What is the management of duodenitis?

Management of Duodenitis

The management of duodenitis should focus on identifying and treating the underlying cause, with H. pylori eradication therapy being the first-line treatment for H. pylori-positive duodenitis, followed by acid suppression therapy with proton pump inhibitors for both H. pylori-positive and negative cases. 1

Diagnostic Approach

Before initiating treatment, it's crucial to determine the etiology of duodenitis:

1. H. pylori testing: All patients with duodenitis should be tested for H. pylori infection using:

   • Urea breath test
   • Monoclonal stool antigen test
   • Validated serological tests 2

2. Medication review: Identify potential causative agents:

   • NSAIDs and aspirin use (common cause of erosive duodenitis) 3
   • Alcohol consumption 4

3. Endoscopic evaluation: To confirm diagnosis and assess severity:

   • Nodularity and erythema (milder form)
   • Erosions and friability (more severe form) 4

Treatment Algorithm

For H. pylori-Positive Duodenitis:

1. First-line therapy: Eradication therapy with triple therapy for 7-14 days 2, 1

   • Omeprazole 20 mg twice daily
   • Plus two antibiotics from:
     • Amoxicillin 1g twice daily
     • Clarithromycin 500 mg twice daily
     • Metronidazole 500 mg twice daily

2. Confirm eradication: Perform urea breath test 4-6 weeks after completion of therapy 1

3. Maintenance therapy: If erosions persist despite successful H. pylori eradication:

   • Continue PPI (omeprazole 20 mg daily) for 4-8 weeks 5

For H. pylori-Negative Duodenitis:

1. Acid suppression therapy:

   • PPI therapy: Omeprazole 20 mg once or twice daily for 4-8 weeks 5
   • Alternative: H2-receptor antagonists like ranitidine 150 mg twice daily 6

2. Address underlying causes:

   • Discontinue NSAIDs if possible 3
   • Reduce alcohol consumption 4
   • Smoking cessation 7

3. Supportive care:

   • Antacids for symptom relief 7
   • Dietary modifications (avoid irritants)

For Refractory Cases:

If symptoms persist despite standard therapy:

1. Reassess diagnosis: Consider repeat endoscopy with biopsies

2. Consider alternative diagnoses:

   • Crohn's disease
   • Hypersecretory conditions (Zollinger-Ellison syndrome) 8
   • Idiopathic ulcer disease 8

3. Extended therapy:

   • Higher dose PPI (omeprazole 40 mg daily) 5
   • Longer duration of treatment (8-12 weeks)

Special Considerations

Erosive Duodenitis with Bleeding:

For patients with hemorrhagic erosive duodenitis:

• Hospital admission may be required for severe bleeding
• IV PPI therapy
• Endoscopic hemostasis if active bleeding is identified
• Close monitoring of hemoglobin levels 4

NSAID-Induced Duodenitis:

• Discontinue NSAIDs if possible
• If NSAIDs must be continued, add gastroprotective therapy:
  • PPI (omeprazole 20 mg daily)
  • Misoprostol (if PPI not tolerated) 3

Immune-Related Duodenitis:

For patients on immune checkpoint inhibitors who develop duodenitis:

• Grade 1: Continue immunotherapy with close monitoring
• Grade ≥2: Hold immunotherapy and consider gastroenterology consultation
• Consider corticosteroids (prednisone 1 mg/kg/day) for moderate to severe cases 2

Follow-up

• Clinical reassessment after 4-8 weeks of therapy
• Consider repeat endoscopy for:
  • Persistent symptoms despite appropriate therapy
  • History of severe erosive disease
  • Recurrent symptoms after treatment completion

Prognosis

Most cases of duodenitis improve with appropriate therapy. In a study of H. pylori-positive duodenitis, healing was achieved in 86% of cases with successful eradication therapy compared to only 37% in those with failed eradication, highlighting the importance of addressing the underlying cause 1.