Peptic Ulcer Disease — SAQ

Stem A (perforation)

A 45-year-old man presents with sudden severe generalised abdominal pain. He takes frequent ibuprofen. Examination: rigid board-like abdomen. Erect CXR: free gas under the right hemidiaphragm. Pulse 110, BP 100/60.^[1]

Stem B (bleed — for part d)

Separately, a 68-year-old on aspirin has melaena, HR 110, BP 96/60, Hb 78 g/L.^[3]

Questions

a) Stem A diagnosis and immediate management with exact standard drugs/doses. (4 marks)

Perforated peptic ulcer (NSAID-associated; free gas classically from anterior DU).^[1]
ABC; oxygen if needed; two large-bore IV cannulae; crystalloid; NG tube; catheter; bloods including lactate/cultures if septic.
Antibiotics: broad-spectrum cover (Gram-positive, Gram-negative, anaerobes) — e.g. co-amoxiclav 1.2 g IV TDS + metronidazole 500 mg IV TDS, or piperacillin-tazobactam 4.5 g IV TDS.^[1]
PPI: pantoprazole/omeprazole 80 mg IV bolus.
Analgesia: morphine IV titrated.
Urgent surgery: laparoscopic or open washout + Graham omental patch. Post-op: continue PPI, test and eradicate H. pylori, stop NSAID permanently if possible.

b) DU versus GU — pain pattern, weight, malignancy. (3 marks)

c) Posterior DU complications and vessel. (3 marks)

Penetration into pancreas → severe back pain.^[2]
Erosion of gastroduodenal artery (GDA) → massive upper GI haemorrhage.^[2]
Bleed pathway: resuscitate → dual endoscopic haemostasis ± IR embolisation or surgical under-running if endoscopy fails.^[3][1]

d) Stem B — transfusion target, PPI infusion after endoscopic therapy, and H. pylori eradication regimen with test of cure. (5 marks)

Restrictive transfusion target Hb about 70 g/L for hospitalised upper GI bleeding (ACG).^[3]
After dual endoscopic therapy of high-risk ulcer: IV PPI 80 mg bolus then 8 mg/h for 72 h (Lau regimen).^[4]
Eradication is 14 days (Toronto). Clarithromycin triple (example in a low macrolide-resistance setting: PPI BD + clarithromycin 500 mg BD + amoxicillin 1 g BD) is restricted to no prior macrolide exposure and known low resistance; most patients are better served by bismuth quadruple or concomitant therapy (Toronto consensus).^[5]
Confirm with urea breath test or stool antigen ≥4 weeks after antibiotics and ≥2 weeks off PPI (serology unsuitable for cure).^[5]

Additional teaching points (mark-scoring phrases)

Forrest high-risk stigmata needing dual therapy: Ia spurting, Ib oozing, IIa non-bleeding visible vessel (± IIb adherent clot after careful management).^[3]

Glasgow-Blatchford vs Rockall: Blatchford = pre-endoscopy need for intervention; Rockall = post-endoscopy mortality/rebleed risk.^[6]

Why adrenaline monotherapy fails: temporary vasoconstriction/tamponade only — always add thermal contact or clips for high-risk lesions.^[3]

Post-Graham-patch package: PPI, H. pylori eradication, stop NSAID, early mobilisation, VTE prophylaxis, diet advance, safety-net for leak/collections.^[1]

References6ShowHide

1. [1]Tarasconi A, Coccolini F, Biffl WL, et al. Perforated and bleeding peptic ulcer: WSES guidelines World J Emerg Surg, 2020.PMID 31921329
2. [2]Zittel TT, Jehle EC, Becker HD Surgical management of peptic ulcer disease today--indication, technique and outcome Langenbecks Arch Surg, 2000.PMID 10796046
3. [3]Laine L, Barkun AN, Saltzman JR, et al. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding Am J Gastroenterol, 2021.PMID 33929377
4. [4]Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers N Engl J Med, 2000.PMID 10922420
5. [5]Fallone CA, Chiba N, van Zanten SV, et al. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults Gastroenterology, 2016.PMID 27102658
6. [6]Blatchford O, Murray WR, Blatchford M A risk score to predict need for treatment for upper-gastrointestinal haemorrhage Lancet, 2000.PMID 11073021