common and occur more often in younger adults. Gastric ulcers usually
occur after middle age.
CAUSES
• Excessive secretion of gastric acid
• Inadequate protection of the lining of the stomach and duodenum
against digestion by acid and pepsin
• Helicobacter pylori (H. pylori) infection
• Medicines e.g. non-steroidal anti-inflammatory drugs (NSAIDs),
corticosteroids
• Inadequate protection of the lining of the stomach and duodenum
against digestion by acid and pepsin
• Helicobacter pylori (H. pylori) infection
• Medicines e.g. non-steroidal anti-inflammatory drugs (NSAIDs),
corticosteroids
SYMPTOMS
• Abdominal pain
• May be a minor discomfort, gnawing, burning, dull ache or very
severe pain
• Typically in the epigastrium or right hypochondrium
• Occasionally high up behind the sternum or low down around the
umbilicus
• In duodenal ulcer, typically comes on when the patient is hungry
and may wake the patient up in the middle of the night.
• In gastric ulcer, it is typically worsened by food
• Is relieved by alkalis and food in duodenal ulcer
• Vomiting may occur in both duodenal and gastric ulcers
SIGNS
• Tenderness in the epigastrium, right hypochondrium or umbilical
region during an attack
INVESTIGATIONS
• Haemoglobin
• Oesophago-gastro-duodenoscopy
• With biopsy for histology and staining (for H. pylori)
• With urease test (for H. pylori)
• Barium meal in the absence of endoscopy
• Stool examination to exclude intestinal parasites
• May be a minor discomfort, gnawing, burning, dull ache or very
severe pain
• Typically in the epigastrium or right hypochondrium
• Occasionally high up behind the sternum or low down around the
umbilicus
• In duodenal ulcer, typically comes on when the patient is hungry
and may wake the patient up in the middle of the night.
• In gastric ulcer, it is typically worsened by food
• Is relieved by alkalis and food in duodenal ulcer
• Vomiting may occur in both duodenal and gastric ulcers
SIGNS
• Tenderness in the epigastrium, right hypochondrium or umbilical
region during an attack
INVESTIGATIONS
• Haemoglobin
• Oesophago-gastro-duodenoscopy
• With biopsy for histology and staining (for H. pylori)
• With urease test (for H. pylori)
• Barium meal in the absence of endoscopy
• Stool examination to exclude intestinal parasites
TREATMENT
Treatment objectives
• To relieve pain and reduce gastric acid secretion
• To promote healing of the ulcer
• To eradicate H. pylori if present
• To prevent recurrence of the ulcer
• To avoid complications.
• To promote healing of the ulcer
• To eradicate H. pylori if present
• To prevent recurrence of the ulcer
• To avoid complications.
Non-pharmacological treatment
• Avoid smoking and alcohol intake
• Avoid foods that aggravate the pain
• Allay anxiety and stress
• Surgery - indications for surgery:
• Chronicity - crippling periodic attacks
• Economic factors which make it difficult for the patient to persevere
with medical treatment
• Complications
• Perforation
• Gastric outlet obstruction
• Haemorrhage that does not respond to conservative measures
• Avoid foods that aggravate the pain
• Allay anxiety and stress
• Surgery - indications for surgery:
• Chronicity - crippling periodic attacks
• Economic factors which make it difficult for the patient to persevere
with medical treatment
• Complications
• Perforation
• Gastric outlet obstruction
• Haemorrhage that does not respond to conservative measures
Pharmacological treatment
(Evidence rating: A)
Dyspepsia
• Magnesium trisilicate, oral,
15 ml 8 hourly (in between meals and at bedtime to control dyspepsia)
Avoid taking antacids within 2 hours of proton pump inhibitors (PPIs).
NSAID-associated duodenal or gastric ulcer and gastro-duodenal
erosions
• Esomeprazole, oral,
Adults
20 mg daily for 4 weeks. Repeat course if ulcer is not fully healed.
Or
Omeprazole, oral,
Adults
20 mg daily for 4 weeks. Repeat course if ulcer is not fully healed.
Or
Rabeprazole, oral,
Adults
20 mg daily for 4 weeks. Repeat course if ulcer is not fully healed.
Bleeding peptic ulcer
• Esomeprazole, IV,
Adults
40 mg daily
Or
Omeprazole, IV,
Adults
40 mg 12 hourly for up to 5 days
29
Helicobacter pylori Eradication
Majority of patients presenting with duodenal ulcer are infected with
Helicobacter pylori. Eradication of H. pylori should therefore be done using a
7-day course of treatment consisting of a PPI plus a combination of two of
the antibiotics indicated in the table below.
Dyspepsia
• Magnesium trisilicate, oral,
15 ml 8 hourly (in between meals and at bedtime to control dyspepsia)
Avoid taking antacids within 2 hours of proton pump inhibitors (PPIs).
NSAID-associated duodenal or gastric ulcer and gastro-duodenal
erosions
• Esomeprazole, oral,
Adults
20 mg daily for 4 weeks. Repeat course if ulcer is not fully healed.
Or
Omeprazole, oral,
Adults
20 mg daily for 4 weeks. Repeat course if ulcer is not fully healed.
Or
Rabeprazole, oral,
Adults
20 mg daily for 4 weeks. Repeat course if ulcer is not fully healed.
Bleeding peptic ulcer
• Esomeprazole, IV,
Adults
40 mg daily
Or
Omeprazole, IV,
Adults
40 mg 12 hourly for up to 5 days
29
Helicobacter pylori Eradication
Majority of patients presenting with duodenal ulcer are infected with
Helicobacter pylori. Eradication of H. pylori should therefore be done using a
7-day course of treatment consisting of a PPI plus a combination of two of
the antibiotics indicated in the table below.
