Duodenal ulcer - Clinicals, Diagnosis, and Management

Gastroenterology

Clinicals - History

Fact Explanation
Epigastric or right hypochondric pain or discomfort This is usually the primary complaint. Discomfort is mostly noted when the patient is hungry, it goes off for hour or two when patient consumes food. He may also experience recurrent upper abdominal pain during night, disturbing to sleep. Patient takes a glass of water, milk or a snack as it allows him to return to sleep. Therefore such patients tend to gain weight. There may be radiation of pain to the back. This indicates ulcers which are posteriorly located and penetrating or irritating into the retroperitoneal tissues. Acute abdominal pain indicates ulcer perforation. Epigastric or right hypochondric pain or discomfort
This is usually the primary complaint. Discomfort is mostly noted when the patient is hungry, it goes off for hour or two when patient consumes food. He may also experience recurrent upper abdominal pain during night, disturbing to sleep. Patient takes a glass of water, milk or a snack as it allows him to return to sleep. Therefore such patients tend to gain weight. There may be radiation of pain to the back. This indicates ulcers which are posteriorly located and penetrating or irritating into the retroperitoneal tissues. Acute abdominal pain indicates ulcer perforation.
Vomiting This is not a frequent finding as in gastric ulcers. However this can occur from time to time in duodenal ulcers even without pyloric stenosis. Vomitus contains partly digested food and clear gastric juice. Vomiting relieves abdominal discomfort, so some patients may perform self induced vomiting . Vomiting
This is not a frequent finding as in gastric ulcers. However this can occur from time to time in duodenal ulcers even without pyloric stenosis. Vomitus contains partly digested food and clear gastric juice. Vomiting relieves abdominal discomfort, so some patients may perform self induced vomiting .
Spicy or greasy food tends to exacerbate symtoms Some patients complain that specific types of food exacerbates symptoms. This intolerance seems to be non specific regarding upper GI symptoms . Spicy or greasy food tends to exacerbate symtoms
Some patients complain that specific types of food exacerbates symptoms. This intolerance seems to be non specific regarding upper GI symptoms .
History of presence of etiologic factors Non steroidal anti inflammatory drugs (diclofenac, ibuprofen), steroids, smoking, Helicobacter pylori infection & high salt diet. The risk is high in advancing age, male gender, alcohol abuse & debilitating comorbidities. History of presence of etiologic factors
Non steroidal anti inflammatory drugs (diclofenac, ibuprofen), steroids, smoking, Helicobacter pylori infection & high salt diet. The risk is high in advancing age, male gender, alcohol abuse & debilitating comorbidities.
Upper GI bleeding: symptoms of upper GI bleeds are coffee ground emesis, hematemesis, black, tarry stools, abdominal pain and chest pain Peptic ulcers are responsible for 60% of upper GI bleeding in patients. Duodenal ulcers tend to erode into large vessels causing more bleeding . Upper GI bleeding: symptoms of upper GI bleeds are coffee ground emesis, hematemesis, black, tarry stools, abdominal pain and chest pain
Peptic ulcers are responsible for 60% of upper GI bleeding in patients. Duodenal ulcers tend to erode into large vessels causing more bleeding .
Constitutional symptoms: weight loss, cachexia, malnutrition The inflammatory mass produces this type of constitutional symptoms and the clinician may suspect malignancy as the most likely diagnosis . Constitutional symptoms: weight loss, cachexia, malnutrition
The inflammatory mass produces this type of constitutional symptoms and the clinician may suspect malignancy as the most likely diagnosis .

Clinicals - Examination

Fact Explanation
Pulse may be normal or tachycardic It is usually normal in patients with duodenal ulcers but without upper GI bleeding. With severe bleeding patients become tachycardic. In instances of perforated ulcers tachycardia is seen as well . Pulse may be normal or tachycardic
It is usually normal in patients with duodenal ulcers but without upper GI bleeding. With severe bleeding patients become tachycardic. In instances of perforated ulcers tachycardia is seen as well .
Blood pressure may be normal or hypotensive Normal in patients with duodenal ulcers but without upper GI bleeding. With severe bleeding and perforation of duodenal ulcer a patient becomes hypotensive. Blood pressure may be normal or hypotensive
Normal in patients with duodenal ulcers but without upper GI bleeding. With severe bleeding and perforation of duodenal ulcer a patient becomes hypotensive.
Pallor Patients with bleeding duodenal ulcers tend to develop anaemia . Pallor
Patients with bleeding duodenal ulcers tend to develop anaemia .
Febrile This is a finding with perforated ulcer, particularly with late presentations. They develop septicemia, fluid & electrolyte imbalances, shock and/or Systemic Inflammatory Response Syndrome (SIRS) . Patients appear to be very ill looking . Febrile
This is a finding with perforated ulcer, particularly with late presentations. They develop septicemia, fluid & electrolyte imbalances, shock and/or Systemic Inflammatory Response Syndrome (SIRS) . Patients appear to be very ill looking .
Epigastric tenderness and right hypochondrial guarding These are findings in possible ulcer perforation . Epigastric tenderness and right hypochondrial guarding
These are findings in possible ulcer perforation .

Investigations - Diagnosis

Fact Explanation
Upper GI endoscopy and biopsy These ulcers occur when there is a breech in GI tract mucosal barrier exposing it to the corrosive effects of gastric acid. Endoscopy will show ulcerations in the duodenum, surrounded inflammation (edema, redness) and the size of the ulcer. Ulcers can be single or multiple . Bleeding or perforation may be noted. It is necessary to take biopsies to exclude malignancy or any associated conditions such as: Coeliac disease. Upper GI endoscopy and biopsy
These ulcers occur when there is a breech in GI tract mucosal barrier exposing it to the corrosive effects of gastric acid. Endoscopy will show ulcerations in the duodenum, surrounded inflammation (edema, redness) and the size of the ulcer. Ulcers can be single or multiple . Bleeding or perforation may be noted. It is necessary to take biopsies to exclude malignancy or any associated conditions such as: Coeliac disease.
Barium contrast radiography indications for this investigation are if endoscopy is unsuitable or not feasible such as in suspected gastric outlet obstruction . Barium contrast radiography
indications for this investigation are if endoscopy is unsuitable or not feasible such as in suspected gastric outlet obstruction .

Investigations - Management

Fact Explanation
Hemoglobin Patients with bleeding duodenal ulcers tend to develop anaemia thus low hemoglobin levels. Hemoglobin
Patients with bleeding duodenal ulcers tend to develop anaemia thus low hemoglobin levels.
Blood grouping and cross matching Bleeding duodenal ulcer patients may require urgent blood transfusions . Blood grouping and cross matching
Bleeding duodenal ulcer patients may require urgent blood transfusions .
Helicobacter pylori testing with ELISA This is used for initial testing, but can not be used to confirm eradication. Sensitivity- 85%, specificity- 79%. Helicobacter pylori testing with ELISA
This is used for initial testing, but can not be used to confirm eradication. Sensitivity- 85%, specificity- 79%.
Urea breath test for H.pylori This is more expensive. Sensitivity- 95%- 100%, specificity- 91% - 98%, can be used to confirm eradication. Urea breath test for H.pylori
This is more expensive. Sensitivity- 95%- 100%, specificity- 91% - 98%, can be used to confirm eradication.

Management - Supportive

Fact Explanation
Lifestyle modification: stop smoking and stress management Smoking delays the healing of ulcer and it increases the incidence of ulcer recurrence. Stress is also a cause; ulcers are seen after acute illness, multi organ failure, extensive burns and head illness. So education on stress management can be helpful. Lifestyle modification: stop smoking and stress management
Smoking delays the healing of ulcer and it increases the incidence of ulcer recurrence. Stress is also a cause; ulcers are seen after acute illness, multi organ failure, extensive burns and head illness. So education on stress management can be helpful.
Dietary modification: increase dietary fibers and Vitamin A intake Additional dietary fiber intake reduces the risk of recurrence. Food types with high soluble fibers (orange, carrots, beans) are more effective reducing duodenal ulcer risk. Vitamin A intake has shown some benefit.There is evidence that fatty food, a high protein intake, consumption of alcohol and caffeine are possible etiological factors. Dietary modification: increase dietary fibers and Vitamin A intake
Additional dietary fiber intake reduces the risk of recurrence. Food types with high soluble fibers (orange, carrots, beans) are more effective reducing duodenal ulcer risk. Vitamin A intake has shown some benefit.There is evidence that fatty food, a high protein intake, consumption of alcohol and caffeine are possible etiological factors.

Management - Specific

Fact Explanation
Proton Pump Inhibitors (PPI) These drugs block the final path of gastric acid release. Though PPI has less side effects when use in short causes, long term use has side effects as hip fracture, iron deficiency anaemia, enteric infections and pneumonia. . Proton Pump Inhibitors (PPI)
These drugs block the final path of gastric acid release. Though PPI has less side effects when use in short causes, long term use has side effects as hip fracture, iron deficiency anaemia, enteric infections and pneumonia. .
Eradication of Helicobacter pylori infection with triple therapy Duodenal ulcer is a H.pylori related illness; main causative factor is acid and pepsin load increase. Eradication of Helicobacter pylori infection with triple therapy
Duodenal ulcer is a H.pylori related illness; main causative factor is acid and pepsin load increase.
Management of bleeding duodenal ulcers initial management should be to obtain IV access, ensure availability of blood for possible transfusion, fluid resuscitation with crystalloid solutions or blood if there is evidence of significant blood loss. Usually this bleeding will stop on its own. Only 5%- 10% patients need surgery to overcome bleeding. Risk assessment scores like Blatchford score, Rockall score are used to decide on further interventions . Management of bleeding duodenal ulcers
initial management should be to obtain IV access, ensure availability of blood for possible transfusion, fluid resuscitation with crystalloid solutions or blood if there is evidence of significant blood loss. Usually this bleeding will stop on its own. Only 5%- 10% patients need surgery to overcome bleeding. Risk assessment scores like Blatchford score, Rockall score are used to decide on further interventions .
Endoscopic interventions: Upper GI endoscopy This is the most important step in managing bleeding ulcers. Via endoscope procedures can be done to achieve clotting such as clipping, sclerosant injection and thermal contact. Endoscopic interventions: Upper GI endoscopy
This is the most important step in managing bleeding ulcers. Via endoscope procedures can be done to achieve clotting such as clipping, sclerosant injection and thermal contact.
Surgery: over sewing the ulcer plus truncal vagotomy and pyloroplasty If an ulcer causes recurrent bleeding, but it fails to respond endoscopic interventions then surgical or radiological treatment is indicated. . Surgery: over sewing the ulcer plus truncal vagotomy and pyloroplasty
If an ulcer causes recurrent bleeding, but it fails to respond endoscopic interventions then surgical or radiological treatment is indicated. .
Surgery: Duodenectomy In this procedure the surgical approach is to remove the bleeding part . Surgery: Duodenectomy
In this procedure the surgical approach is to remove the bleeding part .
Surgery: Ligation of the bleeding vessel with non-absorbable suture This will arrest further bleeding . Surgery: Ligation of the bleeding vessel with non-absorbable suture
This will arrest further bleeding .
Interventional angiography: TAE (Transarterial Embolisation) Before this intervention the bleeding location can be identified during endoscopy. Depending on this suspected location the responsible artery (coeliac artery, superior mesenteric or inferior mesenteric artery) can be filled with contrast. Once the bleeding site is precisely identified a vasoconstrictive (vasopressin) medication is infused or else embolisation is done. Material used are gelatin sponges, poly vinyl alcohol or liquid agents like N-butyl 2 cyanoacrylate (NBCA). Interventional angiography: TAE (Transarterial Embolisation)
Before this intervention the bleeding location can be identified during endoscopy. Depending on this suspected location the responsible artery (coeliac artery, superior mesenteric or inferior mesenteric artery) can be filled with contrast. Once the bleeding site is precisely identified a vasoconstrictive (vasopressin) medication is infused or else embolisation is done. Material used are gelatin sponges, poly vinyl alcohol or liquid agents like N-butyl 2 cyanoacrylate (NBCA).
Management of perforated duodenal ulcer This is a common surgical emergency. Mortality and morbidity rates are high. Surgical repair is done either laparoscopically or as an open surgery. Techniques used to repairing are: primary closure, primary suture with pedicled omental flap, pedicled omental flap sutured into the perforation -Cellan- Jones repair, free omental plug sutured into perforation- Graham patch, use of three long tailed sutures to close perforation & buttress with an omental flap, use of tracking sutures around the perforation. Management of perforated duodenal ulcer
This is a common surgical emergency. Mortality and morbidity rates are high. Surgical repair is done either laparoscopically or as an open surgery. Techniques used to repairing are: primary closure, primary suture with pedicled omental flap, pedicled omental flap sutured into the perforation -Cellan- Jones repair, free omental plug sutured into perforation- Graham patch, use of three long tailed sutures to close perforation & buttress with an omental flap, use of tracking sutures around the perforation.
Supportive treatment for perforated duodenal ulcers Following the diagnosis antibiotics should be started after taking blood cultures. Do not stop antibiotics soon after surgery. Sometimes vagotomy is performed during surgery , so eradication of H.pylori is necessary. Long term antacid treatments are also needed as perforation recurrence in known to occur in 12%of patients . Supportive treatment for perforated duodenal ulcers
Following the diagnosis antibiotics should be started after taking blood cultures. Do not stop antibiotics soon after surgery. Sometimes vagotomy is performed during surgery , so eradication of H.pylori is necessary. Long term antacid treatments are also needed as perforation recurrence in known to occur in 12%of patients .

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