Duodenal ulcer

Epidemiology

The duodenal ulcer is 4-10 times more frequent than the gastric ulcer. It can appear at any age, but the peak of maximum incidence is found between 30 and 40 years. It is more common in males, with a male / female ratio of 3: 1. According to some statistics it is thought that around 10% of the population develops a duodenal ulcer in the course of life. Unlike the gastric one, the duodenal ulcer has no differences in incidence linked to the socio-economic condition.

Causes

Also for duodenal ulcer, no specific causes of onset are known. The factors assumed as responsible are instead multiple. It is believed that the main one is represented by acid hypersecretion . This seems to depend substantially on the numerical increase in acid-secreting cells of the gastric mucosa, from the increase in gastric response to secretory stimuli and from the altered ability to inhibit gastrin release. Furthermore, patients with duodenal ulcer have a more marked response than healthy subjects and gastric ulcer carriers to stimulation by gastrin; this may be indicative of an increased response capacity of the parietal cells to it. Even a particularly intense vagus nerve stimulation could play a significant role in inducing acid hypersecretion.

Many patients with duodenal ulcers have alterations in gastric emptying. In these cases, if the passage of chyme acid into the duodenum occurs too quickly, the local buffering capacity can be overcome and the duodenal mucosa is excessively exposed to the acid. This is compounded by the fact that bicarbonate secretion in duodenal mucus is significantly reduced in patients with duodenal ulcer. Caffeine can facilitate the onset of ulcerative lesions of the duodenum, due to its ability to increase gastric acid production. In the induction of duodenal ulcers, NSAIDs and cortisones can play an important role, with a mechanism that is not yet perfectly known. Cigarette smoking is associated not only with a higher incidence of duodenal ulcer, but also with a reduced response to therapy, a greater number of distant relapses and a higher mortality in the event of complications. However, there is no evidence of a relationship between alcohol consumption and the appearance of duodenal ulcer. The importance of psychological factors is controversial; it seems however that anxious personalities are more exposed to the risk of ulcers also at duodenal level. The role of family predisposition appears to be particularly important. This occurs with triple frequency in first-degree relatives of ulcer patients compared to the general population and, as in the case of gastric ulcer, the subjects of blood group 0 are particularly exposed. Helicobacter pylori gastritis and duodenitis are found in over the 85% of subjects suffering from duodenal ulcer. The inflammatory changes induced by this bacterium could make the duodenal mucosa more sensitive to the acid insult, therefore they would predispose to the onset of the ulcer.

Form and location of the ulcerative lesion

95% of duodenal ulcers are located in the duodenal bulb, within 3 cm of the pylorus. The front wall of the bulb is the most frequently affected site; they follow in order of frequency the posterior wall and the superior and inferior margins of the bulb. The average diameter of duodenal ulcers is about 1 cm. The morphology is similar to that of gastric ulcer. Complications are bleeding, perforation and stenosis (occlusion); the possibility of evolution in a malignant tumor would seem to be excluded.

Due to the thinness of the duodenal wall, ulcers of the anterior wall of the bulb can undergo perforation with a certain ease.

The ulcers of the posterior wall of the bulb tend instead to penetrate into the head of the pancreas, due to the close proximity of the two organs and can lead to the development of inflammatory reactions of the pancreas itself (acute pancreatitis). The hemorrhagic complications of the duodenal ulcer can be fatal, because the deepening of the ulcer can lead to the erosion of important arterial branches

Symptoms and diagnosis

To learn more: Duodenal Ulcer Symptoms

Although some patients with active duodenal ulcers are free of symptoms, usually the presence of the ulcer is characterized by epigastric pain, sometimes referred to as a sense of annoyance or hunger, but more often defined as deaf and constricting. In some cases the pain is located to the right of the median abdominal line, and may radiate to the right shoulder or to the dorsal and lumbar region.

This latter irradiation is often a sign of the deepening of the duodenal ulcer in the head of the pancreas. The pain typically appears from 1 hour and a half to 3 hours after the meal ( late postprandial ), and in more than half of the cases it causes the patient to wake up at night. The intake of food and antacid drugs, involves the resolution of the pain in a short time. There may be episodes of nausea and vomiting. The symptomatology tends to be episodic and recurrent.

Typical is its seasonal exacerbation in spring and autumn. Symptomatic periods lasting a few days or weeks alternate with remissions that can last several months or years.

Patients who are at the same time suffering from gastric ulcer and duodenal ulcer, usually have symptoms mainly referable to that of the duodenal ulcer.

Diagnosis

The differential diagnosis must be placed with gastritis, duodenitis, chronic inflammation of the gallbladder due to stones, biliary colic, pancreatic diseases and, rarely, with hepatitis.

Confirmation of the presence of duodenal ulcer is provided by endoscopic examination (gastroduodenoscopy) or by radiological examination with baritized meal.