Upper Gastrointestinal Bleeding is the Most Common Complication of Gastric Ulcer
Upper gastrointestinal bleeding is by far the most common complication of gastric ulcer disease, with hemorrhage occurring much more frequently than perforation, malignant transformation, or gastric outlet obstruction.
Epidemiology of Gastric Ulcer Complications
Hemorrhage is the most common complication of peptic ulcer disease, with a reported annual incidence in the general population ranging from 0.02% to 0.06%, and a sample size-weighted average 30-day mortality of 8.6% 1.
Although perforation is a serious complication of gastric ulcers, it is less common than bleeding, with a perforation:bleeding ratio of approximately 1:6 1.
Perforation has a reported annual incidence ranging from 0.004% to 0.014%, with a higher sample size-weighted average 30-day mortality of 23.5% 1.
Improvements in medical management have made obstruction from chronic fibrotic disease a rare complication of peptic ulcer disease 1.
Risk Factors for Gastric Ulcer Bleeding
The primary causes of gastric ulcers include Helicobacter pylori infection and the use of non-steroidal anti-inflammatory drugs (NSAIDs) 2.
NSAID use significantly increases the risk of gastric ulcer bleeding, with even low-dose aspirin (75 mg/day) doubling the risk of upper gastrointestinal bleeding compared to non-users 1.
Patients with a history of previous ulcer complications have the highest risk of recurrent ulcer bleeding, especially when continuing NSAID use 1.
Other risk factors include advanced age, concomitant use of anticoagulants, steroids, or multiple NSAIDs, and high-dose NSAID therapy 1.
Diagnosis and Management of Gastric Ulcer Bleeding
Endoscopy is the first recommended diagnostic tool in stable patients presenting with gastrointestinal bleeding from gastric ulcers 1.
Upper endoscopy successfully identifies the source of hemorrhage in 95% of cases, facilitates intervention to achieve hemostasis, decreases the risk for rebleeding, and provides prognostic information 1.
In selected cases of hemodynamically stable bleeding peptic ulcer patients where endoscopic hemostasis fails, angiography with angioembolization is recommended if technical skills and equipment are available 1.
Surgical exploration is recommended without delay in unstable patients presenting with ongoing gastrointestinal bleeding after endoscopic assessment and negative angio-CT scan 1.
A biopsy of the bleeding ulcer is recommended to exclude malignancy 1.
Common Pitfalls in Diagnosis
Excessive blood covering the examination field is the most frequent cause of incomplete endoscopic study, potentially leading to missed diagnoses of bleeding sites 3.
Lesions located in the body of the stomach are most likely to go undiagnosed during initial emergency endoscopy 3.
Inadequate preparation is a common procedural problem associated with missed diagnosis of bleeding gastric ulcers 3.
The high mortality rate in patients with unidentified bleeding gastric ulcers appears to be related to underlying diseases (particularly decompensated liver cirrhosis and hepatic failure) rather than to the nature of the lesions responsible for gastric bleeding 3.
In conclusion, while gastric ulcers can lead to several serious complications, upper gastrointestinal bleeding is definitively the most common complication, occurring approximately six times more frequently than perforation, and much more commonly than malignant transformation or gastric outlet obstruction.