In all patients with any complications of peptic ulcer disease H. pylori eradication is imperative. If the patient has been given eradication therapy previously a further course of eradication therapy is necessary.
This is dealt with below.
The frequency of perforation of peptic ulcer is decreasing;
this is partly attributable to the introduction of Hy-receptor antagonists. Duodenal ulcers perforate more commonly than gastric ulcers, usually into the peritoneal cavity. Perforation into the lesser sac may occur.
MANAGEMENT OF PERFORATION. Detailed management is described on p. 233. Surgery is performed to close the perforation and drain the abdomen. Conservative management using nasogastric suction, intravenous fluids and antibiotics is occasionally used in elderly and very sick patients.
Pyloric stenosis or obstruction
This is more accurately called gastric outflow obstruction, as the obstruction may be prepyloric or in the duodenum. The obstruction occurs either because of an active ulcer with surrounding oedema or because the healing of an ulcer has been followed by scarring. The obstruction can also be due to a gastric malignancy or external compression from a pancreatic carcinoma. The main sym ptom of this condition is vomiting, usually without pain as the characteristic ulcer pain has abated owing to healing.
Vomiting is projectile and huge in volume, and the vomitus contains particles of the previous day’s food. On examination of the abdomen the patient may have a succussion splash. Severe or persistent vomiting causes loss of acid from the stomach and a metabolic alkalosis occurs .
The diagnosis is made by barium meal examination (less commonly by endoscopy) but can be suspected when large quantities of fluid are removed by gastric intubation in the fasting state. Fluid and electrolyte replacement is necessary, together with the regular removal of gastric contents via a nasogastric tube. In some patients with oedema rather than scarring, the symptoms will settle with this conservative management. However, most patients require surgery. Postoperative gastric stasis canbe a problem, particularly if a vagotomy has been performed, even when accompanied by drainage.