Gastric and duodenal ulcers in adults

Clinical features

Burning epigastric pain or epigastric cramps between meals, that wake the patient at night. Recurrent episodes characteristically last a few days and are often accompanied by nausea and even vomiting.
The most common complications are perforation and bleeding.

Treatment of non-complicated ulcers

• For an isolated episode: 
  • identify patients taking NSAID or acetylsalicylic acid; stop treatment;
  • encourage patients to avoid alcohol and tobacco use;
  • omeprazole PO: 20 mg once daily in the morning for 7 to 10 days. In severe or recurrent cases, dose can be increased to 40 mg once daily and the treatment can be prolonged for up to 8 weeks.
• If the patient has frequent recurrences unrelated to NSAID use, that require repeated treatment with antiulcer drugs: see eradication of Helicobacter pylori.

Treatment of complicated ulcers

Perforation

Perforation should be considered in patients presenting with sudden onset intense epigastric pain, particularly if there is rigidity of the abdominal wall. The risk of peritonitis is increased if the perforation occurs on a full stomach.

• To start: 
  • place the patient on a strict fast (NPO); insert a nasogastric tube and aspirate if possible;
  • insert an intravenous line and hydrate (Ringer lactate);
  • treat acute pain (see Pain, Chapter 1);
  • omeprazole IV infusion: 40 mg once daily over 20 to 30 minutes
• Refer to a surgeon.
• If referral not possible, risk of mortality is high:
  • Continue conservative management including maintenance fluid (alternate 5% glucose and Ringer lactate).
  • Start IV antibiotics (see Shock, Chapter 1).
  • If after 3 days, the patient's clinical condition has improved, cautiously restart oral feeding, remove the nasogastric tube and start PO treatment to eradicate Helicobacter pylori (see eradication of Helicobacter pylori).

Gastrointestinal bleeding

Passing of black stool (maelena) and/or vomiting blood (haematemesis). In 80% of cases the bleeding stops spontaneously.

• Insert a nasogastric tube for aspiration and insert an IV line (16G).
• If the haemodynamic state is stable (pulse and blood pressure are normal):
  • Hydrate (Ringer lactate), monitor, keep NPO for 12 hours.
  • If there is no active haemorrhage, restart oral feeding after 12 hours.
  • Gastric lavage with cold water is not essential, but may help evaluate persistence of bleeding.
• If the haemorrhage continues (haematemesis) and/or if the haemodynamic state deteriorates (pulse increases, BP drops):
  • Intensive care and transfusion according to the severity of the bleeding (see haemorrhagic shock, Chapter 1).
  • Emergency surgical intervention.

Eradication of Helicobacter pylori

Most peptic ulcers are caused by Helicobacter pylori infection. If a diagnosis of ulcer is probable, treatment to eradicate H. pylori should be considered if the patient has frequent attacks requiring repeated and/or prolonged treatments with antiulcer drugs over 8 weeks or in cases of complicated ulcers (perforation or gastrointestinal bleeding). Infection should be confirmed with a test where possible.

H. pylori resistance to antibiotics varies globally, follow national recommendations where available. If not, for information, administer a triple therapy for 7 days:
omeprazole PO 20 mg 2 times daily + clarithromycin PO 500 mg 2 times daily + amoxicillin PO 1 g 2 times daily a Citation a. In penicillin-allergic patients, amoxicillin PO can be substituted with metronidazole PO 500 mg 2 times daily. .

In immunocompromised patients, consider mycobacterium avium complex (MAC) infection or other nontuberculous mycobacterium (NTM) infection prior to starting a clarithromycin-containing triple therapy.

If symptoms continue despite treatment, consider the differential diagnosis of gastric cancer. Refer for investigations if possible.

Notes:

• Acetylsalicylic acid (aspirin) and NSAID (ibuprofen, diclofenac, etc.) are contra-indicated in patients suffering from or with a history of ulcers.
• Omeprazole is as effective PO as IV.