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  • • Epigastric pain relieved by food or antacids

    • Epigastric tenderness

    • Normal or increased gastric acid secretion

    • Signs of ulceration on upper GI studies

    Helicobacter pylori infection

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Epidemiology

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  • • More common in young and middle-aged patients (20-45 years old)

    • Men affected more often than women

    • 95% of ulcers occur within 2 cm of pylorus within the duodenal bulb

    H pylori infection is principal cause of duodenal ulcer, making the duodenum more vulnerable to acid and pepsin

    • Prevalence of duodenal ulcer reflects prevalence of H pylori infection

    • Majority of patients infected with H pylori do not develop ulcer disease

    • Duodenal ulcers not associated with H pylori due mostly to NSAID use

    • Gastric acid secretion is characteristically elevated compared with normal

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Symptoms and Signs

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  • • Epigastric pain temporarily relieved by food, milk, or antacids

    • Nausea and vomiting may be present even in absence of obstruction

    • Back pain may be present if ulcer perforates through posterior duodenal wall

    • Localized epigastric tenderness may be present on physical exam

    • Many patients have few vague abdominal symptoms

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Laboratory Findings

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  • • Increased basal acid output (male, 5.5 mEq/h; female, 3.0 mEq/h)

    • Increased maximal acid output after stimulation by histamine or pentagastrin (male, 40 mEq/h; female, 30 mEq/h)

    • Fasting serum gastrin > 200 pg/mL suggests gastrinoma

    • Serum antibodies for H pylori

    • Antral biopsy showing H pylori infection (histology, urease)

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Imaging Findings

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  • • Esophagogastroduodenoscopy showing duodenal ulceration

    • Radiographic upper GI contrast study showing ulcer niche, duodenal deformity, and distortion of duodenal bulb

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Rule Out

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  • • Zollinger-Ellison syndrome (gastrinoma) in patients with severe or refractory duodenal ulcer

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  • • History and physical exam

    • Endoscopic or radiographic evidence of duodenal ulceration

    • Evaluate for H pylori infection by serum testing for screening or endoscopic biopsy testing

    • Evaluate basal acid output and fasting serum gastrin in severe or refractory disease to exclude Zollinger-Ellison syndrome (gastrinoma)

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When to Admit

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  • • Free ulcer perforation

    • Ulcer bleeding

    • Severe duodenal obstruction

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  • • Goals are reduction of acid secretion and eradication of H pylori infection

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Surgery

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  • • Parietal cell or truncal vagotomy with pyloroplasty

    • Antrectomy and vagotomy

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Indications

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  • • Intractibility and failure of medical treatment

    • Bleeding

    • Perforation

    • Duodenal obstruction

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Contraindications

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  • • Inadequate medical treatment

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Medications

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  • • H2 blockers

    • Proton pump inhibitors

    • Antacids

    • Treatment of H pylori infection

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Treatment Monitoring

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  • • Endoscopy to confirm ulcer healing

    • Resolution of symptoms

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Complications

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  • • Bleeding

    • Perforation

    • Obstruction

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Prognosis

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