Duodenal Ulcer

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • 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

Laboratory Findings

• • 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)

Imaging Findings

• • Esophagogastroduodenoscopy showing duodenal ulceration

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

Rule Out

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

• • 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)

When to Admit

• • Free ulcer perforation

  • Ulcer bleeding

  • Severe duodenal obstruction

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

Surgery

• • Parietal cell or truncal vagotomy with pyloroplasty

  • Antrectomy and vagotomy

Indications

• • Intractibility and failure of medical treatment

  • Bleeding

  • Perforation

  • Duodenal obstruction

Contraindications

• • Inadequate medical treatment

Medications

• • H2 blockers

  • Proton pump inhibitors

  • Antacids

  • Treatment of H pylori infection

Treatment Monitoring

• • Endoscopy to confirm ulcer healing

  • Resolution of symptoms

Complications