Multiple simultaneous complications of peptic ulcer

Abstract

A study of 969 cases of perforation, hemorrhage, or obstruction of peptic ulcer discloses that nearly ten per cent of these patients have more than one of these entities at the same time, and that such combinations produce a mortality four times as great as cases with only one such complication. There was a strong association of severe, unrelated diseases, especially malignant tumors, in the multiple entity group. Over a fourth of the patients in this group were thus affected. That these associated lesions are often in an early and previously undiagnosed state at the time of the admission for the combined complications suggests that they may serve to exacerbate an existing ulcer tendency and that a severely complicated peptic ulcer may indeed be an early warning signal of their presence. A vigorous work-up, especially for active pulmonary disease, is indicated in every patient surviving combined complications of peptic ulcer. The triple combination of perforation, hemorrhage and obstruction is much more common than previously believed, having appeared in five instances in this study. The high mortality of the perforation and hemorrhage combination when the hemorrhage is massive is again confirmed. Its management is largely preventive and requires a search for multiple ulcers at the time of plication for perforation. If these are found, primary subtotal gastrectomy should be strongly considered. Simple gastroenterostomy, gastroenterostomy with vagotomy, or primary gastric resection should be performed for an obstructed perforated ulcer. Such an ulcer usually involves both the anterior and posterior pyloric walls and makes more likely the occurrence of a massive postoperative hemorrhage as well as dehydration and electrolyte imbalance from pyloric obstruction, unless the additional procedure is performed. When actually confronted with a massive hemorrhage occurring near the time of perforation, the surgeon may be powerless because of the desperate general condition of the patient. However, vigorous blood replacement coupled with immediate gastric resection usually offers the only hope for survival. The occurrence of multiple combined complications is a positive indication of advanced, intractable ulcer disease requiring definitive surgical treatment, usually gastric resection, at the earliest possible moment.