Duodenal Ulcer

Getting aware about gut and digestion

The gullet (oesophagus) helps in passing the food down into the stomach. The stomach makes acid which is not essential, but helps to digest food. After being mixed in the stomach, food passes into the first part of the small intestine (the duodenum) Food mixes with chemicals called enzymes in the duodenum and the rest of the small intestine,. The enzymes come from the pancreas and from cells lining the intestine. The enzymes break down (digest) the food which is taken up (absorbed) into the body.

Simplified terms

A peptic ulcer is an ulcer caused by stomach acid. An ulcer occurs where the lining of the gut is damaged and the underlying tissue is exposed. If we could see inside our gut, an ulcer looks like a small, red crater on the inside lining of the gut.

The duodenum is the most common site for a peptic ulcer.

Peptic Inflammation is inflammation caused by stomach acid. Inflammation may be in the stomach; in the first part of the small intestine (the duodenum), as acid flows in with food; or in the lower gullet (oesophagus), if acid splashes up to cause reflux oesophagitis.

Grounds of duodenal ulcers

Our stomach normally produces acid to help with the digestion of food and to kill germs (bacteria). This acid is corrosive so some cells on the inside lining of the stomach and the first part of the small intestine (the duodenum) produce a natural mucous barrier. The lining of the stomach and duodenum are protected by this. There is normally a balance between the amount of acid that we make and the mucous defence barrier. An ulcer may develop if there is an alteration in this balance, allowing the acid to damage the lining of the stomach or duodenum. Causes of this include the following:

Infection with Helicobacter pylori (H. pylori)

Infection with H. pylori is the cause in about 19 in 20 cases of duodenal ulcer. Once we are infected, unless treated, the infection usually stays for the rest of our life. In many people it causes no problems and a number of these bacteria just live harmlessly in the lining of the stomach and duodenum. However, in some people this bacterium causes an inflammation in the lining of the stomach or duodenum. This causes the defence mucous barrier to be disrupted (and in some cases the amount of acid to be increased) which allows the acid to cause inflammation and ulcers.

Anti- inflammatory medicines

Anti – inflammatory medicines which are also known as Non-Steroidal anti inflammatory drugs (NSAIDs). Ex: aspirin, ibuprofen, diclofenac etc.. These are used to treat arthriti, muscular pains etc. Aspirin is used in most of cardiac ailment patients to thin the blood and prevent it from forming clots. Rarely these drugs affect duodenal barrier and allow acid to cause an ulcer. About 1 in 20 duodenal ulcers are caused by anti-inflammatory medicines.

Other causes

Other causes are rare. For example, the Zollinger-Ellison syndrome. In this rare condition, much more acid than usual is made by the stomach. Other factors such as smoking, stress, and drinking heavily may possibly increase the risk of having a duodenal ulcer. However, these are not usually the underlying cause of duodenal ulcers.

Symptoms of duodenal ulcer

Pain in the upper tummy (abdomen) just below the breastbone (sternum) is the common symptom. It usually comes and goes. It may occur most before meals, or when we are hungry. It may be eased if we eat food, or take antacid tablets. The pain may wake us from sleep.

Other symptoms which may occur include bloating, retching, and feeling sick. You may feel particularly full after a meal. Sometimes food makes the pain worse.

Complications

Bleeding ulcer. This can range from a trickle to a life-threatening bleed.

Perforation. This is where the ulcer goes right through (perforates) the wall of the first part of the small intestine (duodenum). Food and acid in the duodenum then leak into the abdominal cavity. This usually causes severe pain and is a medical emergency.

Suggested Investigations

Endoscopy (Gastroscopy) In this test a doctor looks inside our stomach and the first part of our small intestine (duodenum). They do this by passing a thin, flexible telescope down our gullet (oesophagus). They can see any inflammation or ulcers.

A test to detect the H. pylori germ (bacterium) is usually done if we have a duodenal ulcer. If H.pylori is found then it is likely to be the cause of the ulcer. Briefly, it can be detected in a sample of stools (faeces), or in a breath test, or from a blood test, or from a biopsy sample taken during an endoscopy.

Duodenal ulcer Treatment

Acid-burking medication

A 4- to 8-week course of a medicine that greatly reduces the amount of acid our stomach makes is usually advised. Proton pump inhibitors (PPI) are the most commonly used medicine. These are a group (class) of medicines that work on the cells that line the stomach, reducing the production of acid. Ex: Omeprazole, Lansaprozole, Pantaprazole, Rabiprazole, Esmoprazole, Iloprazole but there lot of brand names containing same medicines.

Another calss of medicines that are used are H2 blockers.They are also called histamine H2-receptor antagonists but are commonly called H2 blockers. H2 blockers work in a different way on the cells that line the stomach, reducing the production of acid. They include Ranitidine, famotidine, cimetidine, nizatidine and they also come various brand names. As the amount of acid is greatly reduced, the ulcer usually heals.

Ulcer caused by H. pylori

Nearly all duodenal ulcers are caused by infection with H. pylori. Therefore, a main part of the treatment is to clear this infection. If this infection is not cleared, the ulcer is likely to return once we stop taking acid-suppressing medication. Combination of two antbiotics is needed in addition to take an acid-suppressing medicine to reduce the acid in the stomach. This is needed to allow the antibiotics to work well. We need to take this combination therapy (sometimes called triple therapy) for one/two weeks.

One course of combination therapy clears H. pylori infection in up to 9 in 10 cases. If H. pylori is cleared, the chance of a duodenal ulcer returning is greatly reduced. However, in a small number of people, H. pylori infection returns at some stage in the future.

After treatment, a test to check that H. pylori has gone may be advised. If it is done, it needs to be done at least four weeks after the course of combination therapy has finished. In most cases, the test is negative meaning that the infection has gone. If it has not gone then a repeat course of combination therapy with a different set of antibiotics may be advised.

Ulcer caused by an anti-inflammatory medicine

If possible, we should stop the anti-inflammatory medicine. This allows the ulcer to heal. We will also normally be prescribed an acid-suppressing medicine for several weeks (as mentioned above). This stops the stomach from making acid and allows the ulcer to heal.

However, in many cases the anti-inflammatory medicine is needed to ease symptoms of arthritis or other painful conditions, or aspirin is needed to protect against blood clots. In these situations, one option is to take an acid-suppressing medicine each day indefinitely. This reduces the amount of acid made by the stomach, and greatly reduces the chance of an ulcer forming again.

Operation

In the past, surgery was commonly needed to treat a duodenal ulcer. This was before it was discovered that H. pylori was the cause of most duodenal ulcers, and before modern acid-suppressing medicines became available. Surgery is now usually only needed if a complexity of a duodenal ulcer develops such as severe bleeding or a hole (perforation) comes up.

CONCLUSION:

A duodenal ulcer is usually caused by an infection with a germ (bacterium) called Helicobacter pylori (H. pylori). A 4- to 8-week course of acid-burking medication will allow the ulcer to heal. In addition, a one-week course of two antibiotics plus an acid-suppressing medicine will usually clear the H. pylori infection. This usually prevents the ulcer from coming back. Anti-inflammatory medicines used to treat conditions such as arthritis sometimes cause duodenal ulcers. If one needs to continue with the anti-inflammatory medicine then one may need to take long-term acid-suppressing medication.