Symptoms and Treatment of Intestinal Ulcers
Clinical Presentation
Intestinal ulcers most commonly present with sudden onset of epigastric or abdominal pain, though approximately two-thirds of patients with peptic ulcer disease remain asymptomatic. 1, 2
Key Symptoms to Identify:
- Epigastric pain is the most common presenting symptom in symptomatic patients 2
- Associated symptoms include dyspepsia, bloating, abdominal fullness, nausea, or early satiety 2
- Sudden onset of severe abdominal pain with localized or generalized peritonitis suggests perforation, though peritonitis is present in only two-thirds of perforated cases 3, 4
- Hematochezia or chronic gastrointestinal bleeding may occur with isolated colonic ulcers 5
Physical Examination Findings:
- Physical examination findings may be equivocal, particularly in patients with contained or sealed perforations 3, 4
- Laboratory tests are non-specific but may show leukocytosis, metabolic acidosis, and elevated serum amylase in complicated cases 3, 6
Common pitfall: Physical examination can be misleading in perforated ulcers, as peritonitis may be minimal or absent in contained leaks. 3
Diagnostic Approach
Imaging Studies:
- CT scan is the first-line imaging study for suspected perforated peptic ulcer (Strong recommendation) 3, 4
- Chest/abdominal X-ray should be performed as initial assessment only when CT is not immediately available 3, 4
- Critical caveat: Up to 12% of patients with perforations may have a normal CT scan, requiring additional diagnostic measures 4
- Water-soluble contrast (oral or via nasogastric tube) should be added when free air is not seen on imaging but perforation is still suspected 3, 4
Endoscopic Evaluation:
- Endoscopy is the gold standard for diagnosis, allowing direct visualization and biopsy collection 7
- Risk stratification using Blatchford score determines timing: very low-risk patients undergo outpatient endoscopy, low-risk patients undergo early inpatient endoscopy (≤24 hours), and high-risk patients undergo urgent inpatient endoscopy (≤12 hours) 3, 7
Treatment Options
Medical Management for Uncomplicated Ulcers:
Proton pump inhibitors (PPIs) are the primary treatment, healing 80-100% of peptic ulcers within 4 weeks. 1
- Full-dose PPI therapy (omeprazole 20 mg once daily) is first-choice treatment 6, 8
- Gastric ulcers larger than 2 cm may require 8 weeks of treatment 1
- PPIs should be taken before meals, typically once daily 8
H. pylori Eradication:
Eradicating H. pylori reduces ulcer recurrence from 50-60% to 0-2%. 1
- Standard triple therapy (first-line in areas with low clarithromycin resistance): clarithromycin 500 mg twice daily + amoxicillin 1000 mg twice daily + PPI for 10-14 days 6, 8, 9
- Sequential therapy with four drugs (amoxicillin, clarithromycin, metronidazole, and PPI) is recommended in areas with high clarithromycin resistance 6
- Second-line therapy: 10-day levofloxacin-amoxicillin triple therapy if first-line fails 6
- Follow-up endoscopy at 4-6 weeks is recommended 3
Common pitfall: Failure to test for H. pylori in all patients with gastric ulcers is a frequent error. 7
NSAID-Related Ulcers:
- Discontinuing NSAIDs heals 95% of ulcers and reduces recurrence from 40% to 9% 1
- When NSAID discontinuation is not possible: change to a less ulcerogenic NSAID (e.g., from ketorolac to ibuprofen), add a PPI, and eradicate H. pylori if present 1
Management of Complications
Bleeding Ulcers:
Non-operative management with endoscopy is first-line treatment after initial resuscitation. 3, 7
Resuscitation Targets:
- Maintain hemoglobin >7 g/dL (Strong recommendation) 3, 7
- Target systolic blood pressure 90-100 mmHg until major bleeding is controlled 3
- Normalize lactate and base deficit 3, 7
- Correct/prevent coagulopathy 3, 7
Endoscopic Treatment:
- Endoscopic hemostasis is recommended for spurting ulcers (Forrest 1a), oozing ulcers (Forrest 1b), and ulcers with non-bleeding visible vessel (Forrest 2a) 3, 7
- Dual modality endoscopic hemostasis is suggested 3, 7
- PPI therapy for 6-8 weeks following endoscopic treatment 7
- Transcatheter angioembolization is an alternative when endoscopy fails or is not feasible 7
Perforated Ulcers:
Operative treatment is strongly recommended for patients with significant pneumoperitoneum, extraluminal contrast extravasation, or signs of peritonitis. 3
Surgical Timing:
- Surgery should be performed as soon as possible, especially in patients with delayed presentation and those older than 70 years (Strong recommendation) 3
- Critical timing consideration: Each hour of surgical delay beyond hospital admission is associated with a 2.4% decreased probability of survival 3
- Mortality is nil in patients operated within 24 hours versus significantly higher beyond 48 hours 3
Non-Operative Management Criteria (Highly Selective):
Non-operative management may be considered only if ALL of the following are met 3:
- Radiologically undetected leak (no contrast extravasation)
- No signs of peritonitis or sepsis
- Stable vital signs
- Resources for intensive monitoring available
- Readiness to operate immediately if condition deteriorates
Components of non-operative management: nil by mouth, IV hydration, nasogastric decompression, PPI therapy, IV antibiotics, and follow-up endoscopy at 4-6 weeks 3
Critical caveat: Elderly patients (>70 years) experience paradoxically higher mortality if non-operative management fails; caution is strongly advised in this population. 3
Endoscopic Treatment for Perforation:
- Endoscopic treatment (clipping, fibrin glue sealing, or stenting) should be avoided for perforated peptic ulcer (Weak recommendation) 3
- These modalities are not recognized as standard approaches and need further validation 3
Antimicrobial Therapy
- Antibiotic therapy should be prescribed in patients with perforated peptic ulcer 3
- For bleeding peptic ulcer, antimicrobial therapy is indicated for H. pylori testing and treatment if positive 3
- Therapeutic options for H. pylori-positive bleeding ulcers include bismuth, metronidazole, and tetracycline combined with omeprazole 1