Duodenal Ulcer

Understanding your guts and digestion

Food passes down the oesophagus (gullet) into the stomach. The stomach makes acid which is not essential, but helps to digest food. After being mixed in the stomach, food passes into the duodenum (the first part of the small intestine). In the duodenum and the rest of the small intestine, food mixes with enzymes (chemicals). The enzymes come from the pancreas and from cells lining the intestine. The enzymes break down (digest) the food which is absorbed into the body.

• Peptic inflammation is inflammation caused by stomach acid. Inflammation can occur in the stomach, the duodenum (as acid flows in with food), or the lower oesophagus (if some acid splashes back up to cause 'reflux oesophagitis').
   
• A peptic ulcer is an ulcer caused by stomach acid. An ulcer is where the lining of the gut is damaged and the underlying tissue is exposed. If you could see inside your gut, an ulcer looks like a small, red crater on the inside lining of the gut.
   
• The duodenum is the most common site for a peptic ulcer to occur. This leaflet deals only with duodenal ulcers. Separate leaflets deal with stomach ulcers, and acid reflux which causes oesophagitis.

What causes duodenal ulcers?

Many people think that a duodenal ulcer is caused by too much acid coming from the stomach. This is not true. Most people with a duodenal ulcer make a normal amount of acid. The problem is the way the lining of the duodenum copes with the acid. The duodenum makes chemicals and mucus which covers the surface and protects the tissues from the acid. An ulcer occurs if the acid breaks through this protection. The causes of duodenal ulcers include the following.

• Infection by H. pylori is the cause in about 19 in 20 cases. This bacterium (bug) affects the lining of the duodenum in some way which allows the acid to cause inflammation and ulcers.
• Anti-inflammatory medicines which many people take for arthritis, muscular pains, etc. For example: aspirin, ibuprofen, and diclofenac - but there are others. These medicines sometimes affect the lining of the duodenum and allow acid to cause an ulcer.
• Other causes are rare. For example, the Zollinger-Ellison syndrome. In this rare condition, much more acid than usual is made by the stomach.

Other factors such as smoking, stress, and drinking heavily may possibly increase the risk of having a duodenal ulcer. However, these are not the underlying cause of duodenal ulcers.

What are the symptoms of a duodenal ulcer?

• Pain in the upper abdomen just below the sternum (breastbone) is the common symptom. It usually comes and goes. It may occur most before meals, or when you are hungry. It may be eased if you eat food, or take antacid medicines. The pain may wake you from sleep.
• Other symptoms which may occur include: bloating, retching, and feeling sick. You may feel particularly 'full' after a meal. Sometimes food makes the pain worse.
• Complications develop in a small number of cases, but can be serious. These include:
  • Bleeding from the ulcer. This can range from a 'trickle' to a life-threatening bleed.
  • Perforation. This is where the ulcer goes right through ('perforates') the wall of the duodenum. Food and acid in the duodenum then leak into the abdominal cavity. This usually causes severe pain and is a medical emergency.

What tests may be done?

• Endoscopy is the test that can confirm a duodenal ulcer. In this test a doctor looks inside your stomach and duodenum by passing a thin, flexible telescope down your oesophagus. They can see any inflammation or ulcers. (See leaflet called 'Endoscopy' for details.)
• A test to detect the H. pylori bacterium is usually done if you have a duodenal ulcer. If H. pylori is found then it is likely to be the cause of the ulcer. A separate leaflet gives more details about H. pylori and how it can be diagnosed. Briefly, it can be detected in a sample of faeces, or in a 'breath test', or from a biopsy sample taken during an endoscopy.

What are the treatments for a duodenal ulcer?

If you are not taking an anti-inflammatory medicine
Nearly all duodenal ulcers are caused by infection with H. pylori. Therefore, the usual treatment is to clear this infection. Two antibiotics are needed. In addition, a medicine to reduce the acid in the stomach is needed to allow the antibiotics to work well. You need to take this 'combination therapy' (sometimes called 'triple therapy') for a week. It is important to take the full course. One course of combination therapy clears H. pylori infection in up to 9 in 10 cases. In most cases, no further treatment or tests are needed as symptoms usually go. (However, in a small number of cases H. pylori infection returns at some stage in the future.)

Further tests may be done after a course of combination therapy if:

• symptoms do not go, or if they return.
• you had a complication such as a perforation. Tests may be advised in this situation, even if symptoms have gone, to make absolutely sure that the infection and ulcer have cleared.

Have you been treated for a duodenal ulcer for a number of years?
Some people were found to have a duodenal ulcer several years ago. This was before it was known that H. pylori was the cause. The treatment used to be a daily dose of acid-suppressing medicine. This is still taken by some people. This works as it prevents acid from being made in the stomach and causing harm in the duodenum. However, as soon as the medicine is stopped, the ulcer usually returns as the infection remains. The vast majority of such cases are now known to be due to H. pylori. A one week course of 'combination therapy' is likely cure the problem for good.

Treatment if an anti-inflammatory medicine is the cause
If possible, you should stop the anti-inflammatory medicine. This allows the ulcer to heal. However, in many cases the medicine is needed to ease symptoms of arthritis or other painful conditions. One option is to take an acid-suppressing medicine each day. This reduces the amount of acid made by the stomach, and greatly reduces the chance of an ulcer forming again.

© EMIS and PIP 2005   Updated: June 2005   PRODIGY Validated