Examqo › Examqo library › General surgery › GI surgery · IMLE
Complications of peptic ulcer: perforation, bleeding and gastric outlet obstruction
Peptic ulcer has three surgical complications — perforation, bleeding and gastric outlet obstruction; perforation is usually treated by surgery with an omental patch, bleeding is treated first by endoscopy, and in every case H. pylori is treated and NSAIDs are stopped.
Why it matters in the exam
The classic perforation case is sudden severe epigastric pain spreading over the whole abdomen, a "board-like" abdomen, and free air under the diaphragm on an erect chest X-ray. The exam checks that the correct step is resuscitation, a nasogastric tube, intravenous PPI, broad antibiotics and surgery (usually laparoscopic) with an omental patch, and that you know a gastric ulcer is biopsied because of the risk of cancer. Non-operative treatment is possible only in selected cases: a stable patient without generalised peritonitis when a contrast study shows the perforation has sealed.
For ulcer bleeding, the questions cover the timing of endoscopy (within 24 hours after stabilisation), the Forrest classification — which findings need endoscopic therapy — and what to do when bleeding recurs: repeat endoscopy, and if that fails — embolisation or surgery. An ulcer in the posterior wall of the duodenum bleeds from the gastroduodenal artery. Gastric outlet obstruction presents with vomiting of undigested food and a metabolic alkalosis with chloride and potassium depletion, and cancer must be excluded.
Key points
- Perforation: free air, resuscitation, surgery and omental patch; gastric ulcer — biopsy.
- Bleeding: PPI and endoscopy within 24 hours; Forrest Ia–IIa — endoscopic therapy.
- Rebleeding — second endoscopy, then embolisation or surgery.
- Gastric outlet obstruction — alkalosis with chloride and potassium depletion; exclude cancer.
- Always: H. pylori and stopping NSAIDs.
Summary table
| Complication | Key finding | Treatment | Exam note |
|---|---|---|---|
| Perforation | Sudden pain, board-like abdomen, free air under the diaphragm (CT is more sensitive than X-ray) | Resuscitation, PPI, antibiotics; surgery and omental patch | Gastric ulcer — biopsy; non-operative care only in selected patients with a sealed perforation |
| Active bleeding (Forrest Ia–Ib) | Spurting or oozing from the ulcer | Combined endoscopic therapy and high-dose PPI | High risk of rebleeding |
| Visible vessel (Forrest IIa) | A "bump" in the ulcer base | Endoscopic therapy and high-dose PPI | High-risk finding even without active bleeding |
| Adherent clot (IIb), spot or clean base (IIc, III) | No active bleeding | IIb — consider clot removal and treatment; IIc and III — oral PPI | Clean base — low risk, early discharge possible |
| Rebleeding after endoscopy | Further bleeding or shock | Repeat endoscopy; if it fails — embolisation or surgery | Posterior duodenal ulcer — gastroduodenal artery |
| Gastric outlet obstruction | Vomiting of undigested food, succussion splash | Nasogastric tube, fluids and electrolyte correction; endoscopic dilatation or surgery | Alkalosis with chloride and potassium depletion; exclude cancer |
Free exam questions
בן 80 , התאשפז במחלקה פנימית עם דלקת ריאות. באנמנזה מכוונת רושם כי המטופל מתלונן לאחרונה על שינ ?וי בקול וריח רע מהפה. מה הצעד הבא על מנת להגיע לאבחנה (the question as examined, in Hebrew)
- א. Cardiac MRI
- ב. PT CT
- ג. Upper GI Endoscopy
- ד. Barium Swallow
מטופל עבר ניתוח מיוטומיה ע"ש הלר. מספר ימים לאחר מכן מאובחן עם פרפורציה ומובהל לניתוח. איזה מבין האופציות מתאימה ביותר להתחלת הזנה אנטרלית מוקדם ככל הניתן? (the question as examined, in Hebrew)
- א. Nasogastric
- ב. Nasoduodenal
- ג. Gastrostomy
- ד. Jejunostomy
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Medical licensing exam (IMLE), General surgery, Emergency medicine, Internal medicine.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- WSES guidelines on perforated and bleeding peptic ulcer, 2020 — Diagnosis, non-operative and operative management
- International consensus group recommendations on the management of upper gastrointestinal bleeding (Barkun et al.), 2019 — Endoscopic therapy and proton pump inhibitors
- Sabiston Textbook of Surgery, 21st edition (2022) — Stomach
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.