Duodenal ulcer

Last revised by Rohit Sharma on 3 Aug 2023

Duodenal ulcer is defined as injury to the duodenal mucosa, most commonly due to either medication or infection. These ulcers are a subtype of peptic ulcer disease.

The incidence of duodenal ulcers ranges between 5-10% in developed countries. There is, however, evidence of decreasing incidence with ongoing timely identification and treatment of Helicobacter pylori 1.

Risk factors for duodenal ulcer formation include:

Duodenal ulcers share the same pathogenesis of peptic ulcer disease.

  • H. pylori: a gram negative bacterium that secretes toxins and urease which leads to mucosal inflammation

  • NSAIDs: damage to the mucosal via physical irritation, suppression of prostaglandin synthesis (prostaglandin being responsible for mucosal coating of the surface) and reduction of gastric blood flow

Majority of patients are asymptomatic, with 70% of patients with peptic ulcer disease reporting no symptoms 2.

Symptomatic patients typically report:

  • abdominal pain: upper abdominal in location and stereotypically occurring a couple hours following ingestion of food

  • melena

  • bloating and abdominal fullness

  • nausea

  • hematemesis

Isolated abdominal or chest x-ray is non-diagnostic in the setting of duodenal ulcers. Nevertheless, late complications such as perforation demonstrated as subdiaphragmatic free gas may be present.

Barium study findings depend on the location of the ulcer 3:

  •  bulbar ulcers

    • well rounded pools of barium which may have radiating folds converging to a crater (barium pools represent an ulcer that has lead to bulbar deformity with a subsequent "crater" formation)

    • "cloverleaf" appearance of the duodenal cap (represents multiple pseudodiverticula)

  • postbulbar ulcers

    • ring strictures

Double contrast barium images have a higher sensitivity than single contrast barium studies, by which ulcers greater than 1 cm may be detected.

CT may detect duodenal ulcers and subsequent complications. The sensitivity is thought to be around 25-50% in the current literature 4,5.

Features of duodenal ulcers may include:

  • mural thickening of the affected segment

  • mucosal hyperenhancement of the ulcerated duodenum

  • periduodenal or perigastric fat stranding

  • regional lymph nodes

  • signs of perforation include extraluminal gas (anterior wall ulcers) or a leak into the peritoneal cavity (posterior wall ulcers perforate into either the lesser sac or pararenal space).

Duodenal ulcer treatment is tailored towards the underlying cause. In the setting of iatrogenic causes such as medication use, management typically involves cessation of the offending agent i.e. NSAID or steroids, and the use of proton pump inhibitors.

H. pylori management typically involves eradication therapy with concomitant antibiotics and proton pump inhibitor.

Complications of the disease include upper gastrointestinal bleeding, perforation, gastric cancer or outlet obstruction due to stricture formation.

Alternative diagnoses include:

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