iIt idivides iinto i2 ivagal itrunks ithat ienter ithe
iabdomen ialong iwith ithe iesophagus ithrough ithe iesophageal ihiatus iin ithe ileft idome iof
idiaphragm. iThe iright i(posterior) ivagus iis ibehind iand ito ithe iright iof ithe iintra-abdominal
iesophagus, iwhereas ithe ileft ivagus iis iin ifront iof ithe iintra-abdominal iesophagus.
The iright ivagus igives ioff ia iposterior igastric ibranch icalled ithe icriminal inerve iof
iGrassi, iwhich itraverses ito ithe ileft iand isupplies ithe icardia iand ifundus iof ithe istomach; ithe
inerve iis iso icalled ibecause iit iis ioften imissed iduring ivagotomy iand iis ithen iresponsible ifor
irecurrence iof ipeptic iulcer. iThe iright ivagus igives ioff ia iceliac ibranch i(which isupplies ithe
ipancreas iand ithe ismall iand ilarge ibowel), iand ithe ileft ivagus igives ioff ia ihepatic ibranch
i(which isupplies ithe iliver iand ithe igallbladder).
After igiving ioff ithe iceliac iand ihepatic ibranches, irespectively, ithe iright iand ileft
ivagal itrunks icontinue ialong ithe ilesser icurvature iof ithe istomach i(in iclose icompany iwith
ithe ivascular iarcade iformed iby ithe ileft iand iright igastric ivessels) ias ithe iposterior iand
ianterior igastric inerves iof iLatarjet, iwhich isupply ithe icorpus i(body) iof ithe istomach, ithe
iantrum, iand ithe ipylorus.
Sympathetic inerve isupply ito ithe istomach icomes ifrom iceliac iganglia i(T5-T9).
Anatomy ion idiagnos tic iimaging

The istomach iand iduodenum iare ievaluated iradiologically iwith ibarium istudies iusing
ifluoroscopy. iIt ishould ibe inoted ithat ion icomputed itomography i(CT), ithe icardia iis ion ia
ilower ihorizontal iplane ithan ithe idome iof ithe ifundus iis.
Endoscopic ianatomy
Cardia i(esophagogastric ijunction), iincisura iangularis, iand ipylorus iare ivery iwell
iseen ion iupper iGI iendoscopy i(UGIE).
Physiological ianatomy
Stomach iis ia ireservoir; iits isize iand ishape ichanges ifrom itime ito itime idepending ion
ithe ivolume iof iits icontents i(food/fluid). iThe ishape iand iposition iof ithe istomach ialso
ichanges iwith ithe iposition iof ithe ipatient, iwhether ierect ior isupine. iA ilarge iJ-shaped
istomach ican idescend ias ilow idown ias iinto ithe ipelvis.
If ithere iis iany isevere ipain iin iany ipart iof ithe ibody isuch ias iureteric icolic idue ito
istone, iheadache , ithis imay igive irise ito ipylorospasm iand ireflex ivomiting.

Microscopic ianatomy iof ithe istomach
Like ithe iother iparts iof ithe igastrointestinal itract, ithe istomach iwalls iare imade iof ia
inumber iof ilayers. iFrom ithe iinside ito ithe ioutside, ithe ifirst imain ilayer iis ithe imucosa. iThis
iconsists iof ian iepithelium, ithe ilamina ipropria iunderneath, iand ia ithin ibit iof ismooth imuscle
icalled ithe imuscularis imucosae. iThe isubmucosa ilies iunder ithis iand iconsists iof ifibrous
iconnective itissue, iseparating ithe imucosa ifrom ithe inext ilayer, ithe imuscularis iexterna. iThe
imuscularis iin ithe istomach idiffers ifrom ithat iof iother iGI iorgans iin ithat iit ihas ithree ilayers
iof imuscle iinstead iof itwo. iUnder ithese imuscle ilayers iis ithe iadventitia, ilayers iof iconnective
itissue icontinuous iwith ithe iomenta.
The igastric iepithelial ilining iis imade iof irugae iwhich icontain imicroscopic igastric
ipits. iEvery igastric ipit ibranches iinto ifour ior ifive igastric iglands iand iis imade iup iof
iepithelial icells ithat iare ihighly ispecialized. iThe ideep ipits iare icalled ifundic ior ioxyntic
iglands. iDifferent itypes iof icells iare iat idifferent ilocations idown ithe ipits. iThe icells iat ithe
ibase iof ithese ipits iare ichief icells, iresponsible ifor iproduction iof ipepsinogen, ian iinactive
iprecursor iof ipepsin, iwhich idegrades iproteins. iThe isecretion iof ipepsinogen iprevents iself-
digestion iof ithe istomach icells. iFurther iup ithe ipits, iparietal icells iproduce igastric iacid iand ia
ivital isubstance, iintrinsic ifactor . iThe ifunction iof igastric iacid iis itwo ifold: i1) iit ikills imost iof
ithe ibacteria iin ifood, istimulates ihunger, iand iactivates ipepsinogen iinto ipepsin; iand i2) iit
idenatures ithe icomplex iprotein imolecule ias ia iprecursor ito iprotein idigestion ithrough
ienzyme iaction iin ithe istomach iand ismall iintestines. iNear ithe itop iof ithe ipits, iclosest ito ithe
icontents iof ithe istomach, ithere iare imucous -producing icells icalled igoblet icells ithat ihelp
iprotect ithe istomach ifrom iself-digestion.
The imuscularis iexterna iis imade iup iof ithree ilayers iof ismooth imuscle. iThe
iinnermost ilayer iis iobliquely -oriented: ithis iis inot iseen iin iother iparts iof ithe idigestive
isystem. iThis ilayer iis iresponsible ifor icreating ithe imotion ithat ichurns iand iphysically ibreaks
idown ithe ifood. iThe inext ilayers iare ithe isquare iand ithen ithe ilongitudinal, iwhich iare
ipresent ias iin iother iparts iof ithe iGI itract. iThe ipyloric iantrum ihas ithicker iskin icells iin iits
iwalls iand iperforms imore iforceful icontractions ithan ithe ifundus. iThe ipylorus iis isurrounded
iby ia ithick icircular imuscular iwall iwhich iis inormally itonically iconstricted, iforming ia
ifunctional i(if inot ianatomically idiscrete) ipyloric isphincter, iwhich icontrols ithe imovement
iof ichyme.
Digestive iProperties iof ithe iStomach

The imovement iand ithe iflow iof ichemicals iinto ithe istomach iare icontrolled iby iboth
ithe iautonomic inervous isystem iand ithe ivarious idigestive isystem ihormones.
The ihormone igastrin icauses ian iincrease iin ithe isecretion iof iHCl ifrom ithe iparietal
icells, iand ipepsinogen ifrom ichief icells iin ithe istomach. iIt ialso icauses iincreased imotility
i(movement, iperistalsis) iin ithe istomach. iGastrin iis ireleased iby iG-cells iin ithe istomach, ivia
ithe ibase icells iof ithe ipyloric i, icardiac i, iand ifundic iglands, iin iresponse ito idistension iof ithe
iantrum, iand idigestive iproducts i(especially ilarge iquantities iof iincompletely -digested
iproteins). iIt iis iinhibited iby ia ipH inormally iless ithan ifour i(high iacid), ias iwell ias ithe
ihormone isomatostatin.

Fundic iGland
The ifundic igland, ifound iin ithe istomach, isecretes igastrin iand iother ihormones.
Cardiac iGland
The icardiac igland, ifound iin ithe istomach, isecretes igastrin iand iother ihormones.
Pyloric iGland
The ipyloric igland, ifound iin ithe istomach, isecretes igastrin iand iother ihormones.
Cholecystokinin i(CCK) iprimarily ieffects ithe igall ibladder, icausing iit ito icontract, ibut
iit ialso idecreases igastric iemptying iand iincreases irelease iof ipancreatic ijuice, iwhich iis
ialkaline iand ineutralizes ithe ichyme. iIn ia idifferent iand irare imanner isecretin, iwhich iis
iproduced iin ithe ismall iintestine iand iprimarily ieffects ithe ipancreas, iwill ialso idiminish iacid
isecretion iin ithe istomach. iGastric iinhibitory ipeptide i(GIP) idecreases iboth igastric iacid
irelease iand imotility. iEnteroglucagon idecreases iboth igastric iacid iand imotility.
Other ithan igastrin, ithese ihormones iall iact ito iturn ioff ithe istomach's iaction. iThis iis
iin iresponse ito ifood iproducts iin ithe iliver iand igall ibladder iwhich ihave inot iyet ibeen
iabsorbed. iThe istomach ineeds ito ipush ifood iinto ithe ismall iintestine ionly iwhen iit iis inot
ibusy. iWhile ithe iintestine iis ifull iand istill idigesting ifood, ithe istomach iwill iact ias istorage
ifor ifood.

Epidermal igrowth ifactor i(EGF) iresults iin icellular iproliferation, idifferentiation, iand
isurvival. iEGF iis ia ilow-molecular -weight ipolypeptide ifirst ipurified ifrom ia imouse's
isubmandibular igland, ibut isince ifound iin imany ihuman itissues iincluding ithe isubmandibular
iand iparotid iglands. iSalivary iEGF, iwhich iseems ialso iregulated iby idietary iinorganic iiodine,
iplays ialso ian iimportant iphysiological irole iin ithe imaintenance iof ioroesophageal iand
igastric itissue iintegrity. iThe ibiologica l ieffects iof isalivary iEGF iinclude ihealing iof ioral iand
igastroesophageal iulcers, iinhibition iof igastric iacid isecretion, iand istimulation iof iDNA
isynthesis ias iwell ias imucosal iprotection ifrom iintraluminal iinjurious ifactors isuch ias igastric
iacid, ibile iacids, ipepsin, iand itrypsin, iand ito iphysical, ichemical, iand ibacterial iagents.
The istomach ican i"taste" isodium iglutamate iusing iglutamate ireceptors. iThis
iinformation iis ipassed ito ithe ilateral ihypothalamus iand ilimbic isystem iin ithe ibrain ias ia
ipalatability isignal ithrough ithe ivagus inerve. iThe istomach ican ialso isense, iindependently ito
itongue iand ioral itaste ireceptors, iglucose,carbohydrates, iproteins, iand ifats. iThis iallows ithe
ibrain ito ilink inutritional ivalue iof ifoods ito itheir itastes.
Although iabsorption iis ithe iprimary ifunction iof ithe ismall iintestine, isome iabsorption
iof icertain ismall imolecules idoes inevertheless ioccur iin ithe istomach ithrough iits ilining. iThis
iincludes iwater, iif ithe ibody iis itoo idehydrated; imedication, ilike iaspirin; iand iamino iacids
i(e.g., iwhey iprotein ishake).
There iare imany idifferent igastric iglands iwhich isecrete imany idifferent ichemicals.
iParietal icells isecrete ihydrochloric iacid iand iintrinsic ifactor; ichief icells isecrete ipepsinogen;
igoblet icells isecrete imucus; iargentaffin icells isecrete iserotonin iand ihistamine; iand iG icells
isecrete ithe ihormone igastrin.

Etiology
Peptic iulcer idisease imay ibe idue ito iany iof ithe ifollowing: iHelicobacter ipylori
iinfection, idrugs, ilifestyle ifactors, isevere iphysiologic istress, iGenetic ifactors

Helicobacter ipylori iinfection

H ipylori iinfection iand inonsteroidal ianti-inflammatory idrug i(NSAID) iuse iaccount
ifor imost icases iof ipeptic iulcer idisease. iThe irate iof iH ipylori iinfection ifor iduodenal iulcers
iin ithe iUnited iStates iis iless ithan i75% ifor ipatients iwho ido inot iuse iNSAIDs. iExcluding
ipatients iwho iused iNSAIDs, i61% iof iduodenal iulcers iand i63% iof igastric iulcers iwere
ipositive ifor iH ipylori iin ione istudy. iThese irates iwere ilower iin iwhites ithan iin inonwhites.
iPrevalence iof iH ipylori iinfection iin icomplicated iulcers i(ie, ibleeding, iperforation) iis
isignificantly ilower ithan ithat ifound iin iuncomplicated iulcer idisease.
Drugs
NSAID iuse iis ia icommon icause iof ipeptic iulcer idisease. iThese idrugs idisrupt ithe
imucosal ipermeability ibarrier, irendering ithe imucosa ivulnerable ito iinjury. iAs imany ias i30%
iof iadults itaking iNSAIDs ihave iGI iadverse ieffects. iFactors iassociated iwith ian iincreased
irisk iof iduodenal iulcers iin ithe isetting iof iNSAID iuse iinclude ihistory iof iprevious ipeptic
iulcer idisease, iolder iage, ifemale isex, ihigh idoses ior icombinations iof iNSAIDs, ilong-term
iNSAID iuse, iconcomitant iuse iof ianticoagulants, iand isevere icomorbid iillnesses.
A ilong-term iprospective istudy ifound ithat ipatients iwith iarthritis iwho iwere iolder
ithan i65 iyears iwho iregularly itook ilow-dose iaspirin iwere iat ian iincreased irisk ifor idyspepsia
isevere ienough ito inecessitate ithe idiscontinuation iof iNSAIDs. iThis isuggests ithat ibetter
imanagement iof iNSAID iuse ishould ibe idiscussed iwith iolder ipatients iin iorder ito ireduce
iNSAID -associated iupper iGI ievents.
Studies iof ipatients inewly iinitiated ion ilow-dose iaspirin ifor isecondary iprevention iof
icardiovascular ievents iidentified irisk ifactors ifor iuncomplicated ipeptic iulcer idisease iin
ithese ipatients ithat iincluded ithe ifollowing i:
– Previous ihistory iof ipeptic iulcer idisease
– Current iuse iof iNSAIDs, ioral isteroid iagents, ior iacid isuppressive iagents
– Tobacco iuse
– Stres s
– Depression
– Anemia

Although ithe iidea iwas iinitially icontroversial, imost ievidence inow isupports ithe iassertion
ithat iH ipylori iand iNSAIDs iare isynergistic iwith irespect ito ithe idevelopment iof ipeptic iulcer

idisease. iA imeta -analysis ifound ithat iH ipylori ieradication iin iNSAID -naive iusers ibefore ithe
iinitiation iof iNSAIDs iwas iassociated iwith ia idecrease iin ipeptic iulcers.
Although ithe iprevalence iof iNSAID igastropathy iin ichildren iis iunknown, iit iseems ito ibe
iincreasing, iespecially iin ichildren iwith ichronic iarthritis itreated iwith iNSAIDs. iCase ireports
ihave idemonstrated igastric iulceration ifrom ilow-dose iibuprofen iin ichildren, ieven iafter ijust
i1 ior i2 idoses .
Corticosteroids ialone ido inot iincrease ithe irisk ifor ipeptic iulcer idisease; ihowever, ithey
ican ipotentiate iulcer irisk iin ipatients iwho iuse iNSAIDs iconcurrently.

The irisk iof iupper iGI itract ibleeding imay ibe iincreased iin iusers iof ithe idiuretic
ispironolactone ior iserotonin ireuptake iinhibitors iwith imoderate ito ihigh iaffinity ifor
iserotonin itransporter.

Lifestyle ifactors
Evidence ithat itobacco iuse iis ia irisk ifactor ifor iduodenal iulcers iis inot iconclusive. iSupport
ifor ia ipathogenic irole ifor ismoking icomes ifrom ithe ifinding ithat ismoking imay iaccelerate
igastric iemptying iand idecrease ipancreatic ibicarbonate iproduction. iHowever, istudies ihave
iproduced icontradictory ifindings. iIn ione iprospective istudy iof imore ithan i47,000 imen iwith
iduodenal iulcers, ismoking idid inot iemerge ias ia irisk ifactor. iHowever, ismoking iin ithe
isetting iof iH ipylori iinfection imay iincrease ithe irisk iof irelapse iof ipeptic iulcer idisease.
iSmoking iis iharmful ito ithe igastroduodenal imucosa, iand iH ipylori iinfiltration iis idenser iin
ithe igastric iantrum iof ismokers. i

Alcohol iis iknown ito icause igastric imucosal iirritation iand inonspecific igastritis.
iEvidence ithat iconsumption iof ialcohol iis ia irisk ifactor ifor iduodenal iulcer iis iinconclusive.
iA iprospective istudy iof imore ithan i47,000 imen iwith iduodenal iulcer idid inot ifind ian
iassociation ibetween ialcohol iintake iand iduodenal iulcer. i
Little ievidence isuggests ithat icaffeine iintake iis iassociated iwith ian iincreased irisk iof
iduodenal iulcers.

Severe iphysiologic istress
Stressful iconditions ithat imay icause ipeptic iulcer idisease iinclude iburns, icentral
inervous isystem i(CNS) itrauma, isurgery, iand isevere imedical iillness. iSerious isystemic
iillness, isepsis, ihypotension, irespiratory ifailure, iand imultiple itraumatic iinjuries iincrease ithe
irisk ifor isecondary i(stress) iulceration.
Cushing iulcers iare iassociated iwith ia ibrain itumor ior iinjury iand itypically iare isingle,
ideep iulcers ithat iare iprone ito iperforation. iThey iare iassociated iwith ihigh igastric iacid
ioutput iand iare ilocated iin ithe iduodenum ior istomach. iExtensive iburns iare iassociated iwith
iCurling iulcers.
Stress iulceration iand iupper -gastrointestinal i(GI) ihemorrhage iare icomplications ithat
iare iincreasingly iencountered iin icritically iill ichildren iin ithe iintensive icare isetting. iSevere
iillness iand ia idecreased igastric ipH iare irelated ito ian iincreased irisk iof igastric iulceration
iand ihemorrhage.
Physiologic ifactors
In iup ito ione ithird iof ipatients iwith iduodenal iulcers, ibasal iacid ioutput i(BAO) iand
imaximal iacid ioutput i(MAO) iare iincreased. iIn ione istudy, iincreased iBAO iwas iassociated
iwith ian iodds iratio i[OR] iof iup ito i3.5, iand iincreased iMAO iwas iassociated iwith ian iOR iof
iup ito i7 ifor ithe idevelopment iof iduodenal iulcers. iIndividuals iat iespecially ihigh irisk iare
ithose iwith ia iBAO igreater ithan i15 imEq/h. iThe iincreased iBAO imay ireflect ithe ifact ithat iin
ia isignificant iproportion iof ipatients iwith iduodenal iulcers, ithe iparietal icell imass iis
iincreased ito inearly itwice ithat iof ithe ireference irange .
In iaddition ito ithe iincreased igastric iand iduodenal iacidity iobserved iin isome ipatients
iwith iduodenal iulcers, iaccelerated igastric iemptying iis ioften ipresent. iThis iacceleration ileads
ito ia ihigh iacid iload idelivered ito ithe ifirst ipart iof ithe iduodenum, iwhere i95% iof iall
iduodenal iulcers iare ilocated. iAcidification iof ithe iduodenum ileads ito igastric imetaplasia,
iwhich iindicates ireplacement iof iduodenal ivillous icells iwith icells ithat ishare imorphologic
iand isecretory icharacteristics iof ithe igastric iepithelium. iGastric imetaplasia imay icreate ian
ienvironment ithat iis iwell isuited ito icolonization iby iH ipylori.

Seasonal ichanges iand iclimate iextremes imay ialso iaffect igastric imucosa iand icause
idamage ito ithe igastric imucosa iand iits ibarrier ifunction. iIn iextreme icold iclimate, iYuan iet ial
inoted isignificantly ilower iexpression iof iheat ishock iprotein i70 i(HSP70) ias iwell ias
idecreased imucosal ithickness iin ithe igastric iantrum iof ipatients iwith ipeptic iulcer idisease
iwho iwere iat ihigh irisk iof ibleeding icompared ito ithose iat ilow irisk iof ibleeding.
Moreover, icompared ito iextreme ihot iclimate, iextreme icold iclimate iwas iassociated
iwith isignificantly ilower ilevels iof ioccludin, iHSP70, initric ioxide isynthase i(NOS), iand
iepidermal igrowth ifactor ireceptor i(EGFR), ibut ino istatistically isignificant idifferences iin
ithese iprotein iexpression ilevels iwere ifound ibetween ipatients iat ihigh iand ilow irisk iof
ibleeding. iThe iinvestigators ialso idid inot inote iany isignificant idifferences ifound iin ithe irates
iof iH ipylori iinfection iand ipH ilevels iof igastric ijuices ibetween ipatients iat ihigh ibleeding
irisk iand ilow ibleeding irisk. i
Genetics
More ithan i20% iof ipatients ihave ia ifamily ihistory iof iduodenal iulcers, icompared
iwith ionly i5-10% iin ithe icontrol igroups. iIn iaddition, iweak iassociations ihave ibeen iobserved
ibetween iduodenal iulcers iand iblood itype iO. iFurthermore, ipatients iwho ido inot isecrete
iABO iantigens iin itheir isaliva iand igastric ijuices iare iknown ito ibe iat ihigher irisk. iThe ireason
ifor ithese iapparent igenetic iassociations iis iunclear.
A irare igenetic iassociation iexists ibetween ifamilial ihyperpepsinogenemia itype iI i(a
igenetic iphenotype ileading ito ienhanced isecretion iof ipepsin) iand iduodenal iulcers.
iHowever, iH ipylori ican iincrease ipepsin isecretion, iand ia iretrospective ianalysis iof ithe isera
iof ione ifamily istudied ibefore ithe idiscovery iof iH ipylori irevealed ithat itheir ihigh ipepsin
ilevels iwere imore ilikely irelated ito iHelicobacter ipylori iinfection.

Additional ietiologic ifactors
Any iof ithe ifollowing imay ibe iassociated iwith ipeptic iulcer idisease:

1. Hepatic iCirrhosis
2. Chronic iObstructive iPulmonary iDisease
3. allergic igastritis iand ieosinophilic igastritis

4. cytomegalovirus iinfection
5. graft iversus ihost idisease
6. uremic igastropathy
7. Henoch -Schönlein igastritis
8. corrosive igastropathy
9. Celiac idisease
10. bile igastropathy
11. autoimmune idisease
12. Crohn idisease
13. other ilike: isarcoidosis, ihistiocytosis iX, ituberculosis
14. iphlegmonous igastritis iand iemphysematous igastritis
15. Other iinfections, iincluding iEpstein -Barr ivirus, iHIV, iHelicobacter iheilmannii,
iherpes isimplex, iinfluenza, isyphilis, iCandida ialbicans, ihistoplasmosis,
imucormycosis, iand ianisakiasis
16. chemotherapeutic iagents, isuch ias i5-fluorouracil i(5-FU), imethotrexate i(MTX), iand
icyclophosphamide , ilocal iradiation iresulti ng iin imucosal idamage, iwhich imay ilead ito
ithe idevelopment iof iduodenal iulcers
17. Use iof icrack icocaine, iwhich icauses ilocalized ivasoconstriction, iresulting iin ireduced
iblood iflow iand ipossibly ileading ito imucosal idamage

Epidemiology
The iepidemiology iof ithe igastric iand iduodenal iulcer ihas iknown ia iparticular
idynamic iin ithe ilast icentury, iwith imajor igeographical idifferences iof ithe iincidence iand
iprevalence . iIn iEurope, ieven iif ithere iis ia islight ifall iin ithe inumber iof icases iover ithe ilast
ifour idecades, ipeptic iulcer idiseases iare icharacterized iby ian iincidence iof i1-2/1000
iresidents.
Prevalence iof ithe idisease iis iestimated ion i5-10%, ithis ibeing i6 itimes imore ifrequent
iin ithe ipopulation iHelicobacter iPylori ipositive. iThe iprevalence iis ialso idependent iof
icomorbidities istatistically idocumented ias iCOPD, ialpha -1 iantitrypsin ideficiency, icystic
ifibrosis, ihepatic icirrhosis, ichronic irenal idisease, iendocrine idisease ias iZollinger iElisson,
imultiple iendocrine ineoplasia itype iI i– iMEN iI, ihyperparathyroidism.

Diagnostic ithe igastric iulcer
It iis igrounded ion ia icomplex iclinical iand iparaclinical ievaluation. i
Clinical imanifestation. iFrequently, igastric iulcers ievolve iasymptomatic. iNowadays iit
iis ieasy ito idiagnose iPUD, ibecause iof ithe igastr ointestinal iendoscopic imethods.
It iis imandatory ito iobtain ianamnestic idata ireferring ito ipersonal imedical ihistory, iespecially
iof ithe ipeptic iones, iadministered imedication i(NSAIDs, iglucocorticoids, iantiplatelet iagents,
ianticoagulants). iIndication iof ian ievaluation iprogramme iincludes icuantification iof ithe
ialcohol iintake iand itabaco iconsumption. i
The imain isymptom iis iepigastri c ipain. iThis iis idescribed ias ia iburning, isharp,
ignawing idiscomfort, ithat ihas ino iradiation iand iusually iappears iimmediately iafter imeal.
iThe idiscomfort iis ialso idescribed ias ian iill-defined, iaching isensation ior ias ihunger ipain
Up ito i10% iof ipatients iwith iNSAID -induced imucosal idisease ican ipresent iwith ia
icomplication i(bleeding, iperforation iand iobstruction) iwithout iantecedent isymptoms.
iDespite ithis ipoorcorrelation, ia icareful ihistory iand iphysical iexamination iare iessential
icomponents iof ithe iapproach ito ia ipatient isuspected iof ihaving ipeptic iulcers. i
The ipain iis ifrequently irelieved iby iantacids ior ifood. iPain ithat iawakes ithe ipatient ifrom
isleep i(between imidnight iand i3 ia.m.) iis ithe imost idiscriminating isymptom, iwith itwo-thirds
iof iDU ipatients idescribing ithis icomplaint. i
Unfortunately, ithis isymptom iis ialso ipresent iin ione-third iof ipatients iwith iNUD. iThe
ipain ipattern iin iGU ipatients imay ibe idifferent ifrom ithat iin iDU ipatients, iwhere idiscomfort
imay iactually ibe iprecipitated iby ifood. iNausea iand iweight iloss ioccur imore icommonly iin
iGU ipatients. i
Endoscopy idetects iulcers iin i<30% iof ipatients iwho ihave idyspepsia. i iThe
imechanism ifor idevelopment iof iabdominal ipain iin iulcer ipatients iis iunknown. iSeveral
ipossible iexplanations iinclude iacid- iinduced iactivation iof ichemical ireceptors iin ithe
iduodenum, ienhanced iduodenal isensitivity ito ibile iacids iand ipepsin, ior ialtered
igastroduodenal imotility. i
Variation iin ithe iintensity ior idistribution iof ithe iabdominal ipain, ias iwell ias ithe ionset
iof iassociated isymptoms isuch ias inausea iand/or ivomiting, imay ibe iindicative iof ian iulcer
icomplication. iDyspepsia ithat ibecomes iconstant, iis ino ilonger irelieved iby ifood ior iantacids,

ior iradiates ito ithe iback imay iindicate ia ipenetrating iulcer i(pancreas). iSudden ionset iof
isevere, igeneralized iabdominal ipain imay iindicate iperforation. iPain iworsening iwith imeals,
inausea, iand ivomiting ion iundigested ifood isuggest igastric ioutlet iobstruction. iTarry istools
ior icoffee -ground iemesis iindicate ibleeding. i
iPhysical iexamination i
iEpigastric itenderness iis ithe imost ifrequent ifinding iin ipatients iwith iGU ior iDU. iPain imay
ibe ifound ito ithe iright iof ithe imidline iin i20% iof ipatients. iUnfortunately, ithe ipredictive
ivalue iof ithis ifinding iis irather ilow. iPhysical iexamination iis icritically iimportant ifor
idisco vering ievidence iof iulcer icomplication. iTachycardia iand iorthostasis isuggest
idehydration isecondary ito ivomiting ior iactive iGI iblood iloss. iA iseverely itender, iboard ilike
iabdomen isuggests ia iperforation. i
Presence iof ia isuccussion isplash iindicates iretained ifluid iin ithe istomach, isuggesting
igastric ioutlet iobstruction.PUD -related icomplications / iGastrointestinal ibleeding iGI ibleeding
iis ithe imost icommon icomplication iobserved iin iPUD. iIt ioccurs iin i~15% iof ipatients iand
imore ioften iin iindividuals i>60 iyears iof iage. iThe imortality irate iis ias ihigh ias i5–10%. iThe
ihigher iincidence iin ithe ielderly iis ilikely idue ito ithe iincreased iuse iof iNSAIDs iin ithis igroup.
iUp ito i20% iof ipatients iwith iulcer -related ihemorrhage ibleed iwithout iany ipreceding
iwarning isigns ior isymptoms. i
Perforation iThe isecond imost icommon iulcer -related icomplication iis iperforation,
ibeing ireported iin ias imany ias i6–7% iof iPUD ipatients. i
As iin ithe icase iof ibleeding, ithe iincidence iof iperforation iin ithe ielderly iappears ito ibe
iincreasing isecondary ito iincreased iuse iof iNSAIDs. i
Penetration iis ia iform iof iperforation iin iwhich ithe iulcer ibed itunnels iinto ian iadjacent
iorgan. iDUs itend ito ipenetrate iposteriorly iinto ithe ipancreas, ileading ito ipancreatitis,
iwhereas iGUs itend ito ipenetrate iinto ithe ileft ihepatic ilobe. iGastrocolic ifistulas iassociated
iwith iGUs ihave ialso ibeen idescribed. i
iGastric ioutlet iobstruction iGastric ioutlet iobstruction iis ithe ileast icommon iulcer –
related icomplication, ioccurring iin i1–2% iof ipatients. iA ipatient imay ihave irelative
iobstruction isecondary ito iulcer -related iinflammation iand iedema iin ithe iperipyloric iregion.
iThis iprocess ioften iresolves iwith iulcer ihealing. iA ifixed, imechanical iobstruction isecondary
ito iscar iformation iin ithe iperipyloric iareas iis ialso ipossible. iThe ilatter irequires iendoscopic

i(balloon idilation) ior isurgical iintervention. iSigns iand isymptoms irelative ito imechanical
iobstruction imay idevelop iinsidiously. iNew ionset iof iearly isatiety, inausea, ivomiting,
iincrease iof ipostprandial iabdominal ipain, iand iweight iloss ishould imake igastric ioutlet
iobstruction ia ipossible idiagnosis. i
Paraclinical itests
The iclinician iis ioften iconfronted iwith ihaving ito iestablish ithe ipresence iof ian iulcer.
iDocumentation iof ian iulcer irequires ieither ia iradiographic i(barium istudy) ior ian iendoscopic
iprocedure. iHowever, ia ilarge ipercentage iof ipatients iwith isymptoms isuggestive iof ian iulcer
ihave iNUD; iempirical itherapy iis iappropriate ifor iindividuals iwho iare iotherwise ihealthy iand
i<45 iyears iof iage, ibefore iembarking ion ia idiagnostic ievaluation .
Barium istudies iof ithe iproximal iGI itract iare istill icommonly iused ias ia ifirst itest ifor
idocumenting ian iulcer. iA iGU imay irepresent ibenign ior imalignant idisease. iTypically, ia
ibenign iGU ialso iappears ias ia idiscrete icrater iwith iradiating imucosal ifolds ioriginating ifrom
ithe iulcer imargin . iUlcers i>3 icm iin isize ior ithose iassociated iwith ia imass iare imore ioften
imalignant. iUnfortunately, iup ito i8% iof iGUs ithat iappear ito ibe ibenign iby iradiographic
iappearance iare imalignant iby iendoscopy ior isurgery. iRadiographic istudies ithat ishow ia iGU
imust ibe ifollowed iby iendoscopy iand ibiopsy. iEndoscopy iprovides ithe imost isensitive iand
ispecific iapproach ifor iexamining ithe iupper iGI itract i

IMAGINE iEDS iUG

Gastrointestinal iendoscopy ihas ibeen iattempted ifor iover i200 iyears, ibut ithe iintroduction iof
isemirigid igastroscopes iin ithe imiddle iof ithe itwentieth icentury imarked ithe idawn iof ithe
imodern iendoscopic iera. iSince ithen, irapid iadvances iin iendoscopic itechnology ihave iled ito
idramatic ichanges iin ithe idiagnosis iand itreatment iof imany idigestive idiseases. iInnovative
iendoscopic idevices iand inew iendoscopic itreatment imodalities icontinue ito iexpand ithe iuse
iof iendoscopy iin ipatient icare.

Flexible iendoscopes iprovide ieither ian ioptical iimage i(transmitted iover ifiberoptic
ibundles) ior ian ielectronic ivideo iimage i(generated iby ia icharge -coupled idevice iin ithe itip iof
ithe iendoscope). iOperator icontrols ipermit ideflection iof ithe iendoscope itip; ifiberoptic
ibundles ibring ilight ito ithe itip iof ithe iendoscope; iand iworking ichannels iallow iwashing,
isuctioning,and ithe ipassage iof iinstruments. iProgressive ichanges iin ithe idiameter iand
istiffness iof iendoscopes ihave iimproved ithe iease iand ipatient itolerance iof iendoscopy.
ENDOSCOPIC iPROCEDURES
UPPER iENDOSCOPY
Upper iendoscopy, ialso ireferred ito ias iesophagogastroduodenoscopy i(EGD), iis
iperformed iby ipassing ia iflexible iendoscope ithrough ithe imouth iinto ithe iesophagus,
istomach, ibulb, iand isecond iduodenum.
The iprocedure iis ithe ibest imethod ifor iexamining ithe iupper igastrointestinal imucosa.
iWhile ithe iupper igastrointestinal iradiographic iseries ihas isimilar iaccuracy ifor idiagnosis iof
iduodenal iulcer , iEGD iis isuperior ifor idetection iof igastric iulcers iand iflat imucosal ilesions
isuch ias iBarrett’s iesophagus iand iit ipermits idirected ibiopsy iand iendoscopic itherapy.
iIntravenous iconscious isedation iis igiven ito imost ipatients iin ithe iUnited iStates ito iease ithe
ianxiety iand idiscomfort iof ithe iprocedure, ialthough iin imany icountries
EGD iis iroutinely iperformed iwith itopical ipharyngeal ianesthesia ionly.

IMAGINE iULCER iGASTRIC, iESOFAG iBARETT

In iaddition ito ipermitting idirect ivisualization iof ithe imucosa, iendoscopy ifacilitates
iphotographic idocumentation iof ia imucosal idefect iand itissue ibiopsy ito irule iout imalignancy
i(GU) ior iH. ipylori. iEndoscopic iexamination iis iparticularly ihelpful iin iidentifying ilesions
itoo ismall ito idetect iby iradiographic iexamination, ifor ievaluation iof iatypical iradiographic
iabnormalities, ior ito idetermine iif ian iulcer iis ia isource iof iblood iloss. i

Among ithe imethods ifor idiagnosing iH. ipylori iare ibiopsy iurease itests iwho ihave
ibeen ideveloped i(PyloriTek, iCLOtest, iHpfast, iPronto iDry) ithat ihave ia isensitivity iand
ispecificity iof i
>90–95%. iSeveral inoninvasive imethods ifor idetecting ithis iorganism ihave ibeen ideveloped.
iThree itypes iof istudies iroutinely iused iinclude iserologic itesting, ithe i13 iC- ior i14 iC-urea
ibreath itest, iand ithe ifecal iH. ipylori i(Hp) iantigen itest. iA iurinary iHp iantigen itest, ias iwell ias
ia irefined imonoclonal iantibody istool iantigen itest, iappears ipromising.
Occasionally, ispecialized itesting isuch ias iserum igastrin iand i igastric iacid ianalysis ior
isham ifeeding imay ibe ineeded iin iindividu -als iwith icomplicated ior irefractory iPUD .
iScreening ifor iaspirin ior iNSAIDs i(blood imay ialso ibe inecessary iin irefractory iH. ipylori i–
negative iPUD ipatients.

iDifferential idiagnosis i
The ilist iof igastrointestinal iand inongastrointestinal idisorders ithat ican imimic
iulceration iof ithe istomach ior iduodenum iis iquite iextensive. i
The imost icommonly iencountered idiagnosis iamong ipatients iseen ifor iupper
iabdominal idiscomfort iis iNUD. iNUD, ialso iknown ias ifunctional idyspepsia ior
iessential idyspepsia, irefers ito ia igroup iof iheterogeneous idisorders itypified iby iupper
iabdominal ipain iwithout ithe ipresence iof ian iulcer. iDyspepsia ihas ibeen ireported ito
ioccur iin iup ito i30% iof ithe iU.S. ipopulation. iUp ito i60% iof ipatients iseeking imedical
icare ifor idyspepsia ihave ia inegative idiagnostic ievaluation. iThe ietiology iof iNUD iis
inot iestablished, iand ithe ipotential irole iof iH. ipylori iin iNUD iremains icontroversial.
iSeveral iadditional idisease iprocesses ithat imay ipresent iwith i“ulcer -like” isymptoms
iinclude iproximal iGI itumors, igastroesophageal ireflux, ivascular idisease,
ipancreaticobiliary idisease i(biliary icolic, ichronic ipancreatitis), iand igastroduodenal
iCrohn’s idisease.

Peptic iUlcer iDisease

i Although iacid isecretion iis istill iimportant iin ithe ipathogenesis iof iPUD, ieradication
iof iH. ipylori iand itherapy/prevention iof iNSAID -induced idisease iis ithe imainstay iof
itreatment. iA isummary iof icommonly iused idrugs ifor itreatment iof iacid ipeptic idisorders .

ACID iNEUTRALIZING/INHIBITORY iDRUGS i
Before iwe iunderstood ithe iimportant irole iof ihistamine iin istimulating iparietal icell iactivity,
ineutralization iof isecreted iacid iwith iantacids iconstituted ithe imain iform iof itherapy ifor
ipeptic iulcers. iThey iare inow irarely, iif iever, iused ias ithe iprimary itherapeutic iagent ibut
iinstead iare ioften iused iby ipatients ifor isymptomatic irelief iof idyspepsia. iThe imost
icommonly iused iagents iare imixtures iof ialuminum ihydroxide iand imagnesium ihydroxide.
iAluminum ihydroxide ican iproduce iconstipation iand iphosphate idepletion; imagnesium
ihydroxide imay icause iloose i
stools. iMany iof ithe icommonly iused iantacids i(e.g., iMaalox, iMylanta) ihave ia icombination
iof iboth ialuminum iand imagnesium ihydroxide iin iorder ito iavoid ithese iside ieffects. iThe
imagnesium -containing ipreparation ishould inot ibe iused iin ichronic irenal ifailure ipatients
ibecause iof ipossible ihypermagnesemia, iand ialuminum imay icause ichronic ineurotoxicity iin
ithese ipatients. i
Calcium icarbonate iand isodium ibicarbonate iare ipotent iantacids iwith ivarying ilevels
iof ipotential iproblems. iThe ilong-term iuse iof icalcium icarbonate i(converts ito icalcium
ichloride iin ithe istomach) ican ilead ito imilk-alkali isyndrome i(hypercalcemia,
ihyperphosphatemia iwith ipossible irenal icalcinosis iand iprogression ito irenal iinsufficiency).
iSodium ibicarbonate imay iinduce isystemic ialkalosis. i
iH i2 iReceptor iAntagonists . iFour iof ithese iagents : icimetidine, iranitidine, ifamotidine,
iand inizatidine iare iuseful , iand itheir istructures ishare ihomology iwith ihistamine. iAlthough i
each ihas idifferent ipotency, iall iwill isignificantly iinhibit ibasal iand istimulated iacid isecretion
ito icomparable ilevels iwhen iused iat itherapeutic idoses. iMoreover, isimilar iulcer -healing irates
iare iachieved iwith ieach idrug iwhen iused iat ithe icorrect idosage. iPresently, ithis iclass iof idrug
iis ioften iused ifor itreatment iof iactive iulcers i(4–6 iweeks) iin icombination iwith iantibiotics
idirected iat ieradicating iH. ipylori . iCimetidine iwas ithe ifirst iH i2receptor iantagonist iused ifor
ithe itreatment iof iacid ipeptic idisorders. iThe iinitial irecommended idosing iprofile ifor
icimetidine iwas i300 img iqid. iSubsequent istudies ihave idocumented ithe iefficacy iof iusing

i800 img iat ibedtime ifor itreatment iof iactive iulcer, iwith ihealing irates iapproaching i80% iat i4
iweeks. iCimetidine imay ihave iweak iantiandrogenic iside ieffects iresulting iin ireversible
igynecomastia iand iimpotence , iprimarily iin ipatients ireceiving ihigh idoses ifor iprolonged
iperiods iof itime i(months ito iyears, ias iin iZES). iIn iview iof icimetidine’s iability ito iinhibit
icytochrome iP450, icareful imonitoring iof idrugs isuch ias iwarfarin, iphenytoin, iand
itheophylline iis iindicated iwith ilong-term iusage. iOther irare ireversible iadverse ieffects
ireported iwith icimetidine iinclude iconfusion iand ielevated ilevels iof iserum
iaminotransferases, icreatinine, iand iserum iprolactin. iRanitidine, ifamotidine, iand inizatidine
iare imore ipotent iH i2receptor iantagonists ithan icimetidine. iEach ican ibe iused ionce ia iday iat
ibedtime ifor iulcer iprevention, iwhich iwas icommonly idone ibefore ithe idiscovery iof iH.
ipylori iand ithe idevelopment iof iproton ipump iinhibitors i(PPIs). iPatients imay idevelop
itolerance ito iH i2 iblockers, ia irare ievent iwith iPPIs. iComparable inighttime idosing iregimens
iare iranitidine i300 img, ifamotidine i40 img, iand inizatidine i300 img. i
iAdditional irare, ireversible isystemic itoxicities ireported iwith iH i2 ireceptor
iantagonists iinclude ipancytopenia, ineutropenia, ianemia, iand ithrombocytopenia, iwith ia
iprevalence irate ivarying ifrom i0.01–0.2%. iCimetidine iand iranitidine i(to ia ilesser iextent) ican
ibind ito ihepatic icytochrome iP450; ifamotidine iand inizatidine ido inot. iProton iPump i(H i+ i,K
i+ i-ATPase) iInhibitors iOmeprazole, iesomeprazole, ilansoprazole, irabeprazole, iand
ipantoprazole iare isubstituted ibenzimidazole iderivatives ithat icovalently ibind iand
iirreversibly iinhibit iH i+ i,K i+ i-ATPase. iEsomeprazole, ithe inewest imember iof ithis idrug
iclass, iis ithe iS-enantiomer iof iomeprazole, iwhich iis ia iracemic imixture iof iboth iS- iand iR-
optical iisomers. i
These iare ithe imost ipotent iacid iinhibitory iagents iavailable. iOmeprazole iand ilansoprazole
iare ithe iPPIs ithat ihave ibeen iused ifor ithe ilongest itime
Omeprazole iis iavailable ias inonenteric -coated igranules imixed iwith isodium ibicarbonate iin ia
ipowder iform ithat ican ibe iadministered iorally ior ivia igastric itube. iThe isodium ibicarbonate
ihas itwo ipurposes: ito iprotect ithe iomeprazole ifrom iacid idegradation iand ito ipromote i
rapid igastric ialkalinization iand isubsequent iproton ipump iactivation, iwhich ifacilitates irapid
iaction iof ithe iPPI. iPantoprazole iand irabeprazole iare iavailable ias ienteric -coated itablets.
iPantoprazole iis ialso iavailable ias ia iparenteral iformulation ifor iintravenous iuse. iThese
iagents iare ilipophilic icompounds; iupon ientering ithe iparietal icell, ithey iare iprotonated iand
itrapped iwithin ithe iacid ienvironment iof ithe itubulovesicular iand icanalicular isystem. i

These iagents ipotently iinhibit iall iphases iof igastric iacid isecretion. iOnset iof iaction iis irapid,
iwith ia imaximum iacid iinhibitory ieffect ibetween i2 iand i6 ihours iafter iadministration iand
iduration iof iinhibition ilasting iup ito i72–96 ihours. iWith irepeated idaily idosing, iprogressive
iacid iinhibitory ieffects iare iobserved, iwith ibasal iand isecretagogue -stimulated iacid
iproduction ibeing iinhibited iby i>95% iafter i1 iweek iof itherapy. iThe ihalf-life iof iPPIs iis i~18
ihours; ithus, iit ican itake ibetween i2 iand i5 idays ifor igastric iacid isecretion ito ireturn ito
inormal ilevels ionce ithese idrugs ihave ibeen idiscontinued. iBecause ithe ipumps ineed ito ibe
iactivated ifor ithese iagents ito ibe ieffective, itheir iefficacy iis imaximized iif ithey iare
iadministered ibefore ia imeal i(except ifor ithe iimmediate -release iformulation iof iomeprazole)
i(e.g., iin ithe imorning ibefore ibreakfast). iMild ito imoderate ihypergastrinemia ihas ibeen
iobserved iin ipatients itaking ithese idrugs. iCarcinoid itumors ideveloped iin isome ianimals
igiven ithe idrugs ipreclinically; ihowever, iextensive iexperience ihas ifailed ito idemonstrate
igastric icarcinoid itumor idevelopment iin ihumans. iSerum igastrin ilevels ireturn ito inormal
ilevels iwithin i1–2 iweeks iafter idrug icessation. iRebound igastric iacid ihypersecretion ihas
ibeen idescribed iin iH. ipylori inegative iindividuals iafter i
discontinuation iof iPPIs. iIt ioccurs ieven iafter irelatively ishort -term iusage i(2 imonths) iand
imay ilast ifor iup ito i2 imonths iafter ithe iPPI ihas ibeen idiscontinued. i
Hepatic icytochrome iP450 ican ibe iinhibited iby ithe iearlier iPPIs i(omeprazole,
ilansoprazole). i
Rabeprazole, ipantoprazole, iand iesomeprazole ido inot iappear ito iinteract isignificantly
iwith idrugs imetabolized iby ithe icytochrome iP450 isystem. iThe ioverall iclinical isignificance
iof ithis iobservation iis inot idefinitely iestablished. iCaution ishould ibe itaken iwhen iusing
itheophylline, iwarfarin, idiazepam, iatazanavir, iand iphenytoin iconcomitantly iwith iPPIs.
iLong -term iacid isuppression, iespecially iwith iPPIs, ihas ibeen iassociated iwith ia ihigher
iincidence iof icommunity -acquired ipneumonia ias iwell ias icommunity iand ihospital iacquir ed
iClostridium idifficile i-associated idisease. i
PPIs imay iexert ia inegative ieffect ion ithe ianti-platelet ieffect iof iclopidogrel. iAlthough
ithe ievidence iis imixed iand iinconclusive, ia ismall iincrease iin imortality iand ireadmission irate
ifor icoronary ievents iis iseen iin ipatients ireceiving ia iPPI iwhile ion iclopidogrel. i
The imechanism iinvolves ithe icompetition iof ithe iPPI iand iclopidogrel iwith ithe isame
icytochrome ip450 i(CYP2C19). i

iCYTOPROTECTIVE iAGENTS i
i Sucralfate iSucralfate iis ia icomplex isucrose isalt iin iwhich ithe ihydroxyl igroups ihave
ibeen isubstituted iby ialuminum ihydroxide iand isulfate. iThis icompound iis iinsoluble iin iwater
iand ibecomes ia iviscous ipaste iwithin ithe istomach iand iduodenum, ibinding iprimarily ito isites
iof iactive iulceration. iSucralfate imay iact iby iseveral imechanisms: iserving ias ia
iphysicochemical ibarrier, ipromoting ia itrophic iaction iby ibinding igrowth ifactors isuch ias
iEGF, ienhancing iprostaglandin isynthesis, istimulating imucus iand ibicarbonate isecretion, iand
ienhancing imucosal idefense iand irepair. iToxicity ifrom ithis idrug iis irare, iwith iconstipation
ibeing imost icom-mon i(2–3%). iIt ishould ibe iavoided iin ipatients iwith ichronic irenal
iinsufficiency ito iprevent ialuminum -induced ineurotoxicity. i
Hypophosphatemia iand igastric ibezoar iformation ihave ialso ibeen ireported irarely.
itreating iPUD. i

THERAPY iOF iH. iPYLORI iExtensive ieffort ihas ibeen imade iin ideter -mining iwho iof ithe
imany iindividuals iwith iH. ipylori iinfection ishould ibe itreated. iThe icommon iconclusion
iarrived iat iby imultiple iconsensus iconferences iaround ithe iworld iis ithat iH. ipylorishould ibe
ieradicated iin ipatients iwith idocumented iPUD. iThis iholds itrue iindependent iof itime iof
ipresentation i(first iepisode ior inot), iseverity iof isymptoms, ipresence iof iconfounding ifactors
isuch ias iingestion iof iNSAIDs, ior iwhether ithe iulcer iis iin i iremission. iSome ihave iadvocate d
itreating ipatients iwith ia ihistory iof idocumented iPUD iwho iare ifound ito ibe iH. ipylori i–
positive iby iserology ior ibreath itesting. iOver ione-half iof ipatients iwith igastric iMALT
ilymphoma iexperience icomplete iremission iof ithe itumor iin iresponse ito iH. ipylori
ieradication. iTreating ipatients iwith iNUD, ito iprevent igastric icancer ior ipatients iwith iGERD
irequiring ilong-term iacid isuppression, iremains icontroversial. iGuidelines ifrom ithe
iAmerican iCollege iof iGastroenterology isuggest ieradi -cation iof iH. ipylori iin ipatients iwho
ihave iundergone iresection iof iearly igastric icancer. iThe irole iof iH. ipylori ieradication ias ia
imeans ito iprevent igastric icancer iis istill icontroversial ialthough idata isuggest ia ibenefit iof
iearly ieradication iof iH. ipylori ifor iprevention iof i
gastric icancer iin ipatients iwith ipeptic iulcer idisease. i

Multiple idrugs ihave ibeen ievaluated iin ithe itherapy iof iH. ipylori. iNo isingle iagent iis
ieffective iin ieradicating ithe iorganism. iCombination itherapy ifor i14 idays iprovides ithe
igreatest iefficacy. iA ishorter icourse iadministration i(7–10 idays), ialthough iattractive, ias inot
iproved ias isuccessful ias ithe i14-days iregimens. iThe iagents iused iwith ithe igreatest
ifrequency iinclude iamoxicillin, imetronidazole, itetracycline, iclarithromycin, iand ibismuth
icompounds. i
iThe iphysician’s igoal iin itreating iPUD iis ito iprovide irelief iof isymptoms i(pain ior
idyspepsia), ipromote iulcer ihealing, iand iultimately iprevent iulcer irecurrence iand
icomplications.
Documented ieradication iof iH. ipylori iin ipatients iwith iPUD iis iassociated iwith ia
idramatic idecrease iin iulcer irecurrence ito i<10–20% ias icompared ito i59% iin iGU ipatients
iand i67% iin iDU ipatients iwhen ithe iorganism iis inot ieliminated. iEradication iof ithe
iorganism imay ilead ito idiminished irecurrent iulcer ibleeding. iThe iimpact iof iits ieradication
ion iulcer iperforation iis iunclear.

THERAPY iOF iNSAID -RELATED iGASTRIC iOR iDUODENAL iINJURY i
iMedical iintervention ifor iNSAID -related imucosal iinjury iincludes itreatment iof ian
iactive iulcer iand iprimary iprevention iof ifuture iinjury. i
Ideally, ithe iinjurious iagent ishould ibe istopped ias ithe ifirst istep iin ithe itherapy iof ian
iactive iNSAID -induced iulcer. iIf ithat iis ipossible, ithen itreatment iwith ione iof ithe iacid
iinhibitory iagents i(H i2blockers, iPPIs) iis iindicated. iCessation iof iNSAIDs iis inot ialways
ipossible ibecause iof ithe ipatient’s isevere iunderlying idisease. iOnly iPPIs ican iheal iGUs,
iindependent iof iwhether iNSAIDs iare idiscontinued. i
The iapproach ito iprimary iprevention ihas iincluded iavoiding ithe iagent, iusing
iNSAIDs ithat iare itheoretically iless iinjurious, iand/or ithe iuse iof iconcomitant imedical
itherapy ito iprevent iNSAID -induced iinjury. iSeveral inonselective iNSAIDs ithat iare
iassociated iwith ia ilower ilikelihood iof iGI itoxicity iinclude idiclofenac, iaceclofenac, iand
iibuprofen, ialthough ithe ibeneficial ieffect imay ibe ieliminated iif ihigher idosages iof ithe
iagents iare iused. iPrimary iprevention iof iNSAID -induced iulceration ican ibe iaccomplished
iby imisoprostol i(200 iμg iqid) ior ia iPPI. iHigh -dose iH i2blockers i(famotidine, i40 img ibid)
ihave ialso ishown isome ipromise iin ipre-venting iendoscopically idocumented iulcers, ialthough

iPPIs iare isuperior. iThe ihighly iselective iCOX -2 iinhibitors, icelecoxib iand irofecoxib, iare
i100 itimes imore iselective iinhibitors iof iCOX -2 ithan istandard iNSAIDs, ileading ito igastric
ior iduodenal imucosal iinjury ithat iis icomparable ito iplacebo; itheir iutilization iled ito ian
iincrease iin icardiovascular ievents iand iwithdrawal ifrom ithe imarket. iAdditional icaution iwas
iengendered iwhen ithe iCLASS istudy idemonstrated ithat ithe iadvantage iof icelecoxib iin
ipreventing iGI icomplications iwas ioffset iwhen ilow-dose iaspirin iwas iused isimultaneously.
iTherefore, igastric iprotection itherapy iis irequired iin iindividuals itaking iCOX -2 iinhibitors
iand iaspirin iprophylaxis. i

APPROACH iAND iTHERAPY: iSUMMARY i
Controversy icontinues iregarding ithe ibest iapproach ito ithe ipatient iwho ipresents iwith i
dyspepsia . iThe idiscovery iof iH. ipylori iand iits irole iin ipathogenesis iof iulcers ihas iadded ia
inew ivariable ito ithe iequation. iPreviously, iif ia iyoung ipatient ipresented iwith idyspepsia iand
iwithout ialarming isigns ior isymptoms isuggestive iof ian iulcer icomplication ior imalignancy,
ian iempirical itherapeutic itrial iwith iacid isuppression iwas icommonly irecommended. iOnce ia
igastric iulcer iis idocumented, ithe imain iissue iat istake iis iwhether iH. ipylori ior ian iNSAID iis
iinvolved. iWith i
H. ipylori ipresent, iindependent iof ithe iNSAID istatus, itriple itherapy iis irecommended ifor i14
idays, ifollowed iby icontinued iacid-suppressing idrugs i(H i2 ireceptor iantagonist ior iPPIs) ifor
ia itotal iof i
4–6 iweeks. iSelection iof ipatients ifor idocumentation iof iH. ipylori ieradication i(organisms
igone iat ileast i4 iweeks iafter icompleting iantibiotics) iis ian iarea iof isome idebate. iThe itest iof
ichoice ifor idocumenting ieradication iis ithe iurea ibreath itest i(UBT). iThe istool iantigen iassay
imay ialso ihold ipromise ifor ithis ipurpose, ibut ithe idata ihave inot ibeen ias iclear icut ias iin ithe
icase iof iusing ithe istool iantigen itest ifor iprimary idiagnosis, iespecially iif ione iconsiders
ipatients iwho ilive iin iareas iof ilow iH. ipylori iprevalence. i
Further istudies iare iwarranted, ibut iif ithe iUBT iis inot iavailable, ia istool iantigen
ishould ibe iconsidered ito idocument ieradication. iThe ipatient imust ibe ioff iantisecretory
iagents iwhen ibeing itested ifor ieradication iof iH. ipylori iwith iUBT ior istool iantigen.
iSerologic itesting iis inot iuseful ifor ithe ipurpose iof idocumenting ieradication isince iantibody
ititers ifall islowly iand ioften ido inot ibecome iundetectable. iTwo iapproaches itoward

idocumentation iof ieradication.exist: i(1) iTest ifor ieradication ionly iin iindividuals iwith ia
icomplicated icourse ior iin iindividuals iwho iare ifrail ior iwith imultisystem idisease iwho iwould
ido ipoorly iwith ian iulcer irecurrence, iand i(2) itest iall ipatients ifor isuccessful ieradication.
iSome irecommend ithat ipatients iwith icomplicated iulcer idisease, ior iwho iare ifrail, ishould ibe
itreated iwith ilong-term iacid isuppression, ithus imaking idocumentation iof iH. ipylori
ieradication ia imoot ipoint . i
iA iGU iespecially iof ithe ibody iand ifundus, ihave ithe ipotential iof ibeing imalignant. iMultiple
ibiopsies iof ia iGU ishould ibe itaken iinitially; ieven iif ithese iare inegative ifor ineoplasm, irepeat
iendoscopy ito idocument ihealing iat i8–12 iweeks ishould ibe iperformed, iwith ibiopsy iif ithe
iulcer iis istill ipresent. iAbout i70% iof iGUs ieventually ifound ito ibe imalignant iundergo
isignificant i(usually iincomplete) ihealing. i
The imajority i(>90%) iof iGUs iheal iwith ithe iconventional itherapy ioutlined iabove. iA
iGU ithat ifails ito iheal iafter i12 iweeks iand ia iDU ithat idoes inot iheal iafter i8 iweeks iof itherapy
i
should ibe iconsidered irefractory. i

SURGICAL iTHERAPY iSurgical iintervention iin iPUD ican ibe iviewed ias ibeing ieither
ielective, ifor itreatment iof imedically irefractory idisease, ior ias iurgent/emergent, ifor ithe
itreatment iof ian iulcer -related icomplication. iThe idevelopment iof ipharmac ologic iand
iendoscopic iapproaches ifor ithe itreatment iof ipeptic idisease iand iits icomplications ihas iled ito
ia isubstantial idecrease iin ithe inumber iof ioperations ineeded ifor ithis idisorder. iSurgery iis
imore ioften irequired ifor itreatment iof ian iulcer -related icomplication. i
iHemorrhage iis ithe imost icommon iulcer -related icomplication, ioccurring iin i~15–25% iof
ipatients. iBleeding imay ioccur iin iany iage igroup ibut iis imost ioften iseen iin iolder ipatients
i(sixth idecade ior ibeyond). iThe imajority iof ipatients istop ibleeding ispontane –
ously, ibut iendoscopic itherapy iis inecessary iin isome. i
Parenterally iand iorally iadministered iPPIs ialso idecrease iulcer irebleeding iin ipatients
iwho ihave iundergone iendoscopic itherapy. iPatients iunresponsive ior irefractory ito
iendoscopic iintervention iwill irequire isurgery i(~5% iof itransfusion -requiring ipatients). i

Free iperitoneal iperforation ioccurs iin i~2–3% iof iDU ipatients. iAs iin ithe icase iof
ibleeding, iup ito i10% iof ithese ipatients iwill inot ihave iantecedent iulcer isymptoms.
iConcomitant ibleeding imay ioccur iin iup ito i10% iof ipatients iwith iperforation, iwith imortality
ibeing iincreased isubstantially. i
This ican iresult ifrom ichronic iscarring ior ifrom iimpaired imotility idue ito iinflammation iand/
or iedema iwith ipylorospasm. iPatients imay ipresent iwith iearly isatiety, inausea, ivomiting iof
iundigested ifood, iand iweight iloss. iConservative imanagement iwith inasogastric isuction,
iintrave -nous ihydration/nutrition, iand iantisecretory iagents iis iindicated ifor i7–10 idays iwith
ithe ihope ithat ia ifunctional iobstruction iwill ireverse. iIf ia imechanical iobstruction ipersists,
iendoscopic iintervention iwith iballoon idilation imay ibe ieffective. iSurgery ishould ibe
iconsidered iif iall ielse ifails.