What is the initial workup and treatment for a patient presenting with an abdominal ulcer?

Initial Workup and Treatment for Abdominal Ulcer

The initial workup for a patient presenting with an abdominal ulcer should include CT scan imaging as the first-line diagnostic test, followed by prompt initiation of proton pump inhibitor therapy and testing for H. pylori infection. 1

Diagnostic Approach

Initial Assessment

• CT scan is recommended as the first-line imaging study for suspected peptic ulcer, particularly when perforation is a concern 1
• If CT is not promptly available, chest/abdominal X-ray should be performed to detect free air, though sensitivity ranges from 30-85% 1
• Laboratory studies including complete blood count, metabolic panel, and arterial blood gas analysis should be routinely obtained 1
• When free air is not seen on imaging but suspicion remains high, consider water-soluble contrast studies either orally or via nasogastric tube 1

Endoscopic Evaluation

• Endoscopy is the definitive diagnostic test for peptic ulcer disease, allowing direct visualization and biopsy 2
• All patients should undergo H. pylori testing during endoscopy through CLOtest, histology, and/or culture 1
• Non-invasive H. pylori testing options include urea breath test (sensitivity 88-95%) and stool antigen testing (sensitivity 94%) 1

Treatment Approach

Pharmacological Management

• Initiate high-dose proton pump inhibitor therapy immediately (omeprazole 80 mg stat followed by 8 mg/hour infusion for 72 hours) for bleeding ulcers 1
• For non-bleeding ulcers, oral PPI therapy is recommended:
  • Duodenal ulcer: omeprazole 20 mg once daily for 4 weeks 3
  • Gastric ulcer: omeprazole 40 mg once daily for 4-8 weeks 3
• H. pylori eradication therapy should be initiated if testing is positive 1

H. pylori Eradication Protocols

• First-line therapy (low clarithromycin resistance areas):
  • Standard triple therapy: PPI standard dose twice daily + clarithromycin 500 mg twice daily + amoxicillin 1000 mg twice daily for 14 days 1, 4
• Alternative for high clarithromycin resistance areas:
  • Sequential therapy: PPI + amoxicillin for 5 days, followed by PPI + clarithromycin + metronidazole for 5 days 1, 4
• Second-line therapy (if first-line fails):
  • PPI + levofloxacin 500 mg daily + amoxicillin 1000 mg twice daily for 10 days 1, 4

Antimicrobial Therapy for Perforated Ulcers

• Start empiric broad-spectrum antibiotics immediately after collecting peritoneal fluid samples 4
• A beta-lactam/beta-lactamase inhibitor is recommended as first-line therapy 4
• Short-course therapy (3-5 days) is sufficient unless complications arise 4
• Antifungal therapy is not routinely recommended unless the patient is critically ill or severely immunocompromised 4

Management of Complications

Bleeding Ulcers

• Endoscopic therapy is the first-line treatment for actively bleeding ulcers 1
• Following successful endoscopic therapy, high-dose PPI therapy should be administered 1
• Patients who are hemodynamically stable 4-6 hours after endoscopy can start oral intake 1
• Repeat endoscopy is indicated if there is clinical evidence of rebleeding (fresh melena, hematemesis, falling blood pressure, rising pulse) 1

Perforated Ulcers

• Surgical intervention is required for perforated ulcers 1
• Peritoneal fluid should be collected for culture before starting antibiotics 4
• Patients should be closely monitored for signs of sepsis or septic shock 4

Post-Treatment Monitoring

• Patients should be allowed to drink and start a light diet 4-6 hours after endoscopy if hemodynamically stable 1
• Confirm H. pylori eradication with follow-up testing (urea breath test or stool antigen test) at least 4 weeks after completion of therapy and at least 2 weeks after PPI discontinuation 1
• For gastric ulcers, follow-up endoscopy is recommended after 8 weeks of therapy to confirm healing and rule out malignancy 2

Common Pitfalls to Avoid

• Delaying antibiotic administration while waiting for culture results in perforated ulcers 4
• Prolonged antibiotic courses beyond 5 days when adequate source control has been achieved 4
• Failure to test for H. pylori in all patients with peptic ulcer disease 1
• Inadequate acid suppression during the acute phase of treatment 1
• Continuing NSAIDs in patients with peptic ulcer disease, which can reduce healing rates from 95% to 40% 2