What is the recommended management for duodenitis in adults?

Management of Duodenitis in Adults

For duodenitis in adults, initiate proton pump inhibitor therapy and test for Helicobacter pylori, with eradication therapy if positive, as this represents the most effective evidence-based approach for both symptom relief and mucosal healing.

Initial Diagnostic Approach

• Test all patients for H. pylori infection using urea breath test or biopsy-based methods, as 100% of patients with erosive duodenitis in prospective studies were H. pylori positive 1
• Obtain endoscopic biopsies from both the duodenum and gastric antrum/body to confirm histological duodenitis and assess for associated gastritis 1
• Evaluate for NSAID use, as this is a major independent cause of duodenitis and requires specific management considerations 2, 3

Primary Treatment Strategy

For H. pylori-Positive Duodenitis

Implement triple therapy eradication regimen:

• Omeprazole 20 mg twice daily PLUS
• Clarithromycin 500 mg twice daily PLUS
• Amoxicillin 1 g twice daily (or metronidazole 500 mg twice daily if penicillin allergic)
• Duration: 7 days 1

This approach achieves:

• 86% H. pylori eradication rate 1
• 86% duodenal erosion healing when eradication successful 1
• Significant histological improvement in associated gastritis 1

For H. pylori-Negative or NSAID-Associated Duodenitis

• Proton pump inhibitor monotherapy (omeprazole 20 mg daily or equivalent) is the most effective acid suppression strategy 4
• PPIs are superior to H2-receptor antagonists for healing gastroduodenal lesions in NSAID users 2, 4
• If NSAIDs cannot be discontinued, continue PPI therapy long-term for secondary prevention 3

Special Considerations for Crohn's Disease-Related Duodenitis

When duodenitis occurs in the context of Crohn's disease (gastroduodenal Crohn's):

• First-line: Proton pump inhibitors for symptom relief 5
• Second-line: Short course of corticosteroids (prednisolone 40 mg daily) if symptoms worsen despite PPI therapy 5
• Third-line: Consider early anti-TNF therapy (infliximab or adalimumab) for moderate to severe disease refractory to steroids 5
• Nutritional assessment and support is essential in all cases 5
• Balloon dilatation should be used for stricturing disease 5

Follow-Up and Monitoring

• Confirm H. pylori eradication with urea breath test 4-6 weeks after completing therapy 1
• Repeat endoscopy at 1 month post-treatment to document erosion healing if initial therapy fails 1
• For persistent erosions despite negative H. pylori testing, continue PPI therapy and repeat endoscopy at 6 months 1

Common Pitfalls to Avoid

• Do not use H2-receptor antagonists as first-line therapy - they are less effective than PPIs for healing gastric lesions and only protect against duodenal ulcers at standard doses 2, 4
• Do not assume H. pylori eradication alone is sufficient in NSAID users - PPI co-therapy is mandatory for secondary prevention of ulcer relapse 3
• Do not overlook nutritional status - particularly in Crohn's-related gastroduodenal disease where malnutrition is common and requires specific intervention 5
• Failure to achieve erosion healing correlates strongly with persistent H. pylori infection (only 37% healing in eradication failures versus 86% with successful eradication) 1

Treatment Failure Management

If symptoms persist after appropriate therapy:

• Verify H. pylori eradication status - persistent infection is the primary cause of treatment failure 1
• Consider alternative diagnoses including gastroesophageal reflux disease, sarcoidosis, tuberculosis, or malignancy in isolated upper GI disease 5
• For Crohn's-related disease refractory to steroids, escalate to biological therapy rather than prolonging corticosteroid exposure 5