Duodenal Ulcers
Introduction
Ulceration within the duodenum is a common surgical complaint with a wide spectrum of type and severity of presentation. The incidence and complexity of disease in the UK is reducing with the widespread use of drugs for symptoms of “indigestion” which completely suppress stomach acid production.
The recognition that many ulcers are caused by a bacterial infection or particular types of painkilling drugs has also changed the nature of the condition in the UK in the last twenty years.
Causes of duodenal ulcers
Helicobacter Pylori Infection: A bacterium found in the stomach (often in individuals without symptoms) has been shown to have a role in the development of duodenal ulcers and is often responsible for them failing to heal when treated with acid suppression drugs.
Excessive secretion of stomach acid: Is found in some but not all cases of duodenal (and stomach) ulceration.
Non-Steroidal Anti-inflammatory drugs (NSAID): Widely recognised to cause ulceration in some patients
Smoking: May cause and certainly potentiates the development of duodenal ulcers. Alcohol and Caffeine do not appear to have any effect.
Ill or hospitalised patients: A very common finding in this patient group usually with poor nutritional intake
Symptoms
- Abdominal Pain usually centrally in the upper abdomen
- Anaemia usually showing Iron deficiency
- Indigestion
- Vomiting
- Vomiting blood (haematemesis)
- Black stools (melaena)
- Collapse and shock
Investigation
Ulcers may be diagnosed by a variety of means but the most accurate and useful is an OGD (Oesophago-Gastro-Duodenoscopy). A flexible endoscope is inserted via the mouth into the stomach and duodenum. The ulcers may be diagnosed and biopsied. Samples may be taken for Helicobacter Pylori and certain treatments (particularly for bleeding) undertaken.
Treatment
The vast majority of duodenal ulcers will heal with a six week course of acid suppression therapy using a proton pump inhibiting drug (Omeprazole, Esmoprazole etc) and eradication of Helicobacter Pylori (if present) with a week long course of two antibiotics in combination. Clearly treatment should also address other stimulants of ulcer formation, smoking and NSAID (aspirin, Ibuprofen etc) use.
Only very occasionally since the advent of complete acid suppression therapy, do duodenal ulcers that fail to heal completely, require surgery. However duodenal ulcers that present as an emergency to hospital with either bleeding or perforation do require aggressive treatment.
Bleeding may be controlled at endoscopy but in some cases needs surgery when unsuccessful. Perforation is almost always treated with urgent operation and patch repair of the hole created by the ulcer.