Duodenal ulcer

A duodenal ulcer is a loss of substance from the mucosa of the duodenum that extends, at least, to the muscularis mucosa.

This ulcer can be acute, of short evolution, or chronic, of longer duration, in which it is possible to observe the fibrous reaction to continued acid aggression, which when it is very intense causes the ulcer to be called callus. The chronic ulcer shows periods of exacerbation, which alternate with others of calm. In acute periods, the lesion can advance beyond the muscular mucosa and injure the muscular and serous layer of the duodenum and become perforating in the peritoneal cavity or penetrating into a neighboring organ: pancreas, liver, colon.

Duodenal ulcers are preferably found in the transition zone between mucosa with pyloric glands, typical of the antrum, with mucosa with Brunner’s glands, typical of the duodenum. This transition zone is most frequently located in the first portion of the duodenum, but it can also be found in the pylorus or in the prepyloric zone.

It is more frequent in men than in women, although in recent times the differences have been reducing. It affects between 35 and 44 years.

Causes of duodenal ulcer

There are several factors associated with the production of duodenal ulcer:

Serum gastrin: Basal gastrin in these patients is normal, but they secrete more gastrin in response to food, secrete more acid to a gastrin injection, and empty their stomach more quickly.

Genetic factors: 20-50% family history of duodenal ulcer. It is related to blood group O and various histocompatibility antigens.

H. Pylori: it is the most important factor that produces duodenal ulcer.

Non-steroidal anti-inflammatory drugs.

Other factors:

• Systemic mastocytosis.
• Myeloproliferative syndromes with basophilia.
• Chronic renal insufficiency.
• Alcoholic cirrhosis .
• Kidney transplant.
• Hyperparathyroidism
• COPD.
• Vascular insufficiency.
• RT ( radiation therapy ) and QT (chemotherapy).
• Cystic fibrosis.
• Alpha 1-antitrypsin deficiency.
• Nephrolithiasis.
• Sd. by Zollingen-Ellison.

Every ulcer is a consequence of the breakdown of the balance between aggressive agents, mainly hydrochloric acid, and the defense mechanisms of the mucosa. In duodenal ulcer, an increase in secreted volume and acid concentration is considered essential

The causes of duodenal ulcer are:

• Neurogenic acid hypersecretion.
• Hypersecretion of gastrin hormones.
• Increase in the mass of hydrochloric acid-secreting parietal cells.
• Defective acid neutralization in the duodenum.
• Decreased duodenal resistance. The mucosal barrier can be damaged by mucolytic agents, such as aspirin, cortisone, and alcohol.

Duodenal ulcer symptoms

The duodenal ulcer causes pain in the epigastrium. The chronology of the pain is important: it appears on an empty stomach, calms down with food, and appears and reappears after 2-3 hours. of the same, and is relieved with the ingestion of foods or alkalis. It is classic that the patient wakes up at 2 or 3 in the morning with pain that subsides with the ingestion of a glass of milk or alkalis, allowing him to sleep for the rest of the night.

At first the ulcer causes pain every 2-3 months, which then disappears, although the ulcer persists, to return after a long period of calm.

Usually the periods of pain coincide with the arrival of spring and fall.

As the ulcer becomes chronic, the periods of pain lengthen and those of calm are shortened.

Associated symptoms are: feeling of heartburn, nausea, regurgitation, heartburn, intolerance for some foods (tomato juice, foods with spices, alcohol, coffee, etc.).

How is it diagnosed?

After suspicion due to the symptoms, various studies should be carried out:

Gastroduodenal radiological studies: the conventional ones with contrast are obsolete; Double contrast techniques should be performed whose diagnostic safety is close to that of endoscopy.

Endoscopy: it is the safest diagnostic method; it is indicated when:

• Suspicion of a duodenal ulcer that is not visible radiologically.
• Bulbar deformity.
• Ulcers that are too small or too superficial that may go unnoticed by radiology.
• If duodenal ulcer presents as upper gastrointestinal bleeding (UGH).

Gastrin studies when:

• Surgery is scheduled.
• Gastrinoma is suspected.

Investigate for H. Pylori infection.

Duodenal ulcer treatment

Medical treatment is carried out with:

• Antacids; They are useful used one and three hours after meals and at bedtime.
• Hydrochloric acid secreting parietal cell H2 receptor antagonists.
• Anticholinergics.
• Protective agents of the gastric mucosa.
• Synthetic prostaglandins that act on the one hand as antisecretory agents and on the other hand by increasing the resistance of the mucosa through a stimulation of mucus secretion,
• stimulation of bicarbonate secretion and increased blood flow in the gastric mucosa.
• Proton pump inhibitors (omeprazole, pantoprazole). It is the most effective drug for the treatment of duodenal ulcer (duodenal ulcer), being its action of 24 hours.

Surgical treatment is performed when:

• duodenal ulcer resistant to medical treatment.
• Intratability based on subjective criteria.
• Complications (bleeding, perforation, penetration and obstruction).

The procedure of choice is supraselective vagotomy.

How can I avoid it?

It appears mainly in people subjected to great stress so it should be avoided, carrying out various relaxation measures.

The consumption of tobacco, alcohol, NSAIDs and corticosteroids should be avoided.

It is necessary to go to the doctor: when epigastric discomfort appears that subside with the intake of food and alkalis; when such pain awakens you at night and when there is blood in vomit or stool.