Nurofen Plus misuse: an emerging cause of perforated gastric ulcer

A 39-year-old woman was referred by her general practitioner to the emergency department (ED) of our community hospital with a 24-hour history of acute epigastric pain. She had a past history of alcohol misuse, codeine misuse and pancreatitis.

While in the ED, she described recreationally taking 16–24 Nurofen Plus tablets (Reckitt Benckiser, Sydney, NSW) (containing ibuprofen and codeine) per day for the previous 3 weeks. Clinical examination revealed pallor, mild diaphoresis, a heart rate of 130 beats/min and blood pressure of 92/60 mmHg. The patient’s abdomen was grossly distended and maximally tender on palpation in the epigastrium. Bowel sounds were absent. Intravenous access was established and infusion of 2 L crystalloid fluid was commenced.

An erect chest x-ray confirmed the presence of gas under the diaphragm (Box 1). An urgent laparotomy revealed a perforated anterior gastric antrum ulcer and 2.6 L of green turbid fluid in the peritoneal cavity. The patient was given an additional four units of packed red cells intraoperatively, and her ulcer was oversewn. Postoperatively, she was transferred to an intensive care unit at another hospital.

A 41-year-old man presented to our ED with a 12-hour history of progressively worsening severe abdominal pain. The patient had been recreationally taking “a packet” of Nurofen Plus each day for the past year. To ease the abdominal pain, he had already tried a liquid paraffin-based laxative (Parachoc [Paedpharm, Sydney, NSW]) and an osmotic laxative (Microlax [Johnson & Johnson Pacific, Sydney, NSW] at home, with no relief of his discomfort. Clinical examination revealed generalised abdominal tenderness, with no guarding, and the presence of bowel sounds. He had a heart rate of 93 beats/min and blood pressure of 143/93 mmHg.

The pain initially settled in the ED after the patient had received a total of 10 mg intravenous morphine over a 2-hour period. After admission for observation, he developed a slight fever (37.8°C), his heart rate increased to 120 beats/min, and his abdomen became increasingly distended. Pain recurred on the ward, and was not responsive to 20 mg intravenous morphine given over a 2-hour period.

Intravenous contrast computed tomography revealed the presence of free fluid and gas in the peritoneal cavity (Box 2). An urgent laparotomy revealed a 1.5 cm gastric antrum ulcer with gross peritoneal contamination. Postoperatively, the patient was offered care at an inpatient drug and alcohol service, but absconded before transfer could be arranged.