Duodenal Ulcer: Causes, Symptoms & Treatment

A duodenal ulcer is damage to the inner wall of the intestine. Specifically, this involves oozing and excessive gastric juice secretion that attacks the wall of the duodenum. In addition to smoking, stress and medication, the bacterium Helicobacter pylori may also be responsible for duodenal ulcer disease.

What is duodenal ulcer?

Infographic showing the anatomy and location of a duodenal ulcer. Click image to enlarge. The duodenum is a c-shaped portion of the intestine, approximately 30 cm long, and is located between the outlet of the stomach and the small intestine. Duodenal ulcer is a deep substance defect in its wall. By definition, this defect extends deeper than the muscular layer lying beneath the mucosa. Ulceration is the most common disease of the duodenum and is about five times more common than peptic ulcer. If only the mucosa is affected, it is referred to as erosion. Up to two percent of all people develop a duodenal ulcer in the course of their lives, men significantly more frequently than women. The peak incidence is in middle age.

Causes

In general, for a duodenal ulcer to develop, there must have been a mismatch of factors that protect the mucosa and factors that cause damage. The most common cause is an infestation with a bacterium (the Helicobacter pylori), which is detected in 90% of diagnosed duodenal ulcers. This bacterium is able not only to survive in the acidic environment of the upper gastrointestinal tract, but also to multiply due to certain adaptation processes, e.g. the formation of neutralizing enzymes. Additional damaging factors include the use of certain medications (e.g., diclofenac and aspirin), stress (physical and psychological), and circulatory disorders. A rare cause of duodenal ulcer is a tumor disease in which the production of gastric acid is massively increased (by so-called gastrin-producing tumors). It has also been shown that people with blood group 0 are significantly more likely to develop duodenal ulcer, but the cause is not yet fully understood.

Symptoms, complaints, and signs

The symptoms for duodenal ulcer develop very slowly. Only over the course of weeks and months do they become more noticeable. Typical signs at the beginning of the disease may include bloating and frequent flatulence. Likewise, heartburn and acid regurgitation may be initial complaints. A small proportion of those affected by duodenal ulcer do not experience any symptoms during this initial phase. The other sufferers experience an increasing dull pain in the upper abdomen. The pain may radiate to the back. Similarly, nausea and vomiting or loss of appetite may be non-specific signs of duodenal ulcer. This may include an aversion to certain foods. Over time, unnatural weight loss may occur. A more classic symptom is given when pain occurs regularly when the stomach is empty. This may well be at night. Food intake usually leads to an improvement of the symptoms. About one in five duodenal ulcers is associated with bleeding, which is excreted through the stool or during vomiting and thus becomes visible. The stool shows a characteristic black coloration due to the mixing of blood and gastric acid (so-called tarry stools). Depending on the extent of blood loss, additional circulatory problems may occur. In individual cases, the ulcer can cause a life-threatening gastric rupture. This causes very severe pain in the pit of the stomach.

Course of the disease

The symptoms of duodenal ulcer are completely nonspecific at the beginning of the disease, so the diagnosis is often made late. Typical complaints include loss of appetite (with aversion to certain foods), nausea, and pressure in the stomach area or a feeling of fullness in the middle upper abdomen. Unwanted weight loss and stool abnormalities may also occur. If the duodenal ulcer begins to bleed, it is not uncommon to have black-colored stools (called tarry stools). This is because blood turns black when it comes into contact with the aggressive stomach acid (hematin formation). Tarry stools always require clarification and should therefore give rise to further research into the cause.In case of a sudden pain of destruction, perforation (that is a breakthrough of the duodenal ulcer into the free abdominal cavity) must be feared. However, it is not uncommon for sufferers to be completely asymptomatic and the diagnosis is made by chance. The diagnosis of duodenal ulcer is made by gastroscopy. As part of the examination, a rapid test for the typical germ Helicobacter pylori is always performed. In addition, a small piece of tissue is sent in, which enables reliable detection or exclusion of an infestation with the harmful bacterium.

Complications

Bleeding is among the most common complications of duodenal ulcer. People of older age are particularly at risk, and certain pain medications can also trigger bleeding, especially of larger ulcers, with prolonged use. Minor bleeding often goes unnoticed, but can cause anemia: This is often discovered by chance during a routine examination. Black stools known as tarry stools may also indicate a bleeding ulcer. If larger vessels are affected, ulcer bleeding is often highly dramatic: due to massive blood loss in a short time, a life-threatening state of shock is imminent if the bleeding cannot be stopped by immediate surgery. Another feared complication is the rupture of a duodenal ulcer into the abdominal cavity: The gastric contents that escape can cause a life-threatening peritonitis, and immediate emergency surgery is therefore unavoidable. Depending on the location of the ulcer, it can also invade the surrounding organs – such as the pancreas or the colon – and cause damage there. If the ulcer is close to the stomach outlet, it is not uncommon for a narrowing to occur that impedes the onward transport of the food pulp: Constant vomiting and massive weight loss can be the result. In very rare cases, a duodenal ulcer can degenerate into a malignancy and later form daughter tumors in other organs.

When should you see a doctor?

If the affected person suffers from unpleasant flatulence, a feeling of pressure in the abdomen or pain in the lower abdomen, a visit to the doctor is necessary. If there is a steady increase in health disorders within several days, weeks or months, a doctor is needed. Swelling, a general feeling of malaise, or a decrease in physical performance are among the health irregularities that may occur. Nausea, vomiting and loss of appetite are further indications of a present disease. The complaints should be checked by a doctor to enable a diagnosis to be made. A decrease in body weight, a feeling of inner dryness and an inner restlessness should be presented to a physician. Abnormalities of going to the toilet as well as bad breath are also among the health disorders that can be triggered by duodenal ulcer. Changes in behavior, emotional irregularities, and digestive impairments need to be discussed with a physician. The affected person will need medical tests so that a diagnosis can be made. If left untreated, the existing ulcer will continue to grow and can lead to numerous complications as well as a further decline in health. Of concern are bleeding in the stool or discoloration of the feces. If these peculiarities occur, immediate action is required. A visit to the doctor is necessary so that treatment can be initiated and relief of symptoms obtained.

Treatment and therapy

The basic therapy in the treatment of duodenal ulcer consists of effective acid inhibition. This attempts to restore the disturbed balance between mucosal damage and protection. Medications from the proton pump inhibitor group are usually used, e.g. Pantozol or Omeprazole. In many studies, these show the strongest acid protection with comparatively few side effects. Since the cause is usually an infection with Helicobacter pylori, the therapy is supplemented with two antibiotics (triple therapy) once the bacterium has been detected. Clarithromycin is the standard of care, and amoxicillin or alternatively metronidazole is also used. Today, surgical therapy is usually only necessary in the case of complications. As a rule, parts of the stomach are completely removed.Typical indications are uncontrollable bleeding, duodenal ulcer rupture, or suspected malignant tumor. Even if the acid production cannot be effectively reduced by medication, it can be treated surgically by cutting a nerve cord that regulates acid production. In addition, in the case of duodenal ulcer, nicotine and alcohol, as well as spicy foods should be avoided. Likewise, stress reduction and a sports-healthy lifestyle should be aimed for.

Aftercare

In most cases, there are very few and also very limited aftercare measures available to the person affected by a duodenal ulcer, so the person affected by this disease should ideally see a doctor at an early stage and also initiate treatment in the process. The sooner a doctor is consulted in the case of duodenal ulcer, the better the further course of this disease usually is. Most sufferers are dependent on taking various medications that can alleviate and limit the symptoms. The choice of medication depends to a large extent on the cause of the disease. In general, the affected person should pay attention to the regular intake and also to the correct dosage of the medication. If there is any uncertainty or if there are any questions, a doctor should be consulted first so that other complaints or complications do not arise. When taking antibiotics, it should also be noted that they should not be taken together with alcohol. In general, in the case of duodenal ulcer, it is also advisable to pay attention to a healthy lifestyle with a balanced diet. Alcohol and nicotine should be avoided as much as possible. The disease itself can thereby reduce the life expectancy of the affected person in some cases.

What you can do yourself

Duodenal ulcer

A duodenal ulcer basically requires medical treatment. Highly effective medications usually result in rapid improvement, but various self-help measures can support the healing process. They also help to prevent a recurrence of the ulcer. Consistent avoidance of triggers is particularly important. This applies not only to the acute phase of the disease, but also afterwards. The typical triggers of a duodenal ulcer include first and foremost alcohol, tobacco products, milk and sugary foods. However, spices such as mustard, pepper and horseradish can also have a stimulating effect on acid formation. Certain medications such as acetylsalicylic acid, which are not always necessary to take, are also problematic. Diets that are easy on the mucous membrane, such as a tea and rusk diet for 24 to 36 hours, are recommended. After that, the patient gradually returns to his usual diet. During the first two days, a light diet of potatoes and cooked vegetables is recommended. From the third day, low-fat meat dishes can be eaten again. It is also helpful to eat several small meals a day instead of just a few large menus. Another self-help option is relaxation methods such as meditation or autogenic training. They are particularly effective against stress-related complaints. In addition, alternative treatment methods such as acupuncture or taking homeopathics such as Acidum sulfuricum, Nux vomica, Belladonna or Acidum muriaticum can also be used.