Duodenal Ulcer Disease

What is a duodenal ulcer?

The duodenum is the first part of the small intestine, beginning immediately after the stomach. A duodenal ulcer is a sore in the lining of this region that reaches deeper than a surface irritation.

The lining of the stomach and duodenum normally has various protective mechanisms against the damaging effects of stomach acid. When the balance between this protection and the acid is upset, damage to the duodenal wall and in time an ulcer may develop.

A duodenal ulcer is now a condition whose causes are largely known and which can be treated successfully in most patients.

What causes a duodenal ulcer?

One of the most important causes of duodenal ulcers is the bacterium Helicobacter pylori (H. pylori).

H. pylori settles in the stomach and may impair the natural mechanisms that protect the stomach and duodenum from acid. If the infection is not treated, the ulcer may return later even after it has healed.

The second important cause is a group of painkillers called non-steroidal anti-inflammatory drugs (NSAIDs). These may weaken the protective mechanisms of the stomach and duodenum and increase the risk of ulcer and bleeding.

Smoking may adversely affect both the development and the healing of an ulcer.

By contrast, and unlike what is often supposed, stress and spicy foods are not the underlying causes of duodenal ulcer. They may increase existing symptoms in some people, but when an ulcer is found the real cause should be sought.

Rarely, conditions causing excessive acid production or other causes may lead to recurrent ulcers.

What are the symptoms?

The commonest complaint in duodenal ulcer is pain, burning or a gnawing sensation felt in the upper abdomen.

In some people the pain may be more marked:

• When hungry, or some hours after meals,
• At night,
• When food has not been eaten for a long time.

Eating, or drugs that reduce acid, may relieve the pain temporarily. But these classical features are not present in every patient and an ulcer cannot be diagnosed from the character of the pain alone.

Indigestion, bloating, nausea and feeling full early may also accompany it.

In some patients the ulcer may give no symptoms at all and present with bleeding.

Which symptoms are important?

Medical assessment is needed without delay in the following situations:

• Black, tarry stools,
• Vomiting of blood,
• Vomiting resembling coffee grounds,
• Sudden, very severe abdominal pain,
• Dizziness or fainting,
• Marked weakness,
• Unexplained weight loss,
• Persistent vomiting.

Abdominal pain that begins suddenly and increases in particular may be a sign of an emergency such as the ulcer perforating the duodenal wall (perforation).

How is the diagnosis made?

One of the most important methods for diagnosing a duodenal ulcer is gastroscopy.

At endoscopy the gullet, stomach and duodenum are examined directly. The site and size of the ulcer and signs of bleeding can be assessed.

Biopsies may be taken during the procedure where necessary.

How is H. pylori looked for?

Looking for H. pylori infection matters in patients found to have a duodenal ulcer.

H. pylori may be sought by:

• Biopsies taken during endoscopy,
• The urea breath test,
• The H. pylori stool antigen test.

Because certain stomach medications and recently taken antibiotics can affect the test results, which test is done and when should be decided by the doctor.

How is a duodenal ulcer treated?

The main aim of treatment is not merely to heal the ulcer but to remove its cause and so prevent it recurring.

If H. pylori is present

If H. pylori is found, the bacterium should be treated.

Treatment uses drugs that strongly reduce stomach acid together with more than one antibiotic, and in some regimens bismuth.

Because antibiotic resistance is increasing, it is not right to give everyone the same antibiotic combination. Treatment is determined according to antibiotics used previously, the local resistance picture, drug allergies and, where needed, the antibiotic sensitivity of the bacterium.

It therefore matters that H. pylori treatment is planned by the doctor and that the drugs given are taken in full for the period advised.

Acid-suppressing treatment

Proton pump inhibitors (PPIs) strongly reduce stomach acid and help the ulcer to heal.

The duration of treatment may vary with the cause and size of the ulcer, whether there are complications, and the patient’s other medication.

In ulcers due to painkillers

If an NSAID painkiller has contributed to the ulcer, the drug is stopped where possible or alternative treatments considered.

But patients taking aspirin or a similar drug for cardiovascular or other disease should not stop their medication without consulting their doctor.

Is a check needed after H. pylori treatment?

Yes.

In current practice it is not accepted as enough that symptoms have settled in a patient treated for H. pylori. Clearance of the bacterium must be confirmed with a suitable test.

The check is generally made at least four weeks after treatment is completed.

The urea breath test or the H. pylori stool antigen test may be used. To avoid a false negative result, proton pump inhibitors generally need to be stopped about two weeks before the test. How this is done should be decided by the doctor according to the patient’s condition.

Is a check endoscopy needed?

Repeat endoscopy is not essential as a routine in every duodenal ulcer.

In a patient whose H. pylori has been cleared, whose symptoms have settled and whose duodenal ulcer had no complications, repeat endoscopy is usually not required.

But a check endoscopy may be needed if symptoms persist, if the ulcer is thought not to have healed, if there were complications such as bleeding, or if the doctor suspects another condition.

What is done if the ulcer bleeds?

A bleeding duodenal ulcer is a serious situation requiring assessment in hospital.

After the necessary fluid and drug treatment, endoscopy can identify the site of the bleeding. The bleeding vessel can be treated by suitable endoscopic methods.

Thanks to endoscopic treatment and powerful acid-suppressing drugs, the great majority of ulcer bleeds can now be controlled without surgery.

Does a duodenal ulcer turn into cancer?

There is an important difference here between gastric and duodenal ulcers.

It is not expected that typical duodenal ulcers will turn into cancer. The biopsy and follow-up approach needed in gastric ulcers to exclude malignancy is therefore not the same in duodenal ulcers.

If a lesion of unusual appearance is seen at endoscopy, however, the doctor may carry out the necessary further investigations.

What is the course and outlook?

The outlook in duodenal ulcer is generally very good.

Where there is H. pylori infection, successful clearance of the bacterium and control of the other causes mean the ulcer heals completely in the great majority of patients.

Clearing H. pylori also substantially reduces the risk of the ulcer recurring.

By contrast, leaving the bacterium untreated, continuing to take painkillers without control where they are needed, or smoking may make recurrence and complications more likely.

Duodenal ulcer is now a condition that can be brought under control without lasting trouble in most patients, when its cause is correctly identified and suitably treated.

Currency: The information on this page was prepared for patients taking account of current international guidelines on the diagnosis and treatment of duodenal ulcer and H. pylori infection.

This content is for general information. It does not take the place of personal diagnosis or treatment advice.