Duodenal ulcer

A duodenal ulcer is a deep wound in the interior wall of the duodenum – the first part of the small intestine, which is connected to the stomach. The duodenum connects the stomach to the remaining part of the intestine.

Duodenal ulcers usually occur just behind the pyloric orifice. An ulcer of the duodenum is – just like a gastric ulcer – usually the result of an infection with the Helicobacter pylori bacterium. But taking non-steroidal anti-inflammatory drugs regularly can also favor the development of duodenal ulcers. The risk of getting such an ulcer increases with age.

Most ulcers do not cause any symptoms, or only slight discomfort for a long time, and are only noticed due to complications, especially pain in the upper abdomen. In most cases, diagnosis is made with a gastroscopy, which involves taking a tissue sample. As treatment, patients are usually given drugs known as gastric acid inhibitors, sometimes together with antibiotics.

In most cases, a duodenal ulcer goes unnoticed for a long time, especially if it is caused by pain medication. Many of the symptoms that occur with a duodenal ulcer are quite non-specific.

These include:

• a feeling of pressure and fullness
• loss of appetite
• nausea, sometimes with vomiting
• irregular bowel movements and gas
• heartburn and acidic burps

In contrast to gastric ulcers, duodenal ulcers are more likely to cause symptoms when the stomach is empty. Eating often relieves symptoms.

The two most common causes for the development of a duodenal ulcer are an infection of the stomach with the Helicobacter pylori bacterium or taking non-steroidal anti-inflammatory drugs (NSAIDs) over a longer period of time. Such drugs include ibuprofen, acetylsalicylic acid (ASA) and diclofenac.

These drugs inhibit formation of the hormone prostaglandin, which regulates the neutralization of gastric acid, among other things. The absence of prostaglandin can result in an overproduction of gastric acid. The gastric acid can then attack the duodenum. In some cases, an ulcer may develop due to a combination of both causes.

If a duodenal ulcer is not treated, serious complications can occur. The most common complication is bleeding.

It is therefore important to have the following symptoms promptly verified by a doctor:

• black-colored stools
• vomited blood (colored red or black)
• signs of anemia such as abnormal fatigue, shortness of breath during physical exertion or pallor

Frequent vomiting after eating is also a warning sign – this symptom may be caused by scars on the pylorus (the outlet between the stomach and the large bowel) due to ulcers repeatedly occurring in the area. The scarring may cause the pylorus to narrow. As a result, the stomach contents are sometimes vomited because they can no longer be transported into the intestines.

In rare cases, an ulcer may also result in a perforation of the duodenum’s muscle layer. This causes sudden very intense abdominal pain and is life-threatening. If a perforation of the duodenum is suspected, it is important to call emergency services on 112 immediately.

Scientific studies have not yet made it clear whether external factors like diet, smoking or prolonged stress encourage the development of duodenal ulcers. Nevertheless, those who notice that symptoms are triggered by greasy foods, alcohol, or stressful situations, for example, should try to avoid these triggers.

Because regularly taking pain medication can also be a trigger for duodenal ulcers, patients are sometimes also advised to take drugs that inhibit the formation of gastric acid.

It is best to consult a doctor for an explanation of how high the personal risk of a duodenal ulcer is and which drugs are a possibility.

If a doctor suspects a duodenal ulcer, they will first palpate the stomach, i.e. examine it by hand. This is normally followed by a gastroscopy to examine the esophagus, stomach and duodenum.

At the same time, a tissue sample is also taken and examined for the Helicobacter pylori pathogen, signs of an inflammation and tissue changes (cancer).

The treatment depends on the results of the gastroscopy and tissue examination.

A duodenal ulcer sometimes heals on its own without treatment within 2 to 3 months. However, it often develops again after a while.

If there is an ulcer but no Helicobacter are detected, drugs known as proton pump inhibitors (PPIs), such as omeprazole or pantoprazole, are used. These drugs reduce the formation of gastric acid. They are taken over 4 to 8 weeks.

If Helicobacter is detected, two antibiotics with different active ingredients are taken in addition to a PPI (triple therapy).

If taking non-steroidal anti-inflammatory drugs (NSAIDs) causes a duodenal ulcer, these are discontinued or replaced if possible. In addition, people with a duodenal ulcer should give up smoking and drinking alcohol – or at least take a break for a while.

A quadruple therapy with three antibiotics mentioned above plus a proton pump inhibitor is also possible – for example, in the case of antibiotic resistance. In both triple and quadruple therapy, the active ingredients are taken together for 1 to 2 weeks. If symptoms persist after that, the treatment can be continued with the proton pump inhibitor alone.

After the antibiotic treatment has finished, an examination is carried out after 4 weeks at the earliest to check whether the drug therapy was successful. A special breath test (13C breath test) is generally used for this to check whether helicobacter bacteria are still present in the stomach. If they are detectable, the treatment can be repeated with other active ingredients.

If severe bleeding occurs, the ulcer is treated with minimally invasive surgery, involving a small incision in the wall of the abdomen (endoscopy). Open surgery is sometimes also required.