Management of Duodenitis
Start empiric proton pump inhibitor (PPI) therapy immediately with omeprazole 20 mg once daily for 4 weeks, while simultaneously testing for H. pylori infection. 1, 2
Immediate Assessment and Stabilization
Assess hemodynamic status first – if the patient is unstable with signs of hemorrhagic shock or has evidence of perforation (pneumoperitoneum on imaging), proceed directly to emergency surgical consultation rather than medical management. 1
For hemodynamically stable patients:
- Provide IV fluid resuscitation if needed 1
- Correct electrolyte abnormalities and anemia 1
- Administer low-molecular-weight heparin for thromboprophylaxis in hospitalized patients 1
First-Line Medical Treatment
Initiate PPI therapy immediately without waiting for H. pylori test results:
- Omeprazole 20 mg once daily before meals for 4 weeks 2
- Most patients heal within 4 weeks; some may require an additional 4 weeks 2
- Antacids may be used concomitantly for symptom relief 2
Test for H. pylori infection at presentation – duodenitis has a 100% association with H. pylori in research studies, making it essentially a variant of duodenal ulcer disease. 3
H. pylori Eradication (When Positive)
If H. pylori is confirmed, switch to triple therapy:
- Omeprazole 20 mg twice daily PLUS
- Clarithromycin 500 mg twice daily PLUS
- Amoxicillin 1000 mg twice daily
- Duration: 10 days 2
After completing triple therapy, continue omeprazole 20 mg once daily for an additional 18 days to ensure complete healing and symptom relief. 2
This regimen achieves:
- H. pylori eradication in 69-83% of patients 2
- Duodenal erosion healing in 86% when eradication is successful (versus only 37% when eradication fails) 3
- Complete symptom resolution in most eradicated patients at 6-month follow-up 3
Alternative dual therapy option (if amoxicillin allergy or intolerance):
- Omeprazole 40 mg once daily PLUS
- Clarithromycin 500 mg three times daily
- Duration: 14 days, followed by omeprazole 20 mg once daily for an additional 14 days 2
Antibiotic Use: Critical Caveat
Do NOT routinely prescribe antibiotics unless H. pylori is documented or superinfection/abscess is suspected. 1 The only indication for antibiotics in duodenitis is confirmed H. pylori infection requiring eradication therapy. 1
Lifestyle Modifications
Eliminate precipitating factors:
These modifications are essential as duodenitis represents part of the duodenal ulcer disease spectrum. 4
When to Escalate to Urgent Intervention
Immediate surgical exploration is mandatory for:
- Hemodynamically unstable patients despite resuscitation 1
- Radiological signs of pneumoperitoneum with free fluid in the peritoneal cavity 5, 1
- Massive hemorrhage causing hemodynamic instability 5, 1
- Signs of shock or clinical deterioration 1
For hemodynamically stable patients with gastrointestinal bleeding, perform esophagogastroduodenoscopy first to localize and potentially treat the bleeding source endoscopically. 5
Follow-Up and Monitoring
Confirm H. pylori eradication 4-6 weeks after completing therapy using urea breath test or stool antigen test (not serology). 3
Repeat endoscopy is indicated if:
- Symptoms persist after 8 weeks of PPI therapy 2
- H. pylori eradication fails (erosions persist in 80% of these patients at 6 months) 3
- Red flag symptoms develop (bleeding, perforation, obstruction) 1
Common Pitfalls to Avoid
Never delay PPI therapy waiting for H. pylori test results – start empiric treatment immediately while awaiting results, as delayed treatment worsens outcomes. 1
Do not rely on endoscopy alone for diagnosis – endoscopic diagnosis of duodenitis is only 83% accurate compared to histology, so obtain biopsies when performing endoscopy. 6
Recognize that duodenitis behaves like duodenal ulcer disease – it requires the same aggressive acid suppression and H. pylori eradication approach, not just symptomatic treatment. 4, 3, 7