Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 8 Sept 2026Clinical review pending
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Bleeding or perforation
Haematemesis, melaena with shock, sudden generalised peritonism or free intraperitoneal gas converts chronic ulcer disease into a time-critical upper-GI or surgical emergency.
Action: Resuscitate, activate the appropriate haemorrhage or sepsis pathway, involve gastroenterology and surgery, and arrange urgent therapeutic endoscopy or operative source control after stabilisation.
Synopsis
Distinguish gastric from duodenal ulcer patterns, identify Helicobacter and medicine-related injury, exclude gastric malignancy, heal the lesion and prevent bleeding, perforation and obstruction.
Peptic ulcer is a mucosal defect extending through muscularis mucosae; H pylori and NSAIDs are the dominant acquired causes, but malignancy and hypersecretory states remain important exceptions.
Duodenal ulcer generally carries negligible primary malignant potential, whereas gastric ulcer requires multiple biopsies and endoscopic healing confirmation.
Test for active H pylori under valid conditions and eradicate when present; treatment without confirmation can leave recurrent bleeding risk.
Key red flags
Every gastric ulcer needs adequate biopsy and healing confirmation because benign symptoms and appearance cannot reliably exclude an ulcerated adenocarcinoma.
Abrupt severe pain followed by rigid guarding, tachycardia or sepsis suggests free perforation even if earlier dyspepsia was mild.
Sudden severe epigastric pain with generalised guarding and loss of liver dullness suggests escape of gas and gastric contents.
Investigation priorities
01
Upper-GI endoscopyFirst step
Locate and photograph ulceration; obtain at least six targeted gastric-ulcer edge/base biopsies, or at least eight if malignancy is suspected.
Management branches
Gastric ulcer healingProve benign resolution
Endoscopy identifies an 18 mm antral ulcer in a stable NSAID user. Six targeted edge/base biopsies show inflammation without dysplasia; H pylori histology and urease testing are negative after valid medication washout.
Stop the NSAID and give omeprazole 20 mg orally once daily for eight weeks under the NICE NSAID-associated ulcer recommendation, after product safety checks. Confirm photographs, size, site and at least six edge/base samples. An ulcer suspicious for cancer needs at least eight targeted samples; if bleeding prevented any biopsy, repeat endoscopy within two weeks rather than waiting for healing.
Book a six-to-eight-week healing examination in this patient: that appointment sits within the BSG 2026 twelve-week window and is proportionate to his fitness and lesion. NICE specifically recommends six to eight weeks for an H pylori-positive gastric ulcer; it is not a universal claim about this H pylori-negative case.
Key medicines
Omeprazole for uncomplicated peptic-ulcer healingGive omeprazole 20 mg orally once daily. Most active duodenal ulcers heal within 2 weeks and may receive a further 2 weeks if incomplete; most gastric ulcers heal within 4 weeks and may receive a further 4 weeks if incomplete. Use 40 mg once daily for a poorly responsive ulcer under the current SmPC while investigating the cause. Take the once-daily capsule in the morning, swallowed whole with half a glass of water; never chew or crush its enteric-coated pellets.Exclude alarm features and gastric malignancy rather than using symptom response as reassurance. In hepatic impairment the SmPC states 10–20 mg daily may be sufficient, so do not escalate automatically to 40 mg. Review the nelfinavir contraindication, clopidogrel and other CYP2C19 interactions, long-term magnesium and B12 risk, enteric infection and acute tubulointerstitial nephritis. Treatment duration does not replace repeat endoscopy when a gastric ulcer needs healing confirmation. No dose adjustment is required solely for renal impairment.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 8 Sept 2026; clinical approval remains outstanding.