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orders of the stomach and duodenum
Treatment of complicated ulcers
Perforation
Perfo ra tio n s h o uld b e co n s id ered in pa tien ts pres en tin g w ith s ud d en o n s et
in ten s e
epiga s tric pa in , pa rt icula rly if t h ere is rigid it y o f th e a b d o m in a l w a ll. T h e ris k o f
perito n itis is in crea s ed if the perfo ra tio n o ccurs o n a full s to m a ch.
– T o s ta rt:
• pla ce the pa tien t o n a s trict fa s t (N PO ); in s ert a n a s o ga s tric tub e a n d a s pira te if
po s s ib le
• pla ce a n in tra ven o us lin e a n d hyd ra te (a ltern a te b etw een 5 % gluco s e a n d
R in ger
L a cta te)
• hyoscine butylbromide IV o r IM : 1 0 to 2 0 m g, to b e repea ted every 8 ho urs if
n eces s a ry
• omeprazole I V in fus io n : 4 0 m g/ d a y o ver 2 0 to 3 0 m in utes
o r, if n o t a va ila b le, cimetidine co n tin uo us I V in fus io n : 1 6 0 0 m g o ver 2 4 ho urs
– R efer to a s urgeo n if the pa tien t ha s ea ten d urin g the 6 ho urs prio r to the o n s et o f
pa in o r if there is n o im pro vem en t w ithin 1 2 ho urs d es pite m ed ica l trea tm en t.
– C o n tin ue trea tm en t fo r 3 d a ys then res ta rt o ra l feed in g if the perfo ra tio n o ccurred
on
a n em pty s to m a ch a n d if the pa tien t im pro ved d urin g the firs t 1 2 ho urs o f
trea tm en t.
T hen s ta rt PO trea tm en t to era d ica te Helicobacter pylori (s ee further).
Gastrointestinal bleeding
Pa s s in g o f b la ck s to o l ( m a elen a ) a n d / o r vo m itin g b lo o d ( h a em a tem es is ) . I n
80% of
ca s es the b leed in g s to ps s po n ta n eo us ly.
– I n s ert a n a s o ga s tric tub e fo r a s pira tio n a n d in s ert a n I V lin e (1 6 G ).
If the haemodynamic state is stable (puls e a n d b lo o d pres s ure a re n o rm a l)
– H yd ra te (R in ger L a cta te), m o n ito r, keep N PO fo r 1 2 ho urs .
– HI fatehmeroerrishangioc sahocctikv,ephaageem1 o9 )r.rha ge, res ta rt o ra l feed in g a fter 1 2 ho urs .
– G a s tric la va ge w ith co ld w a ter is n o t es s en tia l, b ut m a y help eva lua te pers is ten ce
of
b leed in g.
If the haemorrhage continues ( h a em a t em es is ) and/or if the haemodynamic state
deteriorates (puls e in crea s es , B P d ro ps ):
– I n t en s ive ca re a n d t ra n s fus io n a cco rd in g t o t h e s everit y o f t h e b leed in g ( s ee
– E m ergen cy s urgica l in terven tio n .
iMms etoronsidt apzeopleticPOulcers a re ca usmeedtrobnidyazHoleeliPcOobacter pylori inmfeetcrotionidnaz.oIfleaPOd ia gn o s is o f ulcer
pro b a b le, a n d th e pa t ien t h a s freq uen t a t t a cks req uirin g repea t ed t rea t m en t w it h
a n t iulcer d rugs o r, in ca s es o f co m plica t ed ulcers ( perfo ra t io n o r ga s t ro in t es t in a l
b leed in g) trea tm en t to era d ica te H. pylori s ho uld b e co n s id ered to preven t rela ps es .
O n ce the a cute pha s e ha s pa s s ed , pres crib e o n e o f the fo llo w in g trea tm en ts :
Treatment of choice (10 days) Alternative (14 days)
222
1 g/ d a y in 2 d ivid ed d o s es 1 g/ d a y in 2 d ivid ed d o s es 1 g/ d a y in 2 d ivid ed d o s es
+ amoxicillin PO + amoxicillin PO + amoxicillin PO
2 g/ d a y in 2 d ivid ed d o s es 2 g/ d a y in 2 d ivid ed d o s es 2 g/ d a y in 2 d ivid ed d o s es
+ omeprazole PO + bismuth subcitrate PO + cimetidine PO
4 0 m g/ d a y in 2 d ivid ed d o s es 4 8 0 m g/ d a y in 4 d ivid ed d o s es 1 6 0 0 m g/ d a y in 2
d ivid ed
Treatment of complicated ulcers
Perforation
Perfo ra tio n s h o uld b e co n s id ered in pa tien ts pres en tin g w ith s ud d en o n s et
in ten s e
epiga s tric pa in , pa rt icula rly if t h ere is rigid it y o f th e a b d o m in a l w a ll. T h e ris k o f
perito n itis is in crea s ed if the perfo ra tio n o ccurs o n a full s to m a ch.
– T o s ta rt:
• pla ce the pa tien t o n a s trict fa s t (N PO ); in s ert a n a s o ga s tric tub e a n d a s pira te if
po s s ib le
• pla ce a n in tra ven o us lin e a n d hyd ra te (a ltern a te b etw een 5 % gluco s e a n d
R in ger
L a cta te)
• hyoscine butylbromide IV o r IM : 1 0 to 2 0 m g, to b e repea ted every 8 ho urs if
n eces s a ry
• omeprazole I V in fus io n : 4 0 m g/ d a y o ver 2 0 to 3 0 m in utes
o r, if n o t a va ila b le, cimetidine co n tin uo us I V in fus io n : 1 6 0 0 m g o ver 2 4 ho urs
– R efer to a s urgeo n if the pa tien t ha s ea ten d urin g the 6 ho urs prio r to the o n s et o f
pa in o r if there is n o im pro vem en t w ithin 1 2 ho urs d es pite m ed ica l trea tm en t.
– C o n tin ue trea tm en t fo r 3 d a ys then res ta rt o ra l feed in g if the perfo ra tio n o ccurred
on
a n em pty s to m a ch a n d if the pa tien t im pro ved d urin g the firs t 1 2 ho urs o f
trea tm en t.
T hen s ta rt PO trea tm en t to era d ica te Helicobacter pylori (s ee further).
Gastrointestinal bleeding
Pa s s in g o f b la ck s to o l ( m a elen a ) a n d / o r vo m itin g b lo o d ( h a em a tem es is ) . I n
80% of
ca s es the b leed in g s to ps s po n ta n eo us ly.
– I n s ert a n a s o ga s tric tub e fo r a s pira tio n a n d in s ert a n I V lin e (1 6 G ).
If the haemodynamic state is stable (puls e a n d b lo o d pres s ure a re n o rm a l)
– H yd ra te (R in ger L a cta te), m o n ito r, keep N PO fo r 1 2 ho urs .
– HI fatehmeroerrishangioc sahocctikv,ephaageem1 o9 )r.rha ge, res ta rt o ra l feed in g a fter 1 2 ho urs .
– G a s tric la va ge w ith co ld w a ter is n o t es s en tia l, b ut m a y help eva lua te pers is ten ce
of
b leed in g.
If the haemorrhage continues ( h a em a t em es is ) and/or if the haemodynamic state
deteriorates (puls e in crea s es , B P d ro ps ):
– I n t en s ive ca re a n d t ra n s fus io n a cco rd in g t o t h e s everit y o f t h e b leed in g ( s ee
– E m ergen cy s urgica l in terven tio n .
iMms etoronsidt apzeopleticPOulcers a re ca usmeedtrobnidyazHoleeliPcOobacter pylori inmfeetcrotionidnaz.oIfleaPOd ia gn o s is o f ulcer
pro b a b le, a n d th e pa t ien t h a s freq uen t a t t a cks req uirin g repea t ed t rea t m en t w it h
a n t iulcer d rugs o r, in ca s es o f co m plica t ed ulcers ( perfo ra t io n o r ga s t ro in t es t in a l
b leed in g) trea tm en t to era d ica te H. pylori s ho uld b e co n s id ered to preven t rela ps es .
O n ce the a cute pha s e ha s pa s s ed , pres crib e o n e o f the fo llo w in g trea tm en ts :
Treatment of choice (10 days) Alternative (14 days)
222
1 g/ d a y in 2 d ivid ed d o s es 1 g/ d a y in 2 d ivid ed d o s es 1 g/ d a y in 2 d ivid ed d o s es
+ amoxicillin PO + amoxicillin PO + amoxicillin PO
2 g/ d a y in 2 d ivid ed d o s es 2 g/ d a y in 2 d ivid ed d o s es 2 g/ d a y in 2 d ivid ed d o s es
+ omeprazole PO + bismuth subcitrate PO + cimetidine PO
4 0 m g/ d a y in 2 d ivid ed d o s es 4 8 0 m g/ d a y in 4 d ivid ed d o s es 1 6 0 0 m g/ d a y in 2
d ivid ed
