Duodenal Ulcers – More than just a stomach pain

abominal pain

Of the 4 million Americans who will develop an ulcer this year, more than 3 million will develop a duodenal ulcer. These people will feel a burning, gnawing, painful sensation in their stomachs. This same pain probably wakes them up sometimes in the middle of the night. Fortunately, we now know what causes most ulcers — the organism Helicobacter pylori — and there is currently effective treatment.

Pronunciation

du-ODD-en-al UL-ser

Synonyms

Detailed Description

Duodenal ulcers involve the formation of small erosions along the duodenum — the first 12 inches of the small intestine lying just beyond the stomach. The erosions are caused by acidic stomach fluids, which contain hydrochloric acid and the digestive enzyme pepsin (hence the name “peptic” ulcer.)

The lining of the gastrointestinal (GI) tract is protected by a thick mucosal layer, which continually rebuilds itself as stomach acid destroys it. Ulcers start when an overproduction of acid and the mucosal later is unable to rebuild itself adequately, allowing erosion to occur and ulcers to form.

The mechanisms of erosion are still not fully understood, but with the recent discovery of the H. pylori bacteria, physicians have a better idea of what’s going on. Many, but not all, ulcers are caused by H. pylori.

If you think you might have an ulcer, it is important that you see a doctor for diagnosis and treatment. Untreated, an ulcer can erode tissue until it creates a perforation. Bleeding may also occur. Follow-up is always recommended, as recurrence is likely if the Helicobacter pylori are not completely wiped out. Only in rare cases is surgery needed, since many medical therapies exist that can effectively treat symptoms and heal the ulcer.

Failure to comply with treatment is a major reason for treatment failure. Risk factors like alcohol, coffee, and especially cigarette smoke have been shown to aggravate existing ulcers. It is important to follow the advice of your doctor about lifestyle and diet, as well as which medications to use or avoid.

Characteristics of Duodenal Ulcers

A duodenal ulcer is a small erosion that forms along the first portion of the small intestine. Appearing as a sore or crater surrounded by inflamed tissue, a duodenal ulcer is almost always benign.

How Common Are Duodenal Ulcers?

Approximately 20 million Americans have peptic ulcer disease, and more than 75% of these cases are duodenal ulcers. As many as 4 million Americans develop an ulcer or a recurrence of a previous ulcer each year; more than 75% of those cases are duodenal ulcers. Their incidence peaks in people ages 30 to 60. Men are twice as likely to develop duodenal ulcers as women.

What You Can Expect

Current medical therapies are usually very effective. Duodenal ulcers are not as severe as gastric ulcers and are almost always benign. Occasionally, a biopsy may be necessary to determine if the ulcer is cancerous. If the ulcer is diagnosed before complications or perforation occur, medication can usually heal the ulcer, provide symptomatic relief, and in most cases, prevent a recurrence.

Established Causes

The cause of duodenal ulcers has not been fully established.

Theoretical Causes

Ulcers seem to develop when the stomach’s digestive juices, which consist of pepsin and hydrochloric acid, eat into the gastrointestinal lining. Currently, scientists cannot fully explain exactly how this happens. A few known causes include the following:

Helicobacter pylori: Discovered only within the last 20 years, this bacteria is resilient enough to live in the extremely acidic environment of the stomach. It burrows through the lining into the tissue, where it reproduces, ultimately damaging the tissue and making it more susceptible to ulceration. H. pylori bacteria accounts for the majority of ulcer cases.NSAIDs: Nonsteroidal anti-inflammatory drugs like aspirin, naproxen, and ibuprofen have been shown to cause damage to the lining of the duodenum.Zollinger-Ellison syndrome: This is a rare tumor in which excessive amounts of stomach acid are produced, causing recurrent ulcer formations. It is often genetic, but not always.

Drugs That Can Cause or Aggravate Duodenal Ulcers

NSAIDs like naproxen (Naprosyn), ibuprofen (Advil), and aspirin have been known to cause ulcers.

Risk Factors

Risk factors for duodenal ulcers include:

Cigarette smoking use of NSAIDsCaffeine intake alcohol use of corticosteroids Blood type O Zollinger-Ellison syndrome physical stress (not emotional) such as severe illness, infections, or burnsCertain chronic conditions (liver disease, rheumatoid arthritis) which increase GI tract vulnerability.

Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily “causes” of the condition.

Symptoms

Duodenal ulcers have varied signs and symptoms, including the following:

Gnawing or burning pain in the abdomen (typically late at night or after eating)Indigestion (dyspepsia)AnemiaBloody stools or vomitRecurrent vomiting (especially if obstruction occurs)

Conditions That May Be Mistaken for Duodenal Ulcers

The following conditions have symptoms similar to those of duodenal ulcers:

How Duodenal Ulcers Are Diagnosed

Two imaging techniques, gastroscopy, and the upper GI series are the most reliable procedures when diagnosing an ulcer. Other useful diagnostic procedures can include a discussion of your medical history, laboratory, breath and stool studies, blood tests, or a biopsy of the GI-tract mucosa.

Lab tests

Your doctor may use these diagnostic procedures:

Measurements of elevated blood gastrin (a hormone that stimulates stomach production of hydrochloric acid) levels, to rule out Zollinger-Ellison syndrome testing the stool for blood measurement of blood pepsinogen (the precursor of pepsin) levels Measurement of urea level in breath tool and serum tests for H. pylori antigens

Imaging

Your doctor may do an upper gastrointestinal (GI) series to look at the small intestine and stomach. This test involves swallowing barium, a chalky solution that coats the lining of the GI tract, and then having X-rays taken. It helps to reveal inflammation or ulcers.

Your doctor may also perform an EGD (esophagogastroduodenoscopy), which involves inserting an endoscope into your mouth and threading it down the esophagus into the small intestine. Performed while you are under mild sedation, this procedure allows a doctor to see, photograph, and biopsy the ulcer. It offers the most reliable method of diagnosis, and also allows for the control of bleeding if present.

Goals of Treatment

Ulcers caused by H. pylori can be successfully treated with antibacterial medication. Ulcers caused by certain drugs or substances can be cured by stopping their use and taking medications to protect the gastrointestinal tract lining. Your doctor can prescribe medication to provide symptom relief, promote ulcer healing, and prevent further complications. Surgery is rarely necessary.

Treatment Overview

Treatment for duodenal ulcers includes eliminating any Helicobacter pylori infection, controlling acute stomach acid to provide immediate pain relief and induce ulcer healing, controlling chronic stomach acid to prevent the ulcer from recurring, and preventing further complications. Antibiotics and antacids are typically prescribed, as changes in lifestyle and diet, if necessary. Surgery, while rare, may be needed to repair a severe ulcer.

Drugs

Drug therapy is aimed at eradicating H. pylori and reducing acid production.

Antibiotics used to eliminate H. pylori bacteria:

Histamine receptor antagonists (H2 blockers) that promote healing by slowing or stopping gastric acid production:

Proton pump inhibitors that also stop acid production:

Prilosec (Omeprazole) and Prevacid (Lansoprazole) are reserved for more severe cases or when H2 blockers have failed. They completely shut down acid production.

Antacids that can relieve acute excess acidity through neutralization:

Magnesium agents such as Mylanta, MaaloxAluminum agents such as AmphojelCalcium agents such as Tums, Rolaids

Mucosal protectants that guard the stomach and intestinal lining from damage:

Drugs that provide symptom relief and antibacterial properties:

Pepto-Bismol (Bismuth subsalicylate)

Nondrug treatment (if appropriate):

Smoking and alcohol cessation programs

Surgery

Surgery is usually the last resort. In rare cases, an ulcer might not respond to medication, bleeding is serious enough to pose a danger, or the lining might be completely eaten through, causing acute peritonitis. The latter cases, especially an ulcer that has perforated the lining or caused obstruction, are life-threatening conditions and require emergency surgery. Besides surgical repair of the ulcer, procedures have been developed that can cut down stomach acid production. If a persistent obstruction occurs, surgery may be avoided via tube-suctioning the stomach contents for several days along with the IV administration of anti-ulcer medication.

Appropriate Healthcare Setting

Once you have been diagnosed, treatment is normally done on an outpatient basis under your doctor’s supervision. You may need to be hospitalized if complications like bleeding, perforation, or obstruction develop. In this case, surgery may be necessary as a last resort.

Healthcare Professionals Who May Be Involved in Treatment

When being treated for a duodenal ulcer, you might see any of the following professionals:

Gastroenterologists, General surgeons, family physicians, Geriatricians Internists

Activity & Diet Recommendations

For the most part, eat regularly and avoid alcohol, coffee, tea, and foods that might cause pain or indigestion. Talk to your doctor about discontinuing the use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, and naproxen, as they can irritate the digestive tract.

Considerations for Women

Pregnancy

Pregnant women should not take the mucosal protective agent Cytotec (misoprostol), as it has been shown to cause miscarriages. Certain antibiotics, such as tetracycline and metronidazole, should also be avoided during pregnancy.

Considerations for Children and Adolescents

Children and adolescents are rarely diagnosed with duodenal ulcers.

Considerations for Older People

Special considerations should be taken if you are older because your immune system may be less efficient, leading to an increased risk for other infections. Poor nutrition– a problem with many older people– may also have a greater impact on the course of an ulcer. Finally, ulcer symptoms may be more severe in older people.

Supplements

Vitamin A can help prevent ulcers. Harvard researchers followed the diets of 48,000 middle-aged men for six years. Compared with men whose diets contained the least vitamin A, those who consumed more of it were only half as likely to develop ulcers. The safest way to take vitamin A is in the form of beta-carotene.

Herbs

Licorice: Commission E, the panel of scientists that judges the safety and effectiveness of medicinal herbs for the German government, endorses licorice as an ulcer treatment — 200 to 600 mg of glycyrrhizin a day. You can get this dose from a tea made with one teaspoon of powdered or crushed licorice root per cup of boiling water. Simmer for five minutes, strain, and drink one cup after each meal. Because of the risk of water retention, which can raise blood pressure, Commission E says this treatment should be used for no more than six weeks. [1]Ginger: Ginger contains 11 compounds with scientifically verified anti-ulcer effects. It can be taken in capsule form or in tea. To make your own tea, add one to two teaspoons of freshly grated ginger root per cup of boiling water and steep five to 10 minutes. Commercially prepared ginger teas are also available. [2]

Be careful with alternative therapies if you have had a complicated ulcer.