Peptic Ulcers - Complete Explanation

Your notes cover two types of peptic ulcers (duodenal and peptic/gastric), then go deep on duodenal ulcers and their two main complications: bleeding and perforation.

What is a Peptic Ulcer?

A peptic ulcer is a mucosal break in the gastrointestinal tract caused by the corrosive action of acid and pepsin. Despite the name "peptic," acid is the true driver - ulcers do not occur in the absence of acid, and nearly all can be healed with PPIs (proton pump inhibitors) that suppress acid. Common sites are the first part of the duodenum (most common) and the lesser curve of the stomach.

Duodenal Ulcers (DU)

Site

The 1st part of the duodenum (duodenal bulb) - this is where the acidic gastric contents first enter the duodenum, making it most vulnerable.

Associations

~90% associated with H. pylori - Helicobacter pylori is a gram-negative bacterium that colonizes the gastric mucosa. It undermines mucosal defence by producing urease (which generates ammonia, damaging the epithelium), triggering chronic inflammation, and increasing acid output.
Associated with acid hypersecretion - patients with duodenal ulcers tend to secrete more acid than normal, making the duodenal mucosa more susceptible. Extreme acid hypersecretion occurs in Zollinger-Ellison syndrome (gastrinoma), where massive ulceration can occur.

Clinical Features (C/F)

1. Epigastric Pain

The classic symptom. Pain is usually:

Burning or gnawing in the epigastrium
Classically relieved by food (because food buffers acid) - this helps distinguish it from gastric ulcer, where food often worsens pain
Worse at night (nocturnal pain is typical)

2. Silent Presentation

Many duodenal ulcers are asymptomatic (silent). The patient has no warning symptoms and comes to attention only when a complication occurs.

3. Present with Complication

This is an important clinical point: a significant number of patients first present with a complication - either bleeding or perforation - without any prior symptomatic history.

Complication (1): Bleeding

Why posterior ulcers bleed

Posterior duodenal ulcers are anatomically adjacent to the gastroduodenal artery (GDA). As the ulcer erodes deeper, it can directly erode into the GDA (or the posterior superior pancreaticoduodenal artery), causing torrential hemorrhage that can be fatal. This is why the GDA is the most common (m/c) artery implicated in bleeding DU.

Gray's Anatomy for Students confirms: "Posterior duodenal ulcers erode either directly onto the gastroduodenal artery or, more commonly, onto the posterior superior pancreaticoduodenal artery, which can produce torrential hemorrhage."

Diagnosis

Upper GI Endoscopy (OGD - oesophago-gastroduodenoscopy) - this is both diagnostic and therapeutic. It should be performed within 24 hours of presentation. Endoscopy identifies the source, assesses the Forrest classification (which grades bleeding risk), and can treat the bleeding simultaneously.

Management

Your notes describe a stepwise approach:

Step 1: At least 2 attempts of Endoscopic Management Endoscopic options include:

Band ligation - a rubber band is applied around the bleeding vessel to strangulate and occlude it
Sclerotherapy - injection of a sclerosant (e.g., absolute ethanol, or epinephrine combined with another agent) into or around the bleeding vessel

Other endoscopic modalities: hemostatic clips, electrocoagulation, argon plasma coagulation, heater probe.

If endoscopy fails (2 failed attempts):

Surgery (Sx): Duodenotomy + Underrunning of the vessel

A duodenotomy is made (longitudinal incision into the duodenum)
The bleeding gastroduodenal artery is identified at the base of the ulcer
It is undersewn (underrun) - suture ligation both proximal and distal to the ulcer, plus a U-stitch underneath to control transverse pancreaticoduodenal branches
Sabiston Textbook of Surgery describes exactly this: "A longitudinal incision in the duodenal bulb will allow visualization of the bleeding gastroduodenal artery in the base of the ulcer which should be oversewn proximally and distally."

Note: Interventional radiology (transarterial embolization via the femoral artery) is now also an option for patients who are haemodynamically stable but have failed endoscopy - it may precede surgery in some centres.

Complication (2): Perforation

A perforation occurs when an ulcer erodes through the full thickness of the duodenal wall. The location of the ulcer (anterior vs. posterior) determines the clinical consequence:

	Anterior Wall Ulcer	Posterior Wall Ulcer
Perforates into	Free peritoneal cavity	Retroperitoneum / lesser sac
Result	Peritonitis (frank, sudden onset)	Retroperitoneal leak, or bleeds (erodes GDA)
Classic sign	Subdiaphragmatic free gas on erect CXR	Less dramatic presentation
Treatment	Surgical - Graham patch / omental patch repair	Surgical or conservative depending on leak

Anterior Ulcer Perforation

The ulcer perforates into the free peritoneal cavity
Gastric and duodenal contents (acid, bile, food) spill freely, causing chemical peritonitis followed by bacterial peritonitis
Free gas under the diaphragm is seen on an erect chest X-ray (or abdominal X-ray)
The greater omentum attempts to "seal" the perforation (this is why a Graham patch repair works - it uses omentum)
Treatment: surgical - laparoscopic or open omental (Graham) patch closure + washout + H. pylori eradication

Posterior Ulcer Perforation

The ulcer perforates posteriorly, which is contained by the retroperitoneum / lesser sac
The presentation is less dramatic than anterior perforation
More commonly, posterior ulcers bleed (as above) rather than perforate freely
If they do perforate, they may drain into the lesser sac, causing a lesser sac abscess

Summary Table

Feature	Detail
Site	1st part of duodenum
H. pylori association	~90%
Mechanism	Acid hypersecretion + impaired mucosal defence
Typical symptom	Epigastric pain (relieved by food), nocturnal pain
Silent DU	Common - presents first with complication
Bleeding artery	Gastroduodenal artery (posterior erosion)
Diagnosis of bleed	Upper GI endoscopy
Management of bleed	Endoscopy (band/sclerotherapy) → Surgery (duodenotomy + underrunning)
Anterior perforation	Free peritonitis, subdiaphragmatic gas, surgical patch repair
Posterior perforation	Retroperitoneal/lesser sac, or bleeding (GDA erosion)

Sources: Bailey and Love's Short Practice of Surgery 28th Ed.; Sabiston Textbook of Surgery; Gray's Anatomy for Students

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