Bleeding Peptic Ulcer Disease Research Articles

S677 Overt Gastrointestinal Bleeding in Patients With Cancer: Clinical Characteristics and Outcomes

S677 Overt Gastrointestinal Bleeding in Patients With Cancer: Clinical Characteristics and Outcomes

Bleeding peptic ulcer disease: over or through the scope clipping?

Bleeding peptic ulcer disease: over or through the scope clipping?

Peptic Ulcer Diseases in Patients with Liver Cirrhosis and Portal Hypertension: Experience in a Tertiary Level Hospital in Bangladesh

Introduction: Cirrhosis of liver and peptic ulcer disease (PUD) are very common in Bangladesh. PUD may coexist with cirrhosis and portal hypertension. Haematemesis and melaena in cirrhosis of liver are not always from ruptured oesophageal varices; rather it may be due to bleeding peptic ulcer disease. Objective: To find the prevalence of PUD among patients with liver cirrhosis and portal hypertension. Materials and Methods: This cross sectional, descriptive study was conducted on 96 patients of cirrhosis of liver diagnosed with oesophageal varices at endoscopy unit of Kurmitola general hospital, during endoscopic evaluations in 4 months period from september 2017 to december 2017. Results: Total cirrhotic patients enrolled were 96 (M=61, F=35), mean age was 51.8 ± 14.2 yrs (18-86years). Hepatitis B virus (HBV) was the leading cause of cirrhosis in 54.1%, Hepatitis C virus (HCV) 5.2 %, proven non-alcoholic steatohepatitis (NASH) were 11.5% and rest were from unknown aetiology. Their average Child-Turcotte-Pugh (CTP) score were 8.6 (12-5), 37.6% associated with portal hypertensive gastropathy. Grade-III oesophageal varices found in 52 patients, whereas grade-II in 25 patients. Among this 96 patients 39 (40.6%) revealed peptic ulcer disease more in the form of gastric ulcer (n=23) than duodenal ulcer (n=10) and both (n=6). Most of the ulcers belonged to Forrest class III (76.9%). Conclusions: Variceal bleeding and portal hypertensive gastropathy are the common causes of bleeding and anaemia in patients with cirrhosis of liver. Peptic ulcer disease has been found to be one of the potential causes of haematemesis, melaena, and anaemia among these patients in Bangladesh. Large multicenter controlled studies are needed to confirm the reports. JAFMC Bangladesh. Vol 16, No 2 (December) 2020: 68-71

S1448 Impact of a Gastroenterology Hospitalist Model on Management of Bleeding Peptic Ulcer Disease

S1448 Impact of a Gastroenterology Hospitalist Model on Management of Bleeding Peptic Ulcer Disease

Performance Comparison of the Deep Learning and the Human Endoscopist for Bleeding Peptic Ulcer Disease

PurposeManagement of peptic ulcer bleeding is clinically challenging. Accurate characterization of the bleeding during endoscopy is key for endoscopic therapy. This study aimed to assess whether a deep learning model can aid in the classification of bleeding peptic ulcer disease.MethodsEndoscopic still images of patients (n = 1694) with peptic ulcer bleeding for the last 5 years were retrieved and reviewed. Overall, 2289 images were collected for deep learning model training, and 449 images were validated for the performance test. Two expert endoscopists classified the images into different classes based on their appearance. Four deep learning models, including Mobile Net V2, VGG16, Inception V4, and ResNet50, were proposed and pre-trained by ImageNet with the established convolutional neural network algorithm. A comparison of the endoscopists and trained deep learning model was performed to evaluate the model’s performance on a dataset of 449 testing images.ResultsThe results first presented the performance comparisons of four deep learning models. The Mobile Net V2 presented the optimal performance of the proposal models. The Mobile Net V2 was chosen for further comparing the performance with the diagnostic results obtained by one senior and one novice endoscopists. The sensitivity and specificity were acceptable for the prediction of “normal” lesions in both 3-class and 4-class classifications. For the 3-class category, the sensitivity and specificity were 94.83% and 92.36%, respectively. For the 4-class category, the sensitivity and specificity were 95.40% and 92.70%, respectively. The interobserver agreement of the testing dataset of the model was moderate to substantial with the senior endoscopist. The accuracy of the determination of endoscopic therapy required and high-risk endoscopic therapy of the deep learning model was higher than that of the novice endoscopist.ConclusionsIn this study, the deep learning model performed better than inexperienced endoscopists. Further improvement of the model may aid in clinical decision-making during clinical practice, especially for trainee endoscopist.

Systematic Review and Meta-Analysis of Prophylactic Transarterial Embolization for High-Risk Bleeding Peptic Ulcer Disease

The present systematic review determined the role of transarterial embolization (TAE) as a prophylactic treatment in bleeding peptic ulcers after initial successful endoscopic hemostasis. PubMed and Ovid Medline databases were searched from inception until July 2019 for studies that included patients deemed high-risk based on Forrest Classification, Rockall score ≥ 5, or endoscopic evaluation in addition to those who underwent prophylactic TAE after initial successful endoscopic hemostasis. Meta-analysis was performed to compare patients who underwent endoscopic therapy (ET) and TAE with those who underwent ET alone. The primary outcomes measured included rates of rebleeding, reintervention, and 30-day mortality. Secondary outcome measures evaluated length of hospitalization, technical success rates, and complications associated with TAE. Of 916 publications, 5 were eligible for inclusion; 310 patients with high-risk peptic ulcer bleeding underwent prophylactic TAE, and 255 were compared against a control group of 580 patients that underwent standard treatment with ET alone. Patients who underwent ET with TAE had lower 30-day rebleeding rates (odds ratio [OR], 0.35; 95% confidence interval [CI] 0.15–0.85; P = .02; I2 = 50%). The ET with TAE group had a lower 30-day mortality rate (OR, 0.28; 95% CI, 0.10–0.83; P = .02; I2 = 58%). There was no difference in pooled reintervention rates (OR, 0.68; 95% CI, 0.43–1.08; P = .10; I2 = 0%) and length of hospitalization (mean difference, −0.32; 95% CI, −1.88 to 1.24; P = .69; I2 = 0%). Technical success rate of prophylactic TAE was 90.5% (95% CI, 83.09–97.98; I2 = 75.9%). Pooled proportion of overall complication rate was 0.18% (95% CI, 0.00–1.28; I2 = 0%). Prophylactic TAE has lower rebleeding and mortality with a good success rate and low complications. Prophylactic TAE after primary ET may be recommended for selected patients with high-risk bleeding ulcers; however, further studies should be performed to establish this as a routine tool in patients with bleeding peptic ulcer disease.

Bleeding peptic ulcer disease: over or through the scope clipping?

Bleeding peptic ulcer disease: over or through the scope clipping?

S0592 In-Hospital Outcomes of Transcatheter Arterial Embolization vs Surgical Control of Refractory Bleeding Peptic Ulcer Disease: A Propensity Score-Matched Analysis

S0592 In-Hospital Outcomes of Transcatheter Arterial Embolization vs Surgical Control of Refractory Bleeding Peptic Ulcer Disease: A Propensity Score-Matched Analysis

AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and best practice advice statements regarding the use of endoscopic therapies in treating patients with non-variceal upper gastrointestinal bleeding. This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 10 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors who are gastroenterologists with extensive experience in managing and teaching others to treat patients with non-variceal upper gastrointestinal bleeding (NVUGIB). BEST PRACTICE ADVICE 1: Endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB. BEST PRACTICE ADVICE 2: Initial management of the patient with NVUGIB should focus on resuscitation, triage, and preparation for upper endoscopy. After stabilization, patients with NVUGIB should undergo endoscopy with endoscopic treatment of sites with active bleeding or high-risk stigmata for rebleeding. BEST PRACTICE ADVICE 3: Endoscopists should be familiar with the indications, efficacy, and limitations of currently available tools and techniques for endoscopic hemostasis, and be comfortable applying conventional thermal therapy and placing hemoclips. BEST PRACTICE ADVICE 4: Monopolar hemostatic forceps with low-voltage coagulation can be an effective alternative to other mechanical and thermal treatments for NVUGIB, particularly for ulcers in difficult locations or those with a rigid and fibrotic base. BEST PRACTICE ADVICE 5: Hemostasis using an over-the-scope clip should be considered in select patients with NVUGIB, in whom conventional electrosurgical coagulation and hemostatic clips are unsuccessful or predicted to be ineffective. BEST PRACTICE ADVICE 6: Hemostatic powders are a noncontact endoscopic option that may be considered in cases of massive bleeding with poor visualization, for salvage therapy, and for diffuse bleeding from malignancy. BEST PRACTICE ADVICE 7: Hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement. BEST PRACTICE ADVICE 8: Endoscopists should understand the risk of bleeding from therapeutic endoscopic interventions (eg, endoluminal resection and endoscopic sphincterotomy) and be familiar with the endoscopic tools and techniques to treat intraprocedural bleeding and minimize the risk of delayed bleeding. BEST PRACTICE ADVICE 9: In patients with endoscopically refractory NVUGIB, the etiology of bleeding (peptic ulcer disease, unknown source, post surgical); patient factors (hemodynamic instability, coagulopathy, multi-organ failure, surgical history); risk of rebleeding; and potential adverse events should be taken into consideration when deciding on a case-by-case basis between transcatheter arterial embolization and surgery. BEST PRACTICE ADVICE 10: Prophylactic transcatheter arterial embolization of high-risk ulcers after successful endoscopic therapy is not encouraged.

Outcomes of Salvage Emergency Surgery for Bleeding Peptic Ulcer

The goals of management of bleeding peptic ulcer disease (BPUD) are early diagnosis, prompt resuscitation, and urgent endoscopy to stop bleeding. Last few decades have witnessed a diminishing role of surgery in the management of BPUD. When non-operative strategies such as endoscopy and angioembolization fail to achieve hemostasis, surgery is used as the last resort. This is a case series analysis of 70 patients with BPUD who underwent emergency surgery from January 2002 to December 2014. Demographic profile, clinical parameters, and perioperative outcomes were studied. Baseline data of survivors was compared with non-survivors. Outcome of patients with > 2 endoscopic attempts was compared with ≤ 2 endoscopic attempt patients. Mean age of the patients was 68.5 years (range 38–93) and majority were male (85.7%). Thirty-nine patients (55.7%) had duodenal ulcers (DU). Among patients with gastric ulcers (GU), the most common location was incisura (n = 16, 51.6%). Most patients had two endoscopic procedures before surgery was undertaken. The most frequent operations performed were under running of duodenal ulcer (n = 40, 57.1%). Fifty-nine patients (84.3%) developed complications and 30-day mortality was 15.7%. There was no difference in demographic and clinical profile of survivors compared to non-survivors. Patients who received > 2 endoscopies had lower hemoglobin (p = 0.01) compared to patients with ≤ 2 endoscopies, but there was no difference in 30-day mortality (p = 0.68). Exhaustive non-operative strategy and reserving surgery as salvage in refractory BPUD gives acceptable outcomes.

Risk factors of perioperative mortality from complicated peptic ulcer disease in Africa: systematic review and meta-analysis

IntroductionIn 2013, peptic ulcer disease (PUD) caused over 300 000 deaths globally. Low-income and middle-income countries are disproportionately affected. However, there is limited information regarding risk factors of perioperative mortality...

Comparison of Oral versus Intravenous Proton Pump Inhibitors in Preventing Re-bleeding from Peptic Ulcer after Successful Endoscopic Therapy.

IntroductionPerforation, obstruction, and bleeding remain the most frequently encountered complications of peptic ulcer disease (PUD). Bleeding may be in the form of hematemesis or melena. The treatment of choice in patients with a bleeding peptic ulcer is endoscopic ligation to maintain the hemostatic balance followed by the administration of proton pump inhibitors (PPIs). This study focuses on the evaluation and comparison of intravenous (IV) and oral PPIs in terms of prevention of re-bleeding after successful endoscopy for peptic ulcers.MethodsA prospective, comparative study was conducted in a tertiary care hospital in Pakistan from January 1, 2018 to June 30, 2019. The trial included known cases of PUD admitted with active upper gastrointestinal bleeding (UGIB). They were randomly divided into two groups: one received oral pantoprazole and the other was administered IV pantoprazole. The outcomes for both groups were compared. Data was entered and analyzed using Statistical Package for the Social Sciences (SPSS) software version 23.0 (IBM, Armonk, NY)ResultsThere were 96 (48%) patients in the IV pantoprazole group and 104 (52%) in the oral group. From 24 hours after the medication onwards, the IV pantoprazole group showed a significant improvement in hemoglobin (Hb) levels (p: 0.01); the group also showed improvement in supine systolic BP at 48 hours (p: 0.04) and in diastolic BP at both 12 and 48 hours as compared to the oral pantoprazole group (p: 0.05). The mean duration of hospital stay, need for blood transfusion and repeat endoscopy, re-bleeding, and mortality rates were similar for both groups (p: >0.05).ConclusionWe could not find any statistically significant difference between oral and IV routes of pantoprazole administration in the prevention of rebleeding when used after successful therapeutic endoscopy in patients with bleeding PUDs.

AIDS-associated Kaposi sarcoma mimicking bleeding peptic ulcer disease

Kaposi sarcoma (KS) was the first AIDS defining malignancy described, and it commonly involves the skin, although visceral lesions exist. Visceral KS lesions are easy to miss, especially when symptoms are atypical or suggestive of another condition. This is a case of KS of the stomach in an HIV/AIDS patient presenting with symptoms, suggestive of bleeding peptic ulcer disease.

3130 Unexplained Thrombocytopenia Associated to the Use of PPI in a Patient With a Bleeding Peptic Ulcer Disease

INTRODUCTION: Proton pump inhibitors (PPIs) are used to suppress acid production and to promote hemostasis, which significantly reduces the risk of rebleeding in upper gastrointestinal bleeding [1]. Accumulating evidence indicates an association between PPIs and thrombocytopenia in patients treated for upper gastrointestinal bleeds [2-4]. CASE DESCRIPTION/METHODS: A 38-year-old male with no significant past medical history presented to the hospital complaining of coffee ground emesis, hematochezia, dark stools and three episodes of syncope in the setting of daily naproxen use for one month. Vital signs revealed orthostasis without tachycardia or hypotension. Physical exam revealed a soft, non-tender, non-distended, abdomen with normoactive bowel sounds. Rectal exam was positive for melena but negative for hemorrhoids or any palpable masses. Initial laboratory workup was significant for a hemoglobin of 7.8, platelet count of 163, and BUN of 27. Intravenous (IV) PPI was administered for management of suspected bleeding PUD. The patient received packed red blood cells (PRBCs) with appropriate response to transfusion. Upper endoscopy revealed a pre-pyloric non-bleeding ulcer that was successfully treated. A significant drop in platelet count was noted on hospital day four which continued to decrease from 163 to 107. PPI route of administration was changed from IV to oral, resulting in an increase in platelet count to 116 by hospital day 7. DISCUSSION: PPIs are widely used for the treatment of PUD, GERD, Barrett esophagus, esophagitis, and gastritis. As the main medication used in the treatment of upper gastrointestinal bleeding, it is crucial to understand the effect of PPI therapy on platelets. Literature review suggests an association between thrombocytopenia and the use of PPIs [2-4]. However, further studies are needed to establish a direct association between PPIs and thrombocytopenia. In our case, thrombocytopenia was noted on hospital day 3 of PPI infusion. Route of administration of PPI was changed from IV to oral and thrombocytopenia improved steadily. Although the exact mechanism linking PPI therapy to thrombocytopenia remains unknown, it is important to be aware of this possibility. Close monitoring of platelet count is recommended upon initiation of PPI therapy.

Factors Associated With Adherence to Helicobacter pylori Testing During Hospitalization for Bleeding Peptic Ulcer Disease

Guidelines recommend testing patients with peptic ulcer disease for Helicobacter pylori infection. We sought to identify factors associated with adherence to testing for H pylori in patients hospitalized for bleeding ulcers and to evaluate whether performing these tests affect risk for rebleeding. We performed a retrospective study of 830 inpatients who underwent endoscopy from 2011 through 2016 for gastrointestinal bleeding from gastric or duodenal ulcers. We searched electronic medical records for evidence of tests to detect H pylori by biopsy, serologic, or stool antigen analyses. We used multivariable models to identify clinical, demographic, and endoscopic factors associated with testing for H pylori. Kaplan-Meier analysis was performed to determine whether H pylori testing altered risk for the composite outcome of rebleeding or death within 1 year of admission. Among the patients hospitalized for bleeding peptic ulcer disease during the 6-year period, 19% were not tested for H pylori within 60 days of index endoscopy. Hospitalization in the intensive care unit (ICU) was the factor most frequently associated with nonadherence to H pylori testing guidelines (only 66% of patients in the ICU were tested vs 90% of patients not in the ICU; P < .01), even after we adjusted for ulcer severity, coagulation status, extent of blood loss, and additional factors (adjusted odds ratio, 0.42; 95% CI, 0.27-0.66). Testing for H pylori was associated with a 51% decreased risk of rebleeding or death during the year after admission (adjusted hazard ratio 0.49; 95% CI, 0.36-0.67). In an analysis of hospitalized patients who underwent endoscopy for gastrointestinal bleeding from gastric or duodenal ulcers, we found admission to the ICU to be associated with failure to test for H pylori infection. Failure to test for H pylori was independently associated with increased risk of rebleeding or death within 1 year of hospital admission. We need strategies to increase testing for H pylori among inpatients with bleeding ulcers.

Endoscopic suturing for management of peptic ulcer-related upper gastrointestinal bleeding: a preliminary experience.

Background and study aims Acute non-variceal upper gastrointestinal bleeding (UGIB) due to peptic ulcer disease (PUD) remains a common and challenging emergency managed by gastroenterologists. The proper role of endoscopic suturing on the management of PUD-related UGIB is unknown. Patients and methods This is an international case series of patients who underwent endoscopic suturing for bleeding PUD. Primary outcome was rate of immediate hemostasis and rate of early rebleeding (within 72 hours). Secondary outcomes included technical success, delayed rebleeding (> 72 hours), and rate of adverse events (AEs). Results Ten patients (mean age 66.7 years, 30 % female) were included in this study. Nine (90 %) had prior failed endoscopy hemostasis with an average of 1.4 ± 0.7 (range 1 – 3) prior endoscopic sessions. Forrest classification was Ib in 5 (50 %), IIa in 3 (30 %), IIb in 1(10 %), and IIc in 1 (10 %). Mean suturing time was 13.4 ± 5.6 (range 3.5 to 20) minutes. Technical success was 100 %. Rate of immediate hemostasis was 100 % and rate of early rebleeding was 0 %. Mean number of sutures was 1.5 (range, 1 – 4). No AEs were observed. Delayed recurrent bleeding was not observed in any cases after a median of 11 months (range 2 – 56), after endoscopic suturing. Conclusions Oversewing of a bleeding or high-risk ulcer using endoscopic suturing appears to be a safe and effective method for achieving endoscopic hemostasis. It may be considered as rescue endoscopic therapy when primary endoscopic hemostasis fails to control the bleeding or when hemorrhage recurs after successful control of bleeding.

Adherence to Helicobacter pylori Testing After Hospitalization for Bleeding Peptic Ulcer Disease

Introduction: Guidelines recommend H. pylori testing in patients with bleeding peptic ulcers. Studies have shown that H. pylori eradication after ulcer bleeding lowers the rebleeding rate. The aim of this study was to assess adherence to H. pylori testing for bleeding peptic ulcers and to evaluate whether H. pylori identification altered rebleeding risk among patients hospitalized for bleeding ulcers. Methods: We examined all inpatients at our institution who underwent endoscopy between 2011 and 2016 for suspected upper GI bleeding with findings of gastric or duodenal ulcers. H. pylori testing at the time of index endoscopy was defined as gastric biopsy during endoscopy, or as stool H. pylori antigen or H. pylori antibody testing within 60 days of endoscopy. H. pylori breath testing was not available during the study period. The primary outcome was rebleeding within 1 year, defined as: (1) decrease in hemoglobin by ≥2 mg/dL compared to the pre-index endoscopy hemoglobin or (2) performance of a repeat upper endoscopy with an indication of bleeding. We used a multivariable logistic regression model to assess predictors of failure to test for H. pylori. We also examined the relationship between H. pylori testing and subsequent risk for rebleeding using Cox proportional hazards modeling. Results: Among 976 patients who underwent upper endoscopy for bleeding and had a gastric or duodenal ulcer, 78% were tested for H. pylori within 60 days of the index endoscopy. Significant differences existed between patients who were and were not tested for H. pylori with regards to sex, INR, albumin, platelets, and ICU admission at time of index endoscopy (Table 1). Of these, ICU location was the most significant predictor with only 38% of ICU patients undergoing H. pylori testing compared to 73% non-ICU patients (p < 0.01). H. pylori testing was associated with a 50% reduction in rebleeding risk compared to those without H. pylori testing, after controlling for other factors (Table 2, Figure 1).1088_A Figure 1. Baseline characteristics, stratified by H. pylori testing status.Conclusion: Patients were less likely to undergo H. pylori testing after ulcer bleeding if the index endoscopy was performed in the ICU. Testing for H. pylori after ulcer bleeding was associated with a significantly lower risk of rebleeding within 1 year. Given the benefit in rebleeding risk, biopsy should be strongly considered during upper endoscopy for bleeding ulcers if noninvasive H. pylori testing has been difficult to obtain in the past. This may be especially true in the ICU.1088_B Figure 2. Cox Proportional Hazards Model of Risk of Rebleeding1088_C Figure 3. Kaplan-Meier Curve of Time to Rebleeding or Death

Short-term outcomes after emergency surgery for complicated peptic ulcer disease from the UK National Emergency Laparotomy Audit: a cohort study

ObjectivesThis study used national audit data to describe current management and outcomes of patients undergoing surgery for complications of peptic ulcer disease (PUD), including perforation and bleeding. It was also...

Comparison of Oral versus Intravenous Proton Pump Inhibitors in Preventing Re-bleeding from Peptic Ulcer after Successful Endoscopic Therapy.

BACKGROUND Proton pump inhibitors (PPIs) are now widely prescribed for the management of patients with acute upper gastrointestinal bleeding; although its optimal dose and route of administration has remained a controversial issue. The aim of this study was to assess the clinical effectiveness of high dose oral versus intravenous (IV) PPI after successful endoscopic therapy in patients with bleeding peptic ulcer disease. METHODS 178 patients with active upper gastrointestinal bleeding due to a peptic ulcer with stigmata of high risk for re-bleeding entered the study. After successful endoscopic hemostasis, they were randomized to receive either high dose oral pantoprazole (80 mg stat and 80 mg twice daily for 3 days) or high dose intravenous pantoprazole (80 mg IV infusion within 30 minutes and 8 mg per hour for 3 days). After the 3rd day, the patients in both groups received oral pantoprazole 40 mg twice daily for one month. The end points were comparing the rate of re-bleeding or mortality, and the need for blood transfusion or surgery during the first month between the two groups. RESULTS There were not significant statistical differences between the two groups in the volume of blood transfusion, mean duration of hospital stay, need to surgery, or mortality rates. However, the rates of re-bleeding were 2.3% (2:88) in the IV group and 3.3% (3:90) in the oral group (p = 0.6). CONCLUSION According to our findings, it seems that high dose oral PPI can be a good alternative to high dose IV PPI in patients with bleeding peptic ulcer who are at high risk of re-bleeding. Due to the lower cost and the availability of oral PPIs, their use can be economically much more affordable.

Gastroduodenal Surgery: A Persistent and Continuing Challenge

The number of patients being treated surgically for gastroduodenal disease has decreased over the past five decades as a result of focus on medical treatment. However, perforated and bleeding peptic ulcer disease (PUD) continues to represent a significant percentage of patients who require emergency surgery. The aim of this study was to characterize these critically ill surgical patients treated for gastroduodenal disease in our hospital. A retrospective, single-center, consecutive cohort study of all patients identified from the hospital National Surgical Quality Improvement Program database who were admitted to our institution requiring emergent surgical intervention over the past two years was conducted. Of 423 patients, 33 (7.8%) had operative procedures for complications of PUD, of which 19 patients (57.6%) had perforation; nine patients (27.3%) had hemorrhage; one patient (3.0%) had both perforation and hemorrhage; two patients (6.1%) had distal gastrectomies for ulcers refractory to medical management alone, and two patients (6.1%) had gastrectomies for malignant gastric neoplasms. There is a significant population of patients who present with life-threatening complications of PUD, despite the decline in PUD worldwide. These patients are critically ill and require careful and diligent management for good outcomes.