What is the workup and treatment for duodenitis?

Workup and Treatment for Duodenitis

Initiate proton pump inhibitor therapy with omeprazole 20-40 mg once daily for 4-8 weeks as first-line treatment, while simultaneously testing for H. pylori infection, which if positive requires eradication therapy. 1, 2

Initial Workup

Essential Testing

• Test all patients for H. pylori infection using stool antigen test or urea breath test 3, 4
• Obtain complete blood count, comprehensive metabolic panel to assess for anemia, electrolyte abnormalities, and hypoalbuminemia 3
• Review medication history specifically for NSAIDs, aspirin, anticoagulants, corticosteroids, and other ulcerogenic agents 3
• Assess for alarm features requiring urgent endoscopy: older age at symptom onset, family history of gastric or esophageal cancer, unintentional weight loss, progressive dysphagia, or gastrointestinal bleeding 3

Endoscopic Evaluation

• Perform esophagogastroduodenoscopy (EGD) with duodenal biopsies in patients with alarm features, those not responding to empiric PPI therapy after 4-8 weeks, or when alternative diagnoses need exclusion 3, 1
• Endoscopic findings typically show erythema, nodularity, erosions, or friability in the duodenal bulb 5, 6
• Obtain biopsies from gastric antrum and body to assess for H. pylori-associated gastritis and rule out other pathology 4

Treatment Approach

H. pylori-Positive Duodenitis

If H. pylori testing is positive, eradication therapy is mandatory as this achieves both infection clearance and duodenal healing in 86% of cases. 4

• Triple therapy (preferred): Omeprazole 20 mg twice daily + clarithromycin 500 mg twice daily + amoxicillin 1 g twice daily for 10-14 days 2, 4
• Continue omeprazole 20 mg once daily for an additional 18 days after completing antibiotics 2
• Dual therapy (for clarithromycin allergy/intolerance): Lansoprazole 30 mg three times daily + amoxicillin 1 g three times daily for 14 days 7
• Confirm eradication with urea breath test 4-6 weeks after completing therapy 4

H. pylori-Negative Duodenitis

• Omeprazole 20-40 mg once daily for 4-8 weeks is the cornerstone of therapy 1, 2
• Alternative PPIs include lansoprazole 15-30 mg once daily 7
• For NSAID-associated duodenitis: Continue PPI therapy and discontinue or switch to lowest effective NSAID dose 3, 1
• Consider misoprostol 200 mcg four times daily as alternative gastroprotective agent if PPIs are not tolerated, though diarrhea limits its use 3, 1
• H2-receptor antagonists are less effective than PPIs but may be considered in patients who cannot tolerate PPIs 1

Refractory Cases

• Re-evaluate with repeat endoscopy if symptoms persist despite 4-8 weeks of appropriate PPI therapy 1
• Consider alternative diagnoses including Crohn's disease (gastroduodenal involvement), celiac disease, eosinophilic gastroenteritis, or inflammatory bowel disease-associated duodenitis 3, 8
• For steroid-dependent duodenitis associated with inflammatory bowel disease, advanced therapies like upadacitinib may be required 8
• Sucralfate 1 g four times daily can be added as adjunctive mucosal protective therapy 9

Special Considerations

NSAID Users Requiring Continued Therapy

• Use COX-2 selective NSAIDs in high-risk patients (history of ulcer, elderly, concurrent anticoagulation) 3, 1
• Add PPI prophylaxis at standard doses for all patients requiring ongoing NSAID therapy 3, 1
• Avoid combining multiple NSAIDs including low-dose aspirin when possible 3

Hemorrhagic Erosive Duodenitis

• This represents a potentially serious complication requiring hospitalization for severe cases 5
• Discontinue aspirin, alcohol, and other precipitating factors immediately 5, 6
• Initiate high-dose PPI therapy (omeprazole 40 mg twice daily or IV formulation if unable to take oral medications) 1
• Monitor hemoglobin and provide supportive care with IV fluids and blood transfusion if needed 3

Follow-Up and Monitoring

• Reassess symptoms at 4-8 weeks after initiating therapy 1, 2
• For H. pylori-positive cases with successful eradication, 86% achieve complete duodenal erosion healing 4
• Patients with persistent symptoms despite negative H. pylori testing and adequate PPI therapy require repeat endoscopy to exclude alternative diagnoses 1
• Long-term PPI maintenance is generally not required once healing is achieved, unless there is ongoing NSAID use or recurrent symptoms 2, 9

Common pitfall: Failing to test for H. pylori leads to treatment failure, as 100% of erosive duodenitis cases in one study were H. pylori-positive, and eradication was the only variable correlating with healing. 4