What are the symptoms and treatment of a duodenal ulcer?

Symptoms and Treatment of Duodenal Ulcer

Symptoms of Duodenal Ulcer

The most common symptoms of duodenal ulcer include epigastric pain (typically relieved by food intake or antacids), pain that awakens patients at night or occurs between meals, rectal bleeding, nausea, vomiting, and weight loss. 1

• Epigastric discomfort is the predominant symptom, often described as burning or gnawing pain that occurs 2-3 hours after meals 1, 2
• Pain is typically relieved by food consumption or antacid use, which distinguishes it from other gastrointestinal conditions 1
• Nocturnal pain that causes awakening is highly characteristic of duodenal ulcers 1
• Rectal bleeding may occur and presents as melena (black, tarry stools) 3
• Nausea, vomiting, and weight loss can be present, particularly in more severe cases 1
• Approximately two-thirds of patients with peptic ulcer disease may be asymptomatic 2

Alarm Symptoms Requiring Immediate Attention

• Hematemesis (vomiting blood) indicates active bleeding 3
• Melena (black, tarry stools) suggests gastrointestinal bleeding 3
• Recurrent vomiting may indicate gastric outlet obstruction 3
• Significant weight loss could suggest malignancy or severe disease 3
• Dysphagia (difficulty swallowing) requires prompt evaluation 3

Treatment of Duodenal Ulcer

First-Line Treatment

For patients with duodenal ulcer, testing for H. pylori infection should be performed, and if positive, eradication therapy with triple therapy (PPI + amoxicillin + clarithromycin) for 14 days is strongly recommended, followed by continued PPI therapy to ensure complete healing. 4, 5

• Triple therapy regimen consists of PPI (such as omeprazole 20mg twice daily) + amoxicillin 1000mg twice daily + clarithromycin 500mg twice daily for 14 days 4, 5
• Omeprazole 20mg daily has been shown to heal 75% of duodenal ulcers at 4 weeks compared to 27% with placebo 5
• Omeprazole provides faster symptom relief and healing than ranitidine, with 79% healing at 2 weeks versus 62% with ranitidine 6
• Complete daytime and nighttime pain relief occurs significantly faster with omeprazole than with placebo or ranitidine 5, 6

Treatment Based on Etiology

H. pylori-Associated Ulcers

• Testing for H. pylori should be performed in all patients with duodenal ulcer 4
• H. pylori eradication significantly reduces ulcer recurrence and rebleeding 4
• For bleeding ulcers, eradication therapy should be started after 72-96 hours of intravenous PPI administration 4
• Confirmation of H. pylori eradication is essential to ensure successful treatment 7

NSAID-Induced Ulcers

• Discontinue NSAIDs if possible, as they significantly increase the risk of ulcer recurrence and complications 4
• If NSAIDs must be continued, add a PPI for gastroprotection 4, 7
• H2-receptor antagonists decrease the risk of NSAID-associated duodenal ulcers but are less effective than PPIs 4, 7

Surgical Management

• Surgery is indicated for complications such as bleeding refractory to endoscopic treatment, perforation, or gastric outlet obstruction 3
• For bleeding duodenal ulcers requiring surgery, the bleeding vessel (often the gastroduodenal artery) can be oversewn via duodenotomy 3
• Vagotomy with drainage procedures has been associated with lower mortality than local ulcer oversew alone for intractable bleeding 3

Prevention of Recurrence

• Avoid all NSAIDs as they significantly increase risk of ulcer recurrence 4
• Successful H. pylori eradication reduces the risk of ulcer recurrence 4
• Maintenance PPI therapy may be required for patients with recurrent ulcers or those who must continue NSAID therapy 4, 7
• Regular follow-up to ensure complete healing and symptom resolution 1

Common Pitfalls and Caveats

• Failure to test for H. pylori infection in all duodenal ulcer patients 4
• Inadequate duration of PPI therapy leading to incomplete healing 4
• Poor compliance with gastroprotective agents in patients requiring continued NSAID therapy 4
• Relying solely on symptom resolution without confirming H. pylori eradication 7
• Overlooking alarm symptoms that require prompt endoscopic evaluation 3