A duodenal ulcer is usually caused by an infection with a germ (bacterium) called Helicobacter pylori (H. pylori). A 4- to 8-week course of acid-suppressing medication will allow the ulcer to heal. In addition, a one-week course of two antibiotics plus an acid-suppressing medicine will usually clear the H. pylori infection. This usually prevents the ulcer from coming back. Anti-inflammatory medicines used to treat conditions such as arthritis sometimes cause duodenal ulcers. If you need to continue with the anti-inflammatory medicine then you may need to take long-term acid-suppressing medication.
What is a duodenal ulcer?
Duodenal and gastric ulcers are often called peptic ulcers. A peptic ulcer is an ulcer caused by stomach acid. An ulcer occurs where the lining of the gut is damaged and the underlying tissue is exposed. If you could see inside your gut, an ulcer looks like a small, red crater on the inside lining of the gut.
A duodenal ulcer is an ulcer that occurs in the lining in the part of the small intestine just beyond the stomach (the duodenum). An ulcer in the lining of the stomach is called a gastric ulcer.
What causes duodenal ulcers?
Your stomach normally produces acid to help with the digestion of food and to kill germs (bacteria). This acid is corrosive so some cells on the inside lining of the stomach and the first part of the small intestine (the duodenum) produce a natural mucous barrier. This protects the lining of the stomach and duodenum.
There is normally a balance between the amount of acid that you make and the mucous defence barrier. An ulcer may develop if there is an alteration in this balance, allowing the acid to damage the lining of the stomach or duodenum. Causes of this include the following:
Infection with Helicobacter pylori (H. pylori)
Infection with H. pylori is the cause in about 19 in 20 cases of duodenal ulcer. More than a quarter of people in the UK become infected with H. pylori at some stage in their lives. See the separate leaflet called Stomach Pain (Helicobacter Pylori) for more information.
Anti-inflammatory medicines - including aspirin
Anti-inflammatory medicines are sometimes called non-steroidal anti inflammatory drugs (NSAIDs). There are various types and brands. For example, aspirin, ibuprofen, diclofenac, etc. These medicines sometimes affect the mucous barrier of the duodenum and allow acid to cause an ulcer. About 1 in 20 duodenal ulcers are caused by anti-inflammatory medicines.
Other causes and factors
Other causes are rare. For example, the Zollinger-Ellison syndrome. In this rare condition, much more acid than usual is made by the stomach.
Other factors such as smoking, stress and drinking heavily may possibly increase the risk of having a duodenal ulcer. However, these are not usually the underlying cause of duodenal ulcers.
What are the symptoms of a duodenal ulcer?
- Pain in the upper tummy (abdomen) just below the breastbone (sternum) is the common symptom. It usually comes and goes. It may occur most before meals, or when you are hungry. It may be eased if you eat food, or take antacid tablets. The pain may wake you from sleep.
- Other symptoms which may occur include bloating, retching, and feeling sick. You may feel particularly full after a meal. Sometimes food makes the pain worse.
- Complications occur in some cases and can be serious. These include:
- Bleeding ulcer. This can range from a trickle to a life-threatening bleed.
- Perforation. The ulcer goes right through (perforates) the wall of the first part of the small intestine (duodenum). Food and acid in the duodenum then leak into the abdominal cavity. This usually causes severe pain and is a medical emergency.
What tests may be done?
- Gastroscopy (endoscopy) is the test that can confirm a duodenal ulcer. In this test a doctor or nurse looks inside your stomach and the first part of your small intestine (duodenum). They do this by passing a thin, flexible telescope down your gullet (oesophagus). They can see any inflammation or ulcers.
- A test to detect the H. pylori germ (bacterium) is usually done if you have a duodenal ulcer. If H. pylori is found then it is likely to be the cause of the ulcer. Briefly, it can be detected in a sample of stool (faeces), or in a breath test, or from a blood test, or from a biopsy sample taken during an endoscopy. See separate leaflet called Stomach Pain (Helicobacter Pylori) for more details.
What are the treatments for a duodenal ulcer?
Lifestyle measures can improve symptoms, such as:
- Lose weight if you are overweight.
- Avoid any trigger foods, such as coffee, chocolate, tomatoes, fatty foods or spicy foods.
- Eat smaller meals and eat your evening meal 3-4 hours before going to bed.
- Stop smoking.
- Reduce alcohol consumption to recommended limits.
A 4- to 8-week course of a medicine that greatly reduces the amount of acid your stomach makes is usually advised. The most commonly used medicine is a proton pump inhibitor (PPI). See the separate leaflet called Indigestion Medication for more information.
If your ulcer was caused by H. pylori
Nearly all duodenal ulcers are caused by infection with H. pylori. Therefore, a main part of the treatment is to clear this infection. If this infection is not cleared, the ulcer is likely to return once you stop taking acid-suppressing medication. See the separate leaflet called Stomach Pain (Helicobacter Pylori) for more information.
If your ulcer was caused by an anti-inflammatory medicine
If possible, you should stop the anti-inflammatory medicine. This allows the ulcer to heal. You will also normally be prescribed an acid-suppressing medicine for several weeks (as mentioned above). This stops the stomach from making acid and allows the ulcer to heal.
However, in many cases the anti-inflammatory medicine is needed to ease symptoms of arthritis or other painful conditions, or aspirin is needed to protect against blood clots. In these situations, one option is to take an acid-suppressing medicine each day indefinitely. This reduces the amount of acid made by the stomach, and greatly reduces the chance of an ulcer forming again.
In the past, surgery was commonly needed to treat a duodenal ulcer. This was before it was discovered that H. pylori was the cause of most duodenal ulcers, and before modern acid-suppressing medicines became available. Surgery is now usually only needed if a complication of a duodenal ulcer develops such as severe bleeding or a hole (perforation).
Further reading and references
; NICE Clinical Guideline (Sept 2014)
; History of Helicobacter pylori, duodenal ulcer, gastric ulcer and gastric cancer. World J Gastroenterol. 2014 May 1420(18):5191-204. doi: 10.3748/wjg.v20.i18.5191.
; NICE CKS, September 2017 (UK access only)
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