Special Operations Forces Medical Handbook

4-85

(gastric ulcer); awakening from sleep with pain, that radiated to the mid back (duodenal ulcer); anorexia,
nausea and vomiting.

Objective: Signs
Using Basic Tools: Tender epigastric area; vomiting bright red blood (hematemesis) or coffee grounds
suggests active or recent bleeding from the upper GI tract; melena (“tarry” black, oily and odiferous stool that
suggests upper GI tract bleeding); weight loss.
Vital Signs: Pulse > 100 bpm, systolic BP < 90: probable hypovolemia. Orthostatic change in VS (systolic BP
drop of 20 mm Hg or pulse rise 20 bpm): signicant hypovolemia.
Appearance: Pallor of anemia, diaphoresis: suggests signicant blood loss.
Gastric Contents (check if melena or hematemesis): NG aspirate – bile, no blood or coffee grounds suggests
no active bleeding. Coffee grounds: recent bleeding, bright red blood: active bleeding.
Abdomen: Absent bowel sounds, rigid exam, peritoneal signs: perforated or penetrating ulcer
Rectal Exam: Melena: recent UGI bleeding
Using Advanced Tools: Lab: Hematocrit.

Assessment:
Differential Diagnosis - dyspepsia, gallstones, pancreatitis, angina and malignancy.

Plan:
Treatment

1. Treat the uncomplicated ulcer:
   a. Stop aspirin or NSAIDs.
   b. Suppress acid secretion with oral therapy, or IV therapy until stable, then switch to oral therapy.
   IV therapy: Cimetidine 300 mg q 6 hr, famotidine 20 mg q 12 hr, or ranitidine 50 mg q 6-8 hr;
   Oral therapy: Cimetidine 400 mg bid, famotidine 20 mg bid, or ranitidine 150 mg bid for 8-12 weeks;
   Alternative antacids: Omeprazole 20 mg qd or lansoprazole 30 mg qd for 8-12 weeks


2. Manage bleeding ulcer
   a. Place 2 large bore IVs (>18 gauge) and give Lactated Ringers or Normal Saline to resuscitate and
   normalize blood pressure.
   b. Suppress acid with IV therapy.
   c. Evacuate and be prepared to perform blood transfusion (see Procedures).


3. Eradicate Helicobacter pylori: “triple therapy” includes many choices, but most treat for 10-14 day po course
   with: omeprazole 20 mg bid or lansoprazole 30 mg bid, plus clarithromycin 500 mg bid or amoxicillin 500
   mg tid, plus metronidazole 500 mg bid

Patient Education
General: 90-95% of duodenal ulcers and ~80% of gastric ulcers are caused by infection with Helicobacter
pylori. Most of the remaining ulcers are caused by ingestion of aspirin or NSAIDs. Emotional stress or food
does not cause duodenal and gastric ulcers.
Diet: Consume a healthy diet and avoid foods that aggravate symptoms.
Medications: The ulcer should be treated with medicine to decrease stomach acid production. When
Helicobacter pylori infection is suspected (recurrent ulcer disease), it should be treated with “triple therapy.”
Prevention and Hygiene: Avoid aspirin and NSAIDs. Use acetaminophen instead for head, muscle or
joint aches.
No Improvement/Deterioration: Return if symptoms worsen or persist after 2 weeks of treatment. Also,
return immediately if vomiting blood or coffee grounds, or passing blood or tarry stools from the rectum
(hematemesis or melena).

Follow-up Actions
Return evaluation: Evaluate worsening or persistent symptoms after 2 weeks of treatment with upper
endoscopy to excluded complicated ulcer disease or malignancy. Refer those with hematemesis or melena.
Relapse of symptoms after successful treatment suggests failure to eradicate or reinfection with Helicobacter