3. Pyloric stenosis
4. Malignant change
Haemorrhage (haematemesis and melaena)
The ulcer may erode a blood vessel and thus give rise to haemorrhage. In gastric ulcers the blood is usually vomited (haematemesis), but sometimes it is passed instead through the intestines, making the motions black and tarry (melaena). Haemorrhage from duodenal ulcers usually takes the form of a melaena. As mentioned earlier (p. 220), a slight bleeding from peptic ulcer is often discovered only by chemical examination of the faeces for occult blood.
If the haemorrhage is large it is accompanied by signs of collapse and shock:
(a) The skin becomes cold and clammy.
(b) The pulse becomes very rapid.
(c) The patient is usually very restless.
(d) There is a severe drop in blood pressure.
In haematemesis the blood is dark red and may be mixed with food (compare with Haemoptysis, p. 200). When the haemorrhage is copious, blood can be clearly seen in the vomit, but if the haemorrhage is not so large the blood may be intimately mixed with food and partially digested, whereupon the descriptive term coffee ground vomit is often used. (In carcinoma of the stomach the haemorrhage is often in the form of ‘coffee grounds’.)
Treatment of haemorrhage
If the haemorrhage is large the patient is shocked and measures to overcome this must be taken at once. The patient is kept at absolute rest; in severe haemorrhage raising the foot of the bed is very useful. Adequate warmth is necessary, but care must be taken to avoid overheating, which only makes the condition worse. (For this reason a radiant heat cradle should be avoided.) To relieve the shock and any pain, and also to allay anxiety, a sedative such as morphine (15 mg) should be given. A half or one-hourly pulse chart is kept. This is a guide to the patient’s progress, as if.the haemorrhage goes on the pulse rate continues to rise. The blood pressure, too, is taken at fairly frequent intervals, a falling blood pressure, like a rising pulse, being an indication of continued haemorrhage.
If the abdomen becomes distended, as may happen with a large haemorrhage, a small enema may be ordered. To keep the stools soft and prevent straining, one or two ounces of liquid paraffin daily are useful. The patient must be warned against straining at stool as this may restart bleeding.
Whether or not the patient is given food by mouth depends on the doctor in charge. In former days the patient was usually forbidden to take anything by mouth except sips of water or milk, but in recent years a more liberal diet has been allowed. The usual practice is to allow food by mouth as for patients with an acute ulcer—that is,
Fig. 7.7 Indications for surgical treatment of peptic ulcer.
Fig. 7.8 A large chronic gastric ulcer which failed to heal under medical treatment and was removed by operation (partial gastrectomy).
small frequent feeds of a bland non-irritating variety. Some patients feel like eating more than others, and in the first few days it is wise to accede to the patient’s wishes within the limits of the diet mentioned.
In patients with copious haemorrhage with severe shock, as revealed by a persistently rapid pulse of over 100, a systolic blood pressure below 100 mmHg and restlessness, a blood transfusion is immediately given of at least two pints or more, according to the severity of the case. Of course, before the blood is given all the usual precautions must be taken—blood grouping, determination of the Rh factor and cross-matching. A strict watch must be kept for transfusion reactions.
With patients who do not immediately require a transfusion close observation of the pulse rate and blood pressure, as already mentioned, is essential, as if the haemorrhage continues a blood transfusion may become necessary.
In most patients the haemorrhage subsides with the above treatment, but it does persist in a minority of cases, usually in elderly patients with large chronic ulcers. The arteries in elderly people are more likely to be arteriosclerotic and therefore do not contract down so readily in order to control the bleeding. In these elderly patients with persistent haemorrhage, surgery may be advised after the shock has been overcome with adequate transfusions of blood. Partial gastrectomy is the operation of choice.
Other causes of haemcitemesis and melaena
Before leaving the discussion of haemorrhage as a complication of peptic ulcer it is convenient here to mention the other causes of haematemesis and melaena. It should be remembered, however, that in 90 per cent of cases the cause is peptic ulcer.
(a) Cancer of the stomach
(b) Cirrhosis of the liver
(c) Blood diseases (purpura, leukaemia, vitamin K deficiency)
(d) Swallowed blood, e.g. from epistaxis or following operations on the nose and throat
(e) Irritating drug such as aspirin or phenylbutazone.
Here the ulcer ruptures through into the peritoneal cavity, perforation being one of the common causes of an acute abdomen’. There is shock with severe and agonising pain. When the patient is examined the abdomen is found to be held absolutely rigid. Peritonitis can quickly supervene if an immediate operation is not performed.
A chronic ulcer, when it heals, produces scar tissue. If the ulcer is situated near the pylorus the scar tissue may obstruct the pyloric opening, thus causing a pyloric stenosis. In severe cases very little food may pass through into the duodenum. Usually there are the following symptoms and signs:
(a) Vomiting is frequent and copious, a history of vomiting of food eaten on a previous day being most characteristic of stenosis.
(b) The loss of weight varies with the degree of the stenosis, but it is very marked in the severe cases.
(c) Constipation is usually present.
(d) The resting juice withdrawn when a test meal is done is large in amount, perhaps as much as 500 to 700 ml.
(e) Barium meal examination will show that the stomach is very dilated and there is great delay in emptying.
The treatment for pyloric stenosis is operation, either a partial gastrectomy or gastro-jejunostomy being done.
Malignancy arises only with gastric ulcers, as duodenal ulcers never become malignant. When a gastric ulcer becomes malignant the symptoms become more constant and severe.