**3. Complications of peptic ulcer**

The more frequent complication of peptic ulcer disease (PUD) is the bleeding (hemorrhage), followed by perforation and obstruction [13]. Some differences in the frequency among various complications can be found in the geographic distribution, due to amount of NSAIDs and ASA use, diffusion of *H. pylori* infection, lifestyles of the community. In fact the risk factors for complication occurrence in PUD, as hemorrhage or perforation, are the therapeutic use of NSAIDs or ASA, often as incorrect automedication, and untreated *H. pylori* infection.

#### **3.1 Risk factors for peptic ulcer complications**

In most cases peptic ulcer hemorrhage is connected with the use of NSAIDs and ASA. The risk degree is dose-dependent: the therapeutic employment of high

#### *Introductory Chapter: Complications of Gastroduodenal Ulcers DOI: http://dx.doi.org/10.5772/intechopen.101478*

dose is a greater risk factor for bleeding, compared with the use of medium or low dose of drugs [14]. The bleeding risk by NSAIDs is also drug-specific, for example, higher for Ketoralac and certainly higher for the synchronous use of aspirin and NSAIDs. Moreover these drugs play a real, concrete role in the occurrence of peptic ulcer perforation [15]. Likewise the presence of *H. pylori* infection is associated with the event of peptic ulcer complications as hemorrhage, but its role and mode of action are debatable in the development of the complication [16]. There are some hypotheses, sometimes conflicting, on the *H. pylori* actions: it was reported that the eradication of *H. pylori* infection reduces the bleeding complication; possible independent action or synergic interaction on peptic ulcer hemorrhage has been described; finally protective effect of *H. pylori* in the occurrence of hemorrhage was also communicated [17]. In some studies there is evidence of the absence of association between *H. pylori* infection and ulcer perforation [18]. Other risk factors for the development of the gastroduodenal ulcer complications, in particular bleeding, are the age over 60 years, associated use of corticosteroid and anticoagulants with NSAIDs, the presence of major comorbidities [19]. We could hypothesize a major incidence of peptic ulcer complications as bleeding or perforation in the patients with long history of ulcer disease without correct treatment, but there are not the studies comparing the incidence of complications before and after the wordwide introduction in the therapy of proton pump inhibitors and the eradication of *H. pylori* infection [16]. The pathological features of the peptic ulcer are an important factor that can modify the risk of complications: chronic ulcers, the penetrating character, and the great size of the lesions. The penetration into the gastroduodenal wall up to serosa, with sclerotic tissue, and erosive action on the blood vessels (sometimes of great size as gastroduodenal artery) are the pathological characteristics of bleeding and perforated peptic ulcers. All the complications of peptic ulcers require the preliminary therapeutic management: suspend ingestion of food, drinks, drugs; start the fluid resuscitation, immediate suspension, if previously foreseen in therapy, of ASA, NSAIDs, and also anticoagulant if possible, administer acid suppressive therapy with intravenous proton pump inhibitor (PPI), treatment of *H. pylori* infection, if certainly present [20]. The treatment of *H. pylori* infection actually decreases recurrent ulcers and the incidence of the complications. Consequently the therapeutic procedures for the eradication of the *H. pylori* infection (PPI, antibiotics per os, because the efficacy of antibiotics e.v. has not certainly demonstrated) have a fundamental role in the prevention of the complications and recurrences of the peptic ulcer disease [21].
