Multiple / refractory ulcers, diarrhea
First: Exclude persistent H. pylori as cause of failure
Confirm: Serum gastrin (OFF PPI) elevated → secretin stimulation test
Treat: High-dose PPI; localize (somatostatin-receptor imaging) → resect; screen for MEN-1
Order set
- Fasting gastrin (off PPI)
- Secretin stimulation
- Ca (MEN1)
- Somatostatin-receptor imaging
Criteria
AdmitComplication of refractory ulcers
DischargeAcid controlled, localisation/MEN1 workup
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Refractory multiple ulcers
- Diarrhoea + weight loss
Differentials
- H. pylori PUD
- PPI-induced hypergastrinaemia
- Retained antrum
Common mistakes
- Gastrin on PPI
- Missing MEN1
Disposition & follow-up
High-dose PPI; localise/resect; MEN1 screening.
Discharge package
MedicationsHigh-dose PPI
Follow-upEndocrine/surgery; MEN1 screening
Warning symptomsRecurrent ulcers, bleeding, diarrhoea
💊 Treatment detail — doses & preparation
OmeprazolePPI
Dose20–40 mg OD 30 min before breakfast ×4–8 wk
Preparation20/40 mg capsules (MUPS dispersible for NG)
MonitorLong-term: Mg²⁺, B12, C. diff risk
Octreotidesomatostatin analogue
DoseVariceal bleed: 50 mcg IV bolus then 25–50 mcg/h ×2–5 d. Acromegaly: 100–200 mcg SC TDS or LAR 10–30 mg IM monthly
PreparationInfusion 500 mcg in 50 mL NS via pump; LAR depot deep IM gluteal
MonitorGlucose, gallstones, GI upset; in acromegaly — IGF-1
📖 NCCN Neuroendocrine TumoursReviewed July 2026