Duodenal Ulcer

Definition

Clinical Features

• Common:
  • incidence seems to be decreasing1
• Usually single
• Does not become malignant
• If in second portion of duodenum:
  • may be:
    • upper abdominal pain
    • bleeding
  • not discernible radiographically
• If refractory tends to be:
  • younger patient
  • larger
  • more severe duodenitis2

Pathogenesis

• Most important factor:
  • H. pylori
• Related to interplay of:
  • aggressive factors:
    • gastric juice eroding and digesting its way into the mucosa
  • defensive factors:
    • bicarbonate
    • intact epithelium3,4
• Usually gastric acid hypersecretion:
  • preserved stomach fundic mucosa is therefore prerequisite
• Other causes:
  • Zollinger–Ellison syndrome:
    • multiple
    • randomly distributed in proximal and distal duodenum
  • nonsteroidal anti-inflammatory drugs5

Gross Pathology

• Well-defined margins
• Location:
  • usually within 2cm of pylorus (Fig. 1
    

    Fig. 1: Duodenal peptic ulcer, characteristically located in the first portion of the organ.

    )
  • sometimes second portion of duodenum
• Sometimes, a large vessel with an open lumen at the base
• Fibrosis when healed ulcer may produce:
  • secondary diverticula and considerable shortening of duodenum
• Usually chronic duodenitis6

Histopathology

• Analogous to gastric ulcer
• Commonly gastric metaplasia7

Differential Diagnosis

Management

• H2-receptor antagonists
• Proton pump inhibitors
• H. pylori eradication
• Surgery:
  • need has markedly decreased
  • indications:
    • complications, such as:
      • hemorrhage
      • perforation
      • obstruction
    • lack of response to medical therapy8
  • standard techniques currently performed:
    • vagotomy with antrectomy and gastroenterostomy
    • vagotomy with pyloroplasty
  • gastric resection may not include the ulcer:
    • ulcer is only completely excised in a few instances