31 August 2026Chapter 3: Gastrointestinal disordersPDF page 122
Gastric and duodenal ulcers in adults
Full paraphrased clinical guide to adult peptic ulcers, complications, bleeding, perforation, H. pylori, and follow-up.
This guide supports clinical education and care navigation. It does not replace bedside judgement, emergency care, specialist advice, or local treatment protocol.
Seek urgent care
- Sudden intense epigastric pain with rigid abdomen or suspected perforation.
- Vomiting blood, black stool, fainting, shock signs, severe weakness, or ongoing bleeding.
- Persistent symptoms despite treatment, weight loss, swallowing difficulty, recurrent vomiting, or concern for gastric cancer.
Overview
Gastric and duodenal ulcers are peptic ulcers affecting the stomach or duodenum.
The most common complications are perforation and gastrointestinal bleeding.
Clinical features
- Burning epigastric pain or cramping between meals.
- Pain may wake the patient at night and episodes can recur for several days.
- Nausea and vomiting can occur.
Non-complicated ulcer care
- Aspirin and NSAIDs such as ibuprofen and diclofenac are contraindicated in patients with current or previous ulcers unless a specialist risk-benefit decision is made.
- Use non-NSAID pain control when analgesia is needed.
| Situation | Treatment direction |
|---|---|
| Isolated episode | Identify NSAID or aspirin use and stop when clinically safe; avoid alcohol and tobacco; give omeprazole PO 20 mg once daily in the morning for 7 to 10 days. |
| Severe or recurrent symptoms | Omeprazole dose may be increased to 40 mg once daily and treatment prolonged up to 8 weeks according to clinical assessment. |
| Frequent recurrences unrelated to NSAID use | Assess for H. pylori and consider eradication therapy when criteria are met. |
Complicated ulcers
- Cold-water gastric lavage is not essential, but can help assess whether bleeding is continuing where appropriate.
- Emergency care should include shock assessment, haemoglobin assessment where available, blood availability planning, and surgical referral.
| Step | Action |
|---|---|
| Suspect | Sudden intense epigastric pain, especially with abdominal wall rigidity; peritonitis risk is higher if perforation occurs on a full stomach. |
| Immediate care | Keep NPO, insert nasogastric tube and aspirate if possible, insert IV line, hydrate with Ringer lactate, treat acute pain, and give omeprazole IV infusion 40 mg once daily over 20 to 30 minutes. |
| Definitive care | Refer urgently to a surgeon. |
| If referral impossible | Continue conservative management with maintenance fluid, alternating 5% glucose and Ringer lactate, and start IV antibiotics according to shock/sepsis guidance. |
| If improving after 3 days | Cautiously restart oral feeding, remove NG tube, and begin H. pylori eradication treatment when appropriate. |
| Situation | Action |
|---|---|
| Presentation | Melaena and/or haematemesis; many bleeds stop spontaneously but require assessment. |
| Initial care | Insert nasogastric tube for aspiration and a large IV line, commonly 16G when available. |
| Stable pulse and blood pressure | Hydrate with Ringer lactate, monitor, keep NPO for 12 hours, then restart oral feeding if there is no active haemorrhage. |
| Ongoing haematemesis or haemodynamic deterioration | Intensive care, transfusion according to severity, haemorrhagic shock management, and emergency surgical intervention. |
Helicobacter pylori
Most peptic ulcers are associated with Helicobacter pylori. Confirm infection with a test where possible, especially before eradication therapy.
- Consider eradication when ulcer diagnosis is probable and the patient has frequent attacks requiring repeated or prolonged antiulcer treatment over 8 weeks, or when ulcers are complicated by perforation or bleeding.
- H. pylori resistance varies globally, so national or local recommendations should override the example regimen when available.
- In immunocompromised patients, consider Mycobacterium avium complex or other nontuberculous mycobacterial infection before starting clarithromycin-containing triple therapy.
| Medicine | Dose and duration |
|---|---|
| Omeprazole PO | 20 mg twice daily for 7 days. |
| Clarithromycin PO | 500 mg twice daily for 7 days. |
| Amoxicillin PO | 1 g twice daily for 7 days. |
| Penicillin allergy | Substitute metronidazole PO 500 mg twice daily for amoxicillin. |
Follow-up and differential diagnosis
- If symptoms continue despite treatment, consider gastric cancer and refer for investigations when possible.
- Omeprazole is as effective by oral route as by IV route when the patient can take oral treatment.
- Review medicine risks, recurrence, bleeding signs, nutritional status, and ability to access urgent care if symptoms worsen.
- Handover should include ulcer history, NSAID/aspirin exposure, alcohol/tobacco, haemodynamic status, bleeding/perforation signs, NPO/NG/IV care, PPI route and dose, antibiotics, H. pylori testing, surgical referral status, and follow-up plan.
Medicines in this guide
Omeprazole oralPPI for uncomplicated ulcers and H. pylori eradication regimens.Omeprazole injectableIV PPI used in perforation pathway when oral therapy is not appropriate.Ringer lactateHydration fluid for perforation or gastrointestinal bleeding management.Amoxicillin oralPart of H. pylori eradication triple therapy when not penicillin allergic.Clarithromycin oralPart of H. pylori eradication triple therapy.Metronidazole oralSubstitute for amoxicillin in penicillin allergy according to source guidance.Paracetamol = acetaminophen oralPain option when NSAIDs and aspirin are contraindicated.
Source
MSF Clinical guidelines - Diagnosis and treatment manual (December 2024)
This page is a paraphrased clinician-oriented guide derived from the source topic on PDF page 122. Medicine-specific details should be checked against local protocol and the linked drug-information pages.