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Duodenal Ulcer

Duodenal Ulcers

A duodenal ulcer is an ulcer of the duodenum, often associated with Helicobacter pylori infection. Epigastric pain is the most common symptom of duodenal ulcers.


Presentation

Each and every individual will not experience symptoms from duodenal ulcers; and those who do mostly complain of pain and burning sensation in the abdominal region. The other signs and symptoms are discussed below:

In addition to these, individuals may experience other serious symptoms such as:

  • Blood in stools
  • Pain in the chest
  • Blood in vomiting
Respiratory Abnormalities
  • We report a 23-year-man who showed bilateral cervical subcutaneous emphysema, pneumomediastinum, and pneumothorax with no respiratory abnormality. He was found to have active duodenal ulcers, but no detectable pneumoperitoneum or duodenal leak.[ncbi.nlm.nih.gov]
Vomiting
  • Abstract Typical symptoms of duodenal ulcers include epigastric pain, nausea, vomiting, chest pain and shortness of breath.[ncbi.nlm.nih.gov]
  • Abstract A 78-year-old male presented with the chief complaints of abdominal pain and vomiting.[ncbi.nlm.nih.gov]
  • Abstract A young man presented with a sudden onset of severe abdominal pain and vomiting. He also had shortness of breath with right-sided pleuritic chest pain. On examination he was found to have a rigid and diffusely tender abdomen.[ncbi.nlm.nih.gov]
  • Pain that gets better or worse with eating Nausea or vomiting Signs of blood in vomit Black stools that are sticky like tar, which means the ulcer is bleeding How are ulcers diagnosed? The healthcare provider will ask about your child’s symptoms.[fairview.org]
Abdominal Pain
  • Pneumothorax is a rare complication of perforated duodenal ulcer and should be kept in mind while assessing patients who present with abdominal pain and dyspnoea.[ncbi.nlm.nih.gov]
  • Abdominal pain, diarrhea, GI bleeding, hepatosplenomegaly and small bowel obstruction are well described presentations. Still gastrointestinal histoplasmosis often results in either vague symptomatology or no symptoms.[ncbi.nlm.nih.gov]
  • Abstract An 88-year-old Japanese woman was admitted to our hospital for abdominal pain with a raised inflammatory reaction. Esophagogastroduodenoscopy (EGD) and computed tomography (CT) showed a duodenal ulcer punching a liver cyst.[ncbi.nlm.nih.gov]
  • Abdominal pain, a common complaint in sickle cell disease, can be due to an uncommon etiology, ischemic duodenal ulceration. This is due to primary mucosal infarction caused by sickling, leading to poor healing of infarcted areas.[ncbi.nlm.nih.gov]
  • The patient complained of continuous upper abdominal pain. Her medical history included idiopathic chronic pancreatitis.[ncbi.nlm.nih.gov]
Nausea
  • Abstract Typical symptoms of duodenal ulcers include epigastric pain, nausea, vomiting, chest pain and shortness of breath.[ncbi.nlm.nih.gov]
  • Other symptoms include weight loss, feeling of tiredness, and blood in stools, nausea, vomiting, chest pain and loss of appetite.[symptoma.com]
  • Some people with duodenal ulcers have no symptoms at all, while others may have burning pain, severe nausea, and vomiting. In the case of H pylori -related duodenal ulcer, the infection can be treated successfully with antibiotics.[healthgrades.com]
  • Duodenal ulcers can cause a myriad of unpleasant symptoms, including nausea, upper abdominal pain, weight loss and fatigue. Occasionally, an ulcer perforates, causing a hole that goes all the way through the duodenum.[livestrong.com]
  • Symptoms include nausea , abdomen pain , vomiting, frequent hunger, and weight loss . Treatment for duodenal ulcers includes taking medication and cutting down on foods or habits that can cause ulcers.[goodrx.com]
Hematemesis
  • Gastrointestinal manifestations are commonly encountered, however hematemesis and gastric outlet obstruction are rarely reported.[ncbi.nlm.nih.gov]
  • Hemostasis by transcatheter arterial embolization (TAE) was achieved but the patient unfortunately died soon after because of hemorrhagic shock (10 h after his first hematemesis).[ncbi.nlm.nih.gov]
  • RIGHT: 48 year-old woman with hematemesis and melena. Endoscopy revealed a sentinel clot attached to an underlying ulcer in the duodenal bulb, with active bleeding.[endoatlas.com]
  • Abstract A boy in his early teens visited our hospital with chief complaints of hematemesis and tarry stools. Upper gastrointestinal endoscopy identified a hemorrhagic duodenal ulcer, for which hemostasis was performed using a clip.[ncbi.nlm.nih.gov]
  • In gastric ulcers, there is blood when the patient vomits called hematemesis. In gastric ulcers, pain occurs 1-2 hours after eating. In duodenal ulcers, pain occurs 3-4 hours after eating.[differencebetween.net]
Dyspepsia
  • In the last 2 weeks, the patient suffered from abdominal pain and dyspepsia. Oesophagogastroduodenoscopy showed an ulcerative lesion of the duodenum due to traction of the jejunal tube; the end of the jejunal tube was wrapped in a phytobezoar.[ncbi.nlm.nih.gov]
  • METHODS: H. pylori single colonies were isolated from 156 [non-ulcer dyspepsia (NUD) 97, duodenal ulcer (DU) 34, gastric cancer (GC) 25)] patients. babA and babB genes were evaluated by gene/locus-specific PCR.[ncbi.nlm.nih.gov]
  • Clinical studies in humans demonstrate an ability to heal ulcers as well as antagonize the bacteria (Helicobacter pylori) linked to indigestion (dyspepsia), peptic ulcer disease and stomach cancer. The recommended dosage is 75 to 150 mg twice daily.[doctormurray.com]

Workup

Prompt diagnosis of duodenal ulcers is required to figure out the nature of the condition. A complete medical history is taken and a thorough physical examination conducted. The other diagnostics tests include:

  • X-ray of the abdomen, duodenum and esophagus.
  • Endoscopy in order to study the interior of the digestive tract.
  • Blood tests to detect anemia.
  • Stool tests to detect presence of blood in stool.
  • Breath and stomach tissue tests that is done to detect the presence of bacterial infection.

Treatment

Treatment regime is based on the cause of the duodenal ulcers. It is also dependent on the age of the individual and the extent of disease condition. Primary treatment is focused on medications to eliminate the bacterial infection.

In addition, individuals are put on acid suppressing drugs that work by suppressing the acid contents of the stomach. In the United States, the recommended primary treatment of Helicobacter pylori is proton pump inhibitor which also suppresses acid secretions [7]. Patient should be put on bland diet and strictly advised against smoking. They are also advised to stay away from coffee to allow the medications to work.

If the ulcers have aggravated and are diagnosed at later stages then, surgery is often the preferred treatment plan. It is also the method of choice, when the patients do not respond to medications and lifestyle changes. The use of emergency transcatheter arterial embolization techniques has been successfully used in the control of acute duodenal ulcer hemorrhage [8].

Prognosis

With prompt diagnosis and timely medications, duodenal ulcers get better over time. If the cause of ulcers is infection, then antibiotics form the basis of the treatment plan. Prognosis of the disease is usually good if treatment is initiated quickly.

Meta-analysis studies have shown that duodenal ulcers bleeding dramatically lessens with prompt intravenous proton pump inhibitors after a successful endoscopic procedure [5]. However, one must also understand the fact that modification in lifestyle factors and leading an active lifestyle is also necessary to prevent the recurrence of ulcers. Failure to do so can aggravate existing ulcers and slow down the healing process.

Complications

Untreated ulcers can turn life threatening causing the following complications:

  • Gastrointestinal bleeding. Bleeding maybe induced by medications like aspirin, ibuprofen and spironolactone [6].
  • Perforation due to untreated ulcers. This may further cause peritonitis characterized by inflammation of the cavity and wall of the abdomen.
  • Inflammation and scarring of untreated ulcers can cause narrowing of the intestinal opening.

Etiology

Causes of duodenal ulcer are many; however research has indicated that bacterial infection is the most common factor leading to development of ulcers. Other factors include:

  • Infection due to Helicobacter pylori that weakens the mucous membrane making it susceptible to damage by acids and pepsin.
  • Tea and coffee: Excessive consumption of these can also make one prone to develop duodenal ulcers. The substance present in these beverages is known to stimulate the production of acidic substances causing destruction of the mucous lining.
  • Smoking is yet another causative factor for ulcers. It is also known to worsen existing ulcers and delay the healing process as well.
  • Medications such as non–steroidal anti-inflammatory drugs (like ibuprofen) also reduce the stomach’s natural ability to defend itself against the harmful effects of acid and pepsin even in children [1].
  • Stress: Both physical and emotional also triggers the development of ulcers.
  • Stomach contents: The incapacity of the stomach to protect itself against acid and pepsin also causes ulcers to develop.
  • Previous history of duodenal ulcer or gastric ulcer predisposes one for relapse [2].

Epidemiology

Duodenal ulcers are a common complaint amongst individuals of all age groups. It has been estimated that in the United States, as high as 25 million suffer from duodenal ulcers at least once in their life time. It has also been calculated that the health costs for treating ulcers that includes hospitalization, work loss and outpatient care costs about $5.65 billion in the United States.

Muslim nations who practice the Ramadan has an increased risk for duodenal ulcer due to the 24 hour daytime fasting practices during these days [3].

Sex distribution
Age distribution

Pathophysiology

When food is consumed it passes down the esophageal canal and reaches the stomach. Once the food reaches the stomach, it produces acids that aids in the digestion process. The acid mixes with the food and reaches the duodenum wherein the organ produces enzymes for absorption of the digested food.

Under normal circumstances, the acid that is produced usually does not disturb the lining of the stomach as it is protected by a mucosal barrier. Also, there is certain amount of balance maintained between this mucosal barrier and the amount of acid produced. But, when this balance is disturbed, the corrosive nature of the stomach acids disrupts the mucosal lining causing ulcers.

In duodenal ulcer, histologic examinations have revealed that the acid-secreting parietal cells have doubled in size and have significantly increased basal acid output [4].

Prevention

It is always best to prevent ulcers rather than getting it treated in the later stages. The following measures can be taken to prevent ulcers from developing:

  • It is best to avoid non-steroidal anti-inflammatory drugs. If one is at risk of developing ulcers then use of such drugs should be discontinued. A test for Helicobacter pylori should be conducted before taking these medications. If the result is positive it is best to discontinue these medications.
  • Patients who must take low dose aspirin or non-steroidal anti-inflammatory drugs for other medical conditions may warrant the use proton pump inhibitors to prevent duodenal ulcers and gastro-intestinal bleeding [9].
  • Modification of certain lifestyle factors can go a long way in preventing ulcers. These include cessation of smoking, drinking less tea and coffee and avoiding excessively spiced foods. Studies have shown that smoking increases the risk for duodenal ulcer relapse [10].

Summary

Ulcers are basically open sores that generally develop on the skin and mucous membrane. Such open sores that develop in the duodenum are termed as duodenal ulcers.

It is a type of peptic ulcer and occurs as result of bacterial infection. Acid suppressing medications along with antibiotics for 4 to 6 weeks is required for treating the condition.

Patient Information

Definition

Ulcers that develop in the duodenum are termed as duodenal ulcers. These are common and about 25 million individuals of United States fall prey to this disease condition. Prompt diagnosis and treatment can correct the condition; however lifelong precautions are necessary to prevent recurrence of it.

Causes

Duodenal ulcers develop as a result of bacterial infection, faulty dietary habits, improper lifestyle habits, smoking and alcohol consumption.

Symptoms

Individuals with duodenal ulcers generally complain of burning sensation and pain in the abdomen. Other symptoms include weight loss, feeling of tiredness, and blood in stools, nausea, vomiting, chest pain and loss of appetite.

Diagnosis

Complete physical examinations with X-rays of the abdomen are usually the diagnostic tools employed for confirming duodenal ulcers. In addition, endoscopy may also have to be carried out for studying the nature of the ulceration.

Treatment

Treatment of duodenal ulcers generally depends on the nature and severity of the condition. In initial stages, the ulcers can be taken care of by modification in lifestyle factors and medications. Antibiotics to treat infection and acid suppressants are given for treating the ulcers. In more severe cases, operative procedures may have to be carried out for treating the ulcers.

References

Article

  1. Berezin SH, Bostwick HE, Halata MS, Feerick J, Newman LJ, Medow MS. Gastrointestinal bleeding in children following ingestion of low-dose ibuprofen. J Pediatr Gastroenterol Nutr. Apr 2007; 44(4):506-8.
  2. Udd M, Miettinen P, Palmu A, Heikkinen M, Janatuinen E, Pasanen P, et al. Analysis of the risk factors and their combinations in acute gastroduodenal ulcer bleeding: a case-control study. Scand J Gastroenterol. Dec 2007; 42(12):1395-403.
  3. Bdioui F, Melki W, Ben Mansour W, Loghmari H, Hellara O, Ben Chaabane N, Saffar H. Duodenal ulcer disease and Ramadan .Presse Med. 2012; 41(9 Pt 1):807-12 (ISSN: 0755-4982)
  4. Schubert ML, Peura DA. Control of gastric acid secretion in health and disease. Gastroenterology. Jun 2008; 134(7):1842-60. 
  5. Bardou M, Youssef M, Toubouti Y, et al. Newer endoscopic therapies decrease both re-bleeding and mortality in high risk patients with acute peptic ulcer bleeding: a series of meta-analyses [abstract]. Gastroenterology. 2003; 123: A239.
  6. Gulmez SE, Lassen AT, Aalykke C, Dall M, Andries A, Andersen BS, et al. Spironolactone use and the risk of upper gastrointestinal bleeding: a population-based case-control study. Br J Clin Pharmacol. Aug 2008; 66(2):294-9.
  7. Chey WD, Wong BC. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. Aug 2007; 102(8):1808-25
  8. Wang YL, Cheng YS, Liu LZ, He ZH, Ding KH. Emergency transcatheter arterial embolization for patients with acute massive duodenal ulcer hemorrhage. World J Gastroenterol. 2012; 18(34):4765-70 (ISSN: 2219-2840)
  9. Sugano K, Matsumoto Y, Itabashi T, Abe S, Sakaki N, et al. Lansoprazole for secondary prevention of gastric or duodenal ulcers associated with long-term low-dose aspirin therapy: results of a prospective, multicenter, double-blind, randomized, double-dummy, active-controlled trial. J Gastroenterol. 2011; 46(6):724-35
  10. Sonnenberg A, Müller-Lissner SA, Vogel E, Schmid P, Gonvers JJ, Peter P, et al. Predictors of duodenal ulcer healing and relapse. Gastroenterology. Dec 1981; 81(6):1061-7.

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Last updated: 2018-06-22 11:27