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Bleeding Peptic Ulcer

Peptic Ulcer Hemorrhage


Presentation

  • Abstract Investigation of the bypassed stomach in patients with suspected peptic ulcer disease presents a major challenge to bariatric surgeons. Various methods have been suggested for visualization of the duodenum and bypassed stomach.[ncbi.nlm.nih.gov]
  • In group 1 the sensitivity of the RUT decreased from 0.96 when no blood was present to 0.60 when blood was present (p 0.006). The sensitivity of (13)C-urea breath test was not affected by blood in the stomach.[ncbi.nlm.nih.gov]
  • Recent data on clinical presentation and outcome are sparse in Australia. AIM: To determine the characteristics and outcome of patients presenting with a bleeding peptic ulcer to a tertiary referral centre.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Larger ulcers with severe bleeding at presentation predict failure of endoscopic therapy.[ncbi.nlm.nih.gov]
  • Initial presentation of systolic blood pressure CONCLUSION: Improvement of outcome in patients with bleeding peptic ulcer disease can be achieved by early detection of those patients who are at risk of adverse outcome.[ncbi.nlm.nih.gov]
Anemia
  • As a result there can be slow blood loss which may lead to anemia, or there may be massive blood loss with severe complications in the short term.[healthhype.com]
  • Instead of transporting oxygen and nutrients, the blood pools and causes anemia. Symptoms of anemia and blood loss are dizziness, loss of skin tone or coloring resulting in a pale appearance and general fatigue.[livestrong.com]
  • A blood test for anemia may be done, and a stool sample may be checked for the presence of blood. Both of these tests can indicate a bleeding ulcer.[health.harvard.edu]
Intravenous Administration
  • BACKGROUND: Intravenous administration of proton pump inhibitors after endoscopic treatment of bleeding peptic ulcers has been shown to decrease the rate of recurrent bleeding and the need for subsequent surgery.[ncbi.nlm.nih.gov]
  • Treatment with oral lansoprazole may be a therapeutic alternative to intravenous administration of PPI.[ncbi.nlm.nih.gov]
  • Dose linearity of the pharmacokinetics of the new H /K( )-ATPase inhibitor pantoprazole after single intravenous administration. Int J Clin Pharmacol Ther. 1996 ; 34(Suppl 1): S18 – 24 . Google Scholar 50. Shin, J.M. , Sachs, G. .[journals.sagepub.com]
Melena
  • RESULTS: 263/500 (52.6%) were taking NSAIDs before the acute bleeding. 70/96 (72.9%) patients with red haematemesis showed haemodynamic changes vs 15/107 (14%) with dark haematemesis and melena, and 29/281 (10.3%) with melena alone, p 0.01, OR 20.[ncbi.nlm.nih.gov]
  • A randomized prospective study was performed on 129 bleeding peptic ulcer patients with hematemesis or melena.[ncbi.nlm.nih.gov]
  • Diagnosis UGI bleeding in children often presents with large-volume hematemesis and can be from either a variceal or non-variceal (peptic-ulcer) source or with coffee-ground emesis or melena.[clinicaladvisor.com]
  • Acute hemorrhage from upper gastrointestine was defined as classical presentation with hematemesis, coffee-ground emesis, and/or melena.[clinicaltrials.gov]
  • Hunt PS, Hansky J, Korman MG (1979) Mortality in patient with haematemesis and melena: a prospective study. Br J Med 1: 1238–1340 Google Scholar 8.[link.springer.com]
Black Stools
  • Sometimes, stomach ulcers can lead to more serious symptoms, such as: a sudden sharp pain in your stomach that gets worse vomiting blood blood in your stool (poo) or black stools. If you have any of these symptoms, see a doctor immediately.[healthdirect.gov.au]
  • When symptoms occur, they include: A gnawing or burning pain in the middle or upper stomach between meals or at night Bloating Heartburn Nausea or vomiting In severe cases, symptoms can include: Dark or black stool (due to bleeding) Vomiting Weight loss[my.clevelandclinic.org]
  • Black stool from blood is called maleana and from food supplements or foods like karo (atapa) is called false maleana.[monitor.co.ug]
  • Signs of a bleeding ulcer include lightheadedness, dizziness, and black stools. Scar tissue: This is thick tissue that develops after an injury. This tissue makes it difficult for food to pass through your digestive tract.[healthline.com]
  • Signs of a bleeding ulcer include lightheadedness , dizziness , and black stools. Scar tissue: This is thick tissue that develops after an injury. This tissue makes it difficult for food to pass through your digestive tract.[healthline.com]
Dyspepsia
  • NSAID users may be classified as low or high risk, according to the absence or presence of one or more of the following factors associated with an increased risk of bleeding: co-morbidities; corticosteroid or anticoagulant co-therapy; previous dyspepsia[ncbi.nlm.nih.gov]
  • […] ground, 1, 2 and apparently with good reason, as the increased abnormal psychic stimuli created by the advent of the war and the need for adjustment to a new environment are all reflected in the many reports of an appreciable increase in the incidence of dyspepsia[annals.org]
  • The H. pylori bacterium also prompts many symptoms of dyspepsia, or indigestion. Treatment for stomach ulcers includes the use of antibiotics to kill the infection, and acid-suppressing drugs.[betterhealth.vic.gov.au]
Epigastric Pain
  • There is sudden, intense, continuous epigastric pain that spreads rapidly throughout the abdomen, often becoming prominent in the right lower quadrant and at times referred to one or both shoulders.[merckmanuals.com]
  • Introduction • Burning epigastric pain exacerbated by fasting and improved with meals is a symptom complex associated with peptic ulcer disease (PUD). • An ulcer is defined as disruption of the mucosal integrity of the stomach and/or duodenum leading[slideshare.net]
  • Clinical features As in duodenal ulceration the usual presentation is epigastric pain. The pain is typically exacerbated by food; nausea, unremitting pain and weight loss are common.[surgwiki.com]
Black Vomit
  • Seek emergency care if you experience: A sudden sharp pain in your abdomen Bloody or black vomit Maroon or black stools Prognosis With proper treatment, the outlook for peptic ulcers is excellent.[drugs.com]
Hypotension
  • Multiple logistic regression analysis revealed that hypotension (odds ratio (OR) 2.21, 95% confidence interval (CI) 1.40-3.48), haemoglobin level less that 10 g/dl (OR 1.87, 95% CI 1.18-2.96), fresh blood in the stomach (OR 2.15, 95% CI 1.40-3.31), ulcer[ncbi.nlm.nih.gov]
  • They included hypotension, hemoglobin 2cm and active bleeding during endoscopy [Wong Gut 2003].[clinicaltrials.gov]
  • Rebleeding was defined as patients who, during hospitalization, presented one or more of the following signs: hematemesis, persistent melena (during reevaluation in 12 and 24 h), enterorrhagia, hypotension (fall of the sistolic pressure ³ 25 mm Hg or[scielo.br]
  • ., tachycardia, hypotension, bloody emesis or nasogastric aspirate in hospital) endoscopy within 12 h may be considered to potentially improve clinical outcomes (Conditional recommendation). 83. 2015-04-07 83 Endoscopic diagnosis 12.[slideshare.net]
  • Patients with bleeding ulcers may report passage of black tarry stools (melena), weakness , a sense of light-headedness or ay even pass out upon standing ( orthostatic hypotension or syncope ) and vomiting blood (hematemesis).[medicinenet.com]
Tachycardia
  • […] patients who, during hospitalization, presented one or more of the following signs: hematemesis, persistent melena (during reevaluation in 12 and 24 h), enterorrhagia, hypotension (fall of the sistolic pressure ³ 25 mm Hg or diastolic pressure ³ 15 mm Hg), tachycardia[scielo.br]
  • ., tachycardia, hypotension, bloody emesis or nasogastric aspirate in hospital) endoscopy within 12 h may be considered to potentially improve clinical outcomes (Conditional recommendation). 83. 2015-04-07 83 Endoscopic diagnosis 12.[slideshare.net]
  • Tachycardia, sweaty palms, hypotension, anxiety and agitation are signs of shock and call for urgent blood volume replacement.[surgwiki.com]

Treatment

  • Abstract In managing patients with bleeding peptic ulcers, it has been reported that pharmacologic treatment can be an alternative to endoscopic treatment.[ncbi.nlm.nih.gov]
  • BACKGROUND: Continued or recurrent bleeding after endoscopic treatment for bleeding ulcer is a major adverse prognostic factor. Identification of such ulcers may allow for alternate treatments.[ncbi.nlm.nih.gov]
  • Abstract In 1984, a risk-dependent combined endoscopic and operative approach for the treatment of bleeding peptic ulcer was developed.[ncbi.nlm.nih.gov]
  • The median percentage time that pH was or 6 during the 0-48 h interval was 47% (68% range 28-89) for the 6 mg/h treatment group and 64% (68% range 41-84) for the 8 mg/h treatment group.[ncbi.nlm.nih.gov]
  • […] initial alternative treatment, and in-hospital death were recorded.[ncbi.nlm.nih.gov]

Prognosis

  • Because of a more aged and more diseased ulcer population, the long-term prognosis may be expected as poor.[ncbi.nlm.nih.gov]
  • Prognosis The prognosis of an adequately treated peptic ulcer in children is excellent. Copyright 2017, 2013 Decision Support in Medicine, LLC. All rights reserved.[clinicaladvisor.com]
  • Kraus M, Mendeloff G, Condon RE (1976) Prognosis of gastric ulcer: twenty-five year follow-up. Ann Surg 184: 471–476 Google Scholar 10. Manegold BC (1975) Emergency endoscopy in upper gastrointestinal bleeding.[link.springer.com]
  • Nasogastric or orogastric lavage is NOT REQUIRED in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic effect (Conditional recommendation). Timingofendoscopy 9.[slideshare.net]
  • In the rare cases when surgery cannot be done, prognosis is poor. Obstruction may be caused by scarring, spasm, or inflammation from an ulcer.[merckmanuals.com]

Etiology

  • Several etiologic factors of peptic ulcer are known, the principle one being Helicobacter pylori (H. pylori). Recent studies indicate that H. pylori eradication is associated with the marked reduction in rebleeding rate.[ncbi.nlm.nih.gov]
  • There is no increased risk of cancer with ulcers of other etiology.[merckmanuals.com]
  • The association between NSAIDs and peptic ulcer is fairly known, being implicated as the etiologic of peptic disease and its complications, mainly the bleeding (7, 19, 20, 27). In this study a high prevalence of the use of these drugs was observed.[scielo.br]

Epidemiology

  • Author information 1 Department of Clinical Epidemiology, Aarhus University Hospital, Skejby, Denmark. mo@dce.au.dk Abstract Systemic glucocorticoid use is associated with an increased risk for peptic ulcer bleeding (PUB); however, little is known about[ncbi.nlm.nih.gov]
  • We aimed to update epidemiology of peptic ulcer bleeding and to assess the adherence to guidelines in the French community.[ncbi.nlm.nih.gov]
  • Steering Committee Gastrointestinal Haemorrhage, British Medical Journal, 311(6999), 222-226. [ 8 ] Leerdam, V. (2008) Epidemiology of acute upper gastrointestinal bleeding.[dx.doi.org]
  • Peptic ulcer haemorrhage in Tartu County, Estonia: epidemiology and mortality risk factors. Scand J Gastroenterol. 1997 ; 32(12): 1195 – 200 . Google Scholar 6. Thomsen, R.W. , Riis, A. , Christensen, S. , Nørgaard, M. , Sørensen, H.T. .[journals.sagepub.com]
  • Epidemiology of upper gastrointestinal bleeding. Gastrointest Endosc 1990;36:S8-S13. [ Links ] 9. Graham DY, Heeps KS, Ramirez FC, Lew GM, Saeed ZA. Treatment of Helicobacter pylori reduces the rate of rebleeding in peptic ulcer disease.[scielo.br]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology – H.pylori • Chronic active gastritis – 10-15%  PUD 2015-04-07 31 32.[slideshare.net]

Prevention

  • If routine second-look endoscopy was 100% effective in preventing rebleeding, then the rebleeding threshold for cost neutrality would be 17.5%.[ncbi.nlm.nih.gov]
  • Proton pump inhibitor therapy without endoscopic hemostasis is ineffective clinically for stopping bleeding or preventing rebleeding. Endoscopic hemostasis remains the cornerstone of therapy.[ncbi.nlm.nih.gov]
  • In all bleeding peptic ulcer patients is needed to make the eradication of H. pylori infection with the aim to prevent re-bleeding in long term.[ncbi.nlm.nih.gov]
  • The use of omeprazole may prevent rebleeding by elevating intragastric pH in patients with bleeding peptic ulcer after hemostasis has been achieved.[ncbi.nlm.nih.gov]
  • Both oral and intravenous PPIs have proven to be effective in preventing recurrent bleeding from peptic ulcers. However, the dosing and administration of PPIs have been a source of ongoing debate, specifically in relation to cost.[ncbi.nlm.nih.gov]

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