Ketorolac-induced peptic ulcer bleeding after cholecystectomy in a “healed” ulcer patient: A CARE case report

RATIONALE: Ketorolac tromethamine injection-induced peptic ulcer with bleeding remains rarely reported in clinical case studies. Controversy persists, particularly regarding its analgesic use in patients with a history of gastric ulcer, even after clinical cure. Herein, this article presents a case of peptic ulcer with bleeding after supra-therapeutic dosage of ketorolac tromethamine injection for post‑cholecystectomy analgesia in a patient with a clinically "healed" gastric ulcer, emphasizing the need for cautious and rational prescribing. PATIENT CONCERNS: A 70-year-old male patient with a history of peptic ulcer and gallstones presented with recurrent right upper quadrant pain for over 2 years. Previous treatment with oral Xiaoyan Lidan Tablets (an anti-inflammatory and choleretic agent) did not prevent symptom recurrence. DIAGNOSES: Peptic ulcer with bleeding, Gallstones with chronic cholecystitis, Hypertension (Grade 2). INTERVENTIONS: The patient underwent a laparoscopic cholecystectomy under general anesthesia. For postoperative analgesia, intramuscular ketorolac tromethamine injection was administered at 30 mg twice daily, which exceeded the recommended dosage range. Appropriate symptomatic therapies, including anti‑infection, hepatoprotection, hemostasis, and fluid replacement therapy, were administered as clinically indicated. On the fourth postoperative day, the patient developed gastrointestinal bleeding with a hemoglobin level of 62 g/L. Based on the medication history, the gastrointestinal bleeding was considered associated with the application of ketorolac tromethamine injection. The drug was discontinued for observation, and the patient was started on pantoprazole for acid suppression and gastric protection, along with carbazochrome sodium sulfonate for hemostasis. As the gastrointestinal bleeding symptoms did not improve, the regimen was adjusted to esomeprazole for acid suppression and gastric protection, supplemented with hemostatic therapy using somatostatin and hemocoagulase. Following this adjustment, the patient gastrointestinal bleeding symptoms gradually improved. OUTCOMES: Gastrointestinal bleeding was controlled, and the patient was discharged following clinical improvement. LESSONS: This case supports a potential causal relationship between the use of ketorolac tromethamine injection and the occurrence of peptic ulcer with bleeding, especially in patients with clinically cured gastric ulcer: a risk often overlooked in drug selection. Particular emphasis should be placed on individualized medication, risk assessment, and multidisciplinary collaboration to enhance patient safety and treatment efficacy.