Duodenal Ulcer

A mucosal defect, usually in the first part of the duodenum (the bulb), penetrating through the muscularis mucosae.

• Causes: H. pylori (more than 90% of those without NSAID use), NSAIDs and aspirin (20 to 30%), hypersecretion (Zollinger-Ellison syndrome, about 1 to 2% of refractory ulcers), smoking, stress, and rarely Crohn disease, cytomegalovirus, and infiltrative disease.
• Lifetime risk is about 5 to 10%; peak age 30 to 60 years; incidence has fallen with H. pylori eradication; annual rebleeding and recurrence of about 50 to 70% without eradication falls to less than 5 to 10% afterward.
• Mechanism: H. pylori antral gastritis raises gastrin and acid secretion; high acid load into the duodenum causes gastric metaplasia, H. pylori colonisation of the metaplastic islands and mucosal ulceration; NSAIDs reduce protective prostaglandins.

Epigastric burning pain, often 2 to 5 hours after meals or at night (waking between midnight and 3 am), relieved by food or antacids, recurring in episodes lasting weeks.

• Bloating, nausea, heartburn; may present as bleeding (haematemesis, melaena), anaemia, or perforation (sudden severe pain, rigid abdomen).
• Examination: epigastric tenderness; pallor with blood loss; a succussion splash with obstruction.
• Differential diagnosis: gastric ulcer, duodenitis, functional dyspepsia, pancreatitis, biliary colic, cholecystitis, reflux, coeliac disease, giardiasis, Crohn disease, gastric cancer, myocardial infarction.
• Complications: bleeding (posterior wall ulcers erode the gastroduodenal artery), perforation (anterior wall ulcers), gastric outlet obstruction (about 2%), penetration into the pancreas with back pain, and recurrence.

Upper endoscopy: ulcer in the bulb (less often postbulbar), size, base, stigmata of recent haemorrhage; biopsy of the ulcer is not needed because malignancy is rare, but biopsy the stomach for H. pylori and gastritis.

• Helicobacter pylori testing: histology, rapid urease test, urea breath test or stool antigen (off proton pump inhibitors for 2 weeks and antibiotics for 4 weeks); if a test is negative during bleeding or on acid suppression, repeat later.
• Blood tests: full blood count, ferritin, urea, creatinine, liver tests, group and crossmatch in bleeding; fasting gastrin (and gastric pH) in multiple, postbulbar, recurrent or refractory ulcers, ulcers with diarrhoea or hypercalcaemia (multiple endocrine neoplasia type 1); calcium and parathyroid hormone.
• Chest X-ray (erect) or CT abdomen for suspected perforation; coeliac and Crohn assessment for postbulbar ulcers.
• NSAID and aspirin history; assessment of bleeding risk.

Acid suppression: omeprazole 20 to 40 mg daily (or lansoprazole 30 mg, esomeprazole 20 to 40 mg, pantoprazole 40 mg daily) for 4 weeks; healing in 90 to 95% at 4 weeks; extend to 8 weeks for large or complicated ulcers or when NSAIDs continue.

• Helicobacter pylori eradication for 14 days (cures the disease and prevents recurrence in about 90%):
  • Omeprazole 20 mg twice daily, amoxicillin 1 g twice daily and clarithromycin 500 mg twice daily (where clarithromycin resistance is less than 15%).
  • Omeprazole 20 mg twice daily, bismuth subsalicylate 524 mg four times daily, tetracycline 500 mg four times daily and metronidazole 500 mg three to four times daily (first choice in high resistance areas and penicillin allergy).
  • Rescue therapy after failure: omeprazole 20 mg twice daily, amoxicillin 1 g twice daily and levofloxacin 500 mg daily for 14 days, or rifabutin 150 mg twice daily instead of levofloxacin.
  • Test of cure at least 4 weeks after antibiotics and 2 weeks off the proton pump inhibitor.
• Stop NSAIDs or use the lowest dose with omeprazole 20 mg daily (or celecoxib 100 to 200 mg twice daily with omeprazole 20 mg daily); continue aspirin 75 mg daily for secondary prevention with omeprazole 20 mg daily; stop smoking and alcohol.
• Bleeding ulcer:
  • Resuscitation, transfusion at 70 g/L (80 g/L in cardiovascular disease), correction of coagulopathy (vitamin K 10 mg IV, prothrombin complex concentrate 25 to 50 units/kg for warfarin, platelets to 50 x 10^9/L or more), and holding of anticoagulants.
  • Endoscopy within 24 hours with adrenaline 1 in 10,000 injection (up to 10 mL) combined with a thermal probe or haemoclip for active bleeding or a visible vessel.
  • Omeprazole 80 mg IV bolus then 8 mg/hour for 72 hours (or 40 mg IV twice daily), then omeprazole 40 mg orally twice daily for 2 weeks, then daily.
  • Rebleeding: repeat endoscopy, then angiographic embolisation of the gastroduodenal artery, or surgery (under-running of the ulcer with pyloroplasty) for failure; large posterior ulcers have the highest risk.
• Perforation: nil by mouth, fluid resuscitation, nasogastric tube, omeprazole 40 mg IV, piperacillin-tazobactam 4.5 g IV every 6 hours (or ceftriaxone 2 g IV daily with metronidazole 500 mg IV every 8 hours), laparoscopic omental patch repair within 12 to 24 hours; non-operative management only in selected stable patients with a sealed perforation on contrast imaging.
• Outlet obstruction: nasogastric decompression, IV fluids with potassium chloride 20 to 40 mmol/L, omeprazole 40 mg IV daily, thiamine if vomiting is prolonged, then endoscopic balloon dilatation (up to 15 to 18 mm); surgery for failure.
• Refractory or recurrent ulcer: check adherence, H. pylori (and resistance), covert NSAID use, smoking, Zollinger-Ellison syndrome (omeprazole 60 mg daily rising to 120 mg daily in divided doses with tumour localisation and resection), cytomegalovirus, Crohn disease, and consider surgery.
• Special groups: children (omeprazole 1 mg/kg daily, maximum 40 mg, with weight-based eradication using amoxicillin 25 mg/kg twice daily and clarithromycin 7.5 mg/kg twice daily); pregnancy (alginate-antacid, famotidine 20 mg twice daily, omeprazole 20 mg daily; defer eradication); elderly (stop NSAIDs, higher mortality with bleeding); renal impairment (famotidine 10 to 20 mg daily; avoid sucralfate and aluminium antacids); anticoagulated patients (restart when haemostasis is secure, with omeprazole 20 mg daily).
• Red flags: haematemesis, melaena, collapse, rigid abdomen, persistent vomiting, weight loss, anaemia, ulcer recurrence after eradication, diarrhoea with multiple ulcers.
• Follow-up: review at 4 to 8 weeks; test of cure for H. pylori at 4 to 8 weeks; repeat endoscopy for refractory symptoms, large ulcers or complications; haemoglobin and ferritin at 3 months; yearly review of those continuing NSAID or aspirin.