#
Peptic Ulcer & Perforation
Peptic ulcers (gastric and duodenal) present with epigastric pain. Distinguishing between them clinically is unreliable. Simple cases can be treated conservatively:
- Epigastric pain
- 'Heartburn’
- Nausea
- Bloating
- Bloods
- CXR – looking for air under the diaphragm
- ABC
- Analgesia
- Commence PPI – e.g. omeprazole PO 20mg OD or PO 40mg OD if severe or recurrent (continue for 4 weeks for duodenal ulcer, 8 weeks for gastric ulcer)
- Outpatient OGD
Cases complicated by haemorrhage or perforation require more active intervention. The initial management is the same:
- Bloods including amylase and X-Match.
- NBM and IV fluid resuscitation.
- Analgesia.
- ECG (MI may present as an acute abdomen).
- CXR and AXR (air under diaphragm will be seen in over 70% of cases)
- IV Ranitidine 50mg TDS (Not PPI pre endoscopy).
- Urinary catheter.
- Refer urgently to SpR/SHO: Prepare patient for endoscopy or theatre.
- Broad-spectrum IV antibiotics as per Gastroenterology/Hepatobiliary policy (microguide) should be given and a nasogastric tube inserted.
The diagnosis of this condition should not be in doubt as the presentation is sudden and dramatic. A sudden onset of pain and a rigid abdomen are characteristic. It is particularly important to exclude pancreatitis in such cases. Gas is present under the diaphragm on an erect CXR in over 70% of cases. After resuscitation urgent laparotomy is indicated.