Complications of peptic ulcer disease (PUD) include bleeding, perforation, penetration, and gastric outlet obstruction. With time, there have been major shifts in the etiologies of complicated peptic ulcers and in the affected patient populations. In addition, management has undergone dramatic changes. Management now includes the early use of high-dose intravenous proton pump inhibitors (PPIs), treatment to eradicate Helicobacter pylori (H. pylori), improved endoscopic methods for control of hemorrhage, and changes in surgical indications and procedures. (See "Treatment regimens for Helicobacter pylori" and "Overview and comparison of the proton pump inhibitors for the treatment of acid-related disorders" and "Overview of the treatment of bleeding peptic ulcers".)
This topic will provide an overview of the major complications of PUD. The approach to patients with complicated PUD, the endoscopic management of peptic ulcer bleeding, and the surgical approaches to complications of PUD are discussed separately. (See "Diagnosis of peptic ulcer disease" and "Overview of the natural history and treatment of peptic ulcer disease" and "Overview of the treatment of bleeding peptic ulcers" and "Surgical management of peptic ulcer disease".)
With time, there has been a dramatic fall in the prevalence of peptic ulcer disease (PUD) in developed countries. While older studies suggested that hospitalizations for potentially life-threatening ulcer complications were stable or even increasing [1-7], several more recent studies indicate a consistent decrease in hospitalization rates and in the incidence of bleeding and perforation . For example, using analysis of a large database from the United States found an approximate 30 to 40 percent fall in hospitalizations for PUD complications between 1993 and 2006 . Another study from the United States evaluated the National Inpatient Database and found that the rate of perforation and bleeding has been decreasing in the United States, presumably reflecting the fall in H. pylori prevalence . A large systematic review estimated that the annual incidence of peptic ulcer hemorrhage is on the order of 19 to 57 cases per 100,000 individuals, and that the annual incidence of ulcer perforation is on the order of 4 to 14 cases per 100,000 individuals . (See "Epidemiology and etiology of peptic ulcer disease", section on 'Epidemiology'.)
Peptic ulcer bleeding is seen most commonly in older patients [1,2,5-8]. Sixty percent of patients are above the age of 60 years and 20 percent are over the age of 80 years . This age distribution likely reflects increasing nonsteroidal anti-inflammatory drug (NSAID) use among older adults, combined with decreasing prevalence of H. pylori infection among younger patients.
Complications of PUD vary in frequency geographically. In the United States, hemorrhage is the most common complication of PUD (73 percent), followed by perforation (9 percent), and obstruction (3 percent) . The mortality rate from complications of PUD is more than 10 times that of acute appendicitis or acute cholecystitis. Perforation has the highest mortality rate, followed by obstruction and hemorrhage. By contrast, a 13-year review of all surgical procedures for peptic ulcer complications at a Nigerian hospital found that obstruction was the most common complication (56 percent), followed by perforation (30 percent), and bleeding (10 percent) . Some regional factors that may account for these differences include the rates of NSAID use, the prevalence of H. pylori infection, and the distribution and extent of gastritis. (See "Epidemiology and etiology of peptic ulcer disease", section on 'Regional and other demographic variation'.)