Gastric and duodenal ulcers in adults

Clinical features

Burning epigastric pain or epigastric cramps between meals, that wake the patient at night. They are most characteristic when they occur as episodes of a few days and when 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
or, if not available, cimetidine PO: 800 mg once daily at bedtime for 7 to 10 days

– 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 (alternate between 5% glucose and Ringer Lactate)
• hyoscine butylbromide slow IV or IM: 10 to 20 mg every 8 hours if necessary
• omeprazole IV infusion: 40 mg once daily over 20 to 30 minutes
or, if not available, cimetidine IV infusion: 1600 mg once daily over 24 hours

– Refer to a surgeon if the patient has eaten during the 6 hours prior to the onset of pain or if there is no improvement within 12 hours despite medical treatment.

– Continue treatment for 3 days then restart oral feeding if the perforation occurred on an empty stomach and if the patient improved during the first 12 hours of treatment. Then 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, and the patient has frequent attacks requiring repeated treatment with antiulcer drugs or, in cases of complicated ulcers (perforation or gastrointestinal bleeding) treatment to eradicate H. pylori should be considered to prevent relapses.
Once the acute phase has passed, prescribe one of the following treatments:

Treatment of choice
(10 days)

Alternative
(14 days)

metronidazole PO1
500 mg 2 times daily

+ amoxicillin PO
1 g 2 times daily

+ omeprazole PO
20 mg 2 times daily

metronidazole PO1
500 mg 2 times daily

+ amoxicillin PO
1 g 2 times daily

+ cimetidine PO
800 mg 2 times daily


Notes
:
– Acetylsalicylic acid (aspirin) and NSAID (ibuprofen, diclofenac etc) are contraindicated in patients suffering from or with a history of ulcers.
– Omeprazole is as effective PO as IV.



Footnotes
Ref Notes
1 Metronidazole PO can be replaced with tinidazole PO: 500 mg 2 times daily [ a b ]