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Stem A (perforation)
A 45-year-old man presents with sudden severe generalised abdominal pain. He takes frequent ibuprofen. Examination: rigid board-like abdomen. Erect CXR: free gas under the right hemidiaphragm. Pulse 110, BP 100/60.[1]
Stem B (bleed — for part d)
Separately, a 68-year-old on aspirin has melaena, HR 110, BP 96/60, Hb 78 g/L.[3]
Questions
a) Stem A diagnosis and immediate management with exact standard drugs/doses. (4 marks)
Perforated peptic ulcer (NSAID-associated; free gas classically from anterior DU).[1]
ABC; oxygen if needed; two large-bore IV cannulae; crystalloid; NG tube; catheter; bloods including lactate/cultures if septic.
Antibiotics: broad-spectrum cover (Gram-positive, Gram-negative, anaerobes) — e.g. co-amoxiclav 1.2 g IV TDS + metronidazole 500 mg IV TDS, or piperacillin-tazobactam 4.5 g IV TDS.[1]
PPI: pantoprazole/omeprazole 80 mg IV bolus.
Analgesia: morphine IV titrated.
Urgent surgery: laparoscopic or open washout + Graham omental patch. Post-op: continue PPI, test and eradicate H. pylori, stop NSAID permanently if possible.
b) DU versus GU — pain pattern, weight, malignancy. (3 marks)
| DU | GU | |
|---|---|---|
| Pain vs food | Relieved by food/antacids; often 2–3 h post-prandial | Worsened by food |
| Night pain | Classic nocturnal waking | Less specific |
| Weight | Often gain (food helps) | Loss common |
| Malignancy | Almost never | 2–5% of benign-appearing GUs prove malignant (4–14% in perforated-GU series) — always biopsy; confirm healing |
c) Posterior DU complications and vessel. (3 marks)
Penetration into pancreas → severe back pain.[2]
Erosion of gastroduodenal artery (GDA) → massive upper GI haemorrhage.[2]
Bleed pathway: resuscitate → dual endoscopic haemostasis ± IR embolisation or surgical under-running if endoscopy fails.[3][1]
d) Stem B — transfusion target, PPI infusion after endoscopic therapy, and H. pylori eradication regimen with test of cure. (5 marks)
Restrictive transfusion target Hb about 70 g/L for hospitalised upper GI bleeding (ACG).[3]
After dual endoscopic therapy of high-risk ulcer: IV PPI 80 mg bolus then 8 mg/h for 72 h (Lau regimen).[4]
Eradication is 14 days (Toronto). Clarithromycin triple (example in a low macrolide-resistance setting: PPI BD + clarithromycin 500 mg BD + amoxicillin 1 g BD) is restricted to no prior macrolide exposure and known low resistance; most patients are better served by bismuth quadruple or concomitant therapy (Toronto consensus).[5]
Confirm with urea breath test or stool antigen ≥4 weeks after antibiotics and ≥2 weeks off PPI (serology unsuitable for cure).[5]
Additional teaching points (mark-scoring phrases)
Forrest high-risk stigmata needing dual therapy: Ia spurting, Ib oozing, IIa non-bleeding visible vessel (± IIb adherent clot after careful management).[3]
Glasgow-Blatchford vs Rockall: Blatchford = pre-endoscopy need for intervention; Rockall = post-endoscopy mortality/rebleed risk.[6]
Why adrenaline monotherapy fails: temporary vasoconstriction/tamponade only — always add thermal contact or clips for high-risk lesions.[3]
Post-Graham-patch package: PPI, H. pylori eradication, stop NSAID, early mobilisation, VTE prophylaxis, diet advance, safety-net for leak/collections.[1]
References6ShowHide
- [1]Tarasconi A, Coccolini F, Biffl WL, et al. Perforated and bleeding peptic ulcer: WSES guidelines World J Emerg Surg, 2020.PMID 31921329
- [2]Zittel TT, Jehle EC, Becker HD Surgical management of peptic ulcer disease today--indication, technique and outcome Langenbecks Arch Surg, 2000.PMID 10796046
- [3]Laine L, Barkun AN, Saltzman JR, et al. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding Am J Gastroenterol, 2021.PMID 33929377
- [4]Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers N Engl J Med, 2000.PMID 10922420
- [5]Fallone CA, Chiba N, van Zanten SV, et al. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults Gastroenterology, 2016.PMID 27102658
- [6]Blatchford O, Murray WR, Blatchford M A risk score to predict need for treatment for upper-gastrointestinal haemorrhage Lancet, 2000.PMID 11073021