What should be done for a patient with severe abdominal pain suspected to be due to peptic ulcer disease?

Management of Severe Abdominal Pain from Suspected Peptic Ulcer Disease

For a patient with severe abdominal pain suspected to be from peptic ulcer disease, immediately obtain CT scan imaging to rule out perforation, initiate resuscitation with IV fluids and laboratory studies, and start empiric proton pump inhibitor therapy while arranging urgent endoscopy. 1, 2, 3

Immediate Assessment and Resuscitation

Obtain routine laboratory studies and arterial blood gas analysis immediately to assess for complications, though these findings are non-specific. 1, 2, 3

• Leukocytosis, metabolic acidosis, and elevated serum amylase commonly indicate perforation but do not confirm it. 1, 2, 3
• Complete blood count, metabolic panel, and arterial blood gas help guide resuscitation and assess severity. 2

Begin aggressive IV fluid resuscitation and correct electrolyte abnormalities in all patients presenting with acute severe abdominal pain. 1

Diagnostic Imaging Algorithm

CT scan of the abdomen is the first-line imaging modality for suspected perforated peptic ulcer (Strong recommendation, 1C). 1, 2, 3

• CT scan has superior sensitivity for detecting free air, contained perforations, and other complications compared to plain radiography. 1
• Only perform chest/abdominal X-ray as initial assessment if CT is not promptly available (Strong recommendation, 1C). 1, 3
• Erect chest X-ray detects free air in only 30-85% of perforations, making negative X-ray unreliable for excluding perforation. 1

If free air is not seen on imaging but clinical suspicion remains high, perform imaging with water-soluble contrast (oral or via nasogastric tube) to detect contained leaks (Weak recommendation, 2D). 1

Critical Decision Point: Perforation vs Non-Perforation

If Perforation is Confirmed:

Surgery is the standard treatment for perforated peptic ulcer. 1, 4, 5

• Immediate surgical consultation is mandatory for patients with signs of peritonitis or hemodynamic instability. 1, 5
• Graham patch repair (open or laparoscopic) is the primary surgical technique for perforated ulcers. 5
• Conservative management can only be considered in highly selected cases: hemodynamically stable patients without generalized peritonitis, with contained perforation on CT, and ability for close monitoring. 4

Start broad-spectrum antibiotics immediately if perforation is present, covering gram-negative aerobic/facultative bacilli, gram-positive streptococci, and obligate anaerobic bacilli. 1

If No Perforation (Uncomplicated Peptic Ulcer):

Initiate proton pump inhibitor therapy immediately - omeprazole 40 mg IV or oral can heal 80-100% of peptic ulcers within 4 weeks. 6, 7

• Gastric ulcers larger than 2 cm may require 8 weeks of treatment. 7
• PPIs should be given at the lowest effective dose for the shortest duration necessary. 6

Arrange urgent upper endoscopy (EGD) with biopsy as the definitive diagnostic test. 2, 8, 9

• Endoscopy establishes diagnosis, excludes malignancy, and tests for H. pylori infection. 2
• Biopsy all gastric ulcers from both base and edges to exclude adenocarcinoma. 2
• Obtain additional biopsies from antrum (2 biopsies within 2-3 cm of pylorus) and body (2 biopsies) for H. pylori testing. 2

Helicobacter pylori Testing and Treatment

All patients with peptic ulcer disease must undergo H. pylori testing to identify the underlying cause. 2, 8, 9

• Non-invasive tests (urea breath test with 88-95% sensitivity or stool antigen test with 94% sensitivity) are recommended. 2
• Stop PPIs, antibiotics, and bismuth for at least 2 weeks before testing to avoid false-negative results. 2

If H. pylori is positive, eradicate the infection with combination therapy (bismuth, metronidazole, tetracycline plus omeprazole) to reduce ulcer recurrence from 50-60% to 0-2%. 8, 7

• Confirm eradication with repeat testing after treatment to prevent recurrence. 2

NSAID Management

Discontinue NSAIDs immediately if the patient is taking them - this heals 95% of NSAID-related ulcers and reduces recurrence from 40% to 9%. 8, 7

• If NSAID continuation is unavoidable, switch to a less ulcerogenic agent (e.g., from ketorolac to ibuprofen), add a PPI, and eradicate H. pylori. 7

Common Pitfalls to Avoid

Do not rely on physical examination alone - peritonitis may be minimal or absent in up to one-third of patients with perforated peptic ulcer, particularly with contained or sealed perforations. 3

Do not delay imaging when perforation is suspected - negative X-ray does not rule out perforation; proceed directly to CT scan. 1

Do not assume symptomatic response to PPI excludes gastric malignancy - consider endoscopy in patients with suboptimal response or early relapse, especially in older patients. 6

Do not forget to test for H. pylori - approximately 42% of peptic ulcer disease is caused by H. pylori infection, and eradication dramatically reduces recurrence. 7