What causes a duodenal perforation ulcer?

From the Guidelines

A duodenal perforation ulcer is primarily caused by the erosion of the duodenal wall, creating a hole that allows digestive contents to leak into the abdominal cavity, with the most common cause being Helicobacter pylori infection, as stated in the 2023 guidelines 1. The most common causes of duodenal perforation ulcers include:

• Helicobacter pylori infection, which damages the protective mucus layer of the duodenum and increases acid production
• Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, and naproxen, which reduce protective prostaglandins in the digestive tract
• Other contributing factors, such as excessive alcohol consumption, smoking, severe physiological stress, and Zollinger-Ellison syndrome, a rare condition causing excessive stomach acid According to the 2020 guidelines 1, the incidence of peptic ulcer disease has decreased over the past 30 years, but complications such as perforation and bleeding are still encountered in 10-20% of patients. The 2017 guidelines 1 suggest that surgery is the treatment of choice for perforated peptic ulcers, with simple closure with or without an omental patch being a safe and effective procedure for small perforated ulcers. The most recent guidelines from 2023 1 recommend a tailored approach based on the location of the ulcer for the treatment of perforated peptic ulcer larger than 2 cm, with resection with contextual operative frozen pathologic examination for large gastric ulcers that raise the suspicion of malignancy, and considering the need of resections or repair plus/minus pyloric exclusion/external bile drainage for large duodenal ulcers. It is essential to note that perforation is a medical emergency requiring immediate attention, as it can lead to peritonitis, sepsis, and death if not promptly treated, as highlighted in the 2020 guidelines 1. Prevention involves avoiding NSAIDs, treating H. pylori infections, stopping smoking, limiting alcohol intake, and using acid-reducing medications when necessary, as stated in the 2022 guidelines 1.

From the FDA Drug Label

Adult Patients only Helicobacter pylori Infection and Duodenal Ulcer Disease: Triple therapy for Helicobacter pylori (H. pylori) with clarithromycin and lansoprazole : Amoxicillin, in combination with clarithromycin plus lansoprazole as triple therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) to eradicate H. pylori. Eradication of H. pylori has been shown to reduce the risk of duodenal ulcer recurrence.

The cause of a duodenal perforation ulcer is Helicobacter pylori (H. pylori) infection. Eradication of H. pylori has been shown to reduce the risk of duodenal ulcer recurrence 2.

From the Research

Causes of Duodenal Perforation Ulcer

• Duodenal perforation is a rare, but potentially life-threatening injury, with multiple etiologies associated with it, including peptic ulcer disease, iatrogenic causes, and trauma 3
• The majority of spontaneous perforation is due to peptic ulcer disease, with improved medical management of peptic ulceration reducing the incidence of perforation 4
• Approximately 1 in 5 peptic ulcers is associated with Helicobacter pylori infection, with most of the rest due to nonsteroidal anti-inflammatory drug (NSAID) use 5
• The combination of H. pylori infection and NSAID use synergistically increases the risk of bleeding ulcers more than sixfold 5
• Chronic use of NSAIDs in patients with H. pylori infection increases the risk of peptic ulcer disease (PUD) 6

Risk Factors

• Age: older persons are at higher risk of PUD because of high-risk medication use, including antiplatelet drugs, warfarin, selective serotonin reuptake inhibitors, and bisphosphonates 6
• NSAID use: increases the risk of PUD, especially when combined with H. pylori infection 5, 6
• H. pylori infection: approximately 1 in 5 peptic ulcers is associated with it, and eradicating it reduces the likelihood of peptic ulcers by one-half in NSAID users 5
• Smoking and alcohol consumption: may be associated with an increased risk of duodenal perforation, but the evidence is not conclusive 7