History

Fact Explanation
Epigastric or right hypochondric pain or discomfort This is usually the primary complaint. Discomfort is mostly noted when the patient is hungry, it goes off for hour or two when patient consumes food. He may also experience recurrent upper abdominal pain during night, disturbing to sleep. Patient takes a glass of water, milk or a snack as it allows him to return to sleep[1]. Therefore such patients tend to gain weight. There may be radiation of pain to the back. This indicates ulcers which are posteriorly located and penetrating or irritating into the retroperitoneal tissues[1]. Acute abdominal pain indicates ulcer perforation[6].
Vomiting This is not a frequent finding as in gastric ulcers. However this can occur from time to time in duodenal ulcers even without pyloric stenosis. Vomitus contains partly digested food and clear gastric juice. Vomiting relieves abdominal discomfort, so some patients may perform self induced vomiting [1].
Spicy or greasy food tends to exacerbate symtoms Some patients complain that specific types of food exacerbates symptoms. This intolerance seems to be non specific regarding upper GI symptoms [1].
History of presence of etiologic factors Non steroidal anti inflammatory drugs (diclofenac, ibuprofen), steroids, smoking, Helicobacter pylori infection & high salt diet[2]. The risk is high in advancing age, male gender, alcohol abuse & debilitating comorbidities[5].
Upper GI bleeding: symptoms of upper GI bleeds are coffee ground emesis, hematemesis, black, tarry stools, abdominal pain and chest pain Peptic ulcers are responsible for 60% of upper GI bleeding in patients. Duodenal ulcers tend to erode into large vessels causing more bleeding [3].
Constitutional symptoms: weight loss, cachexia, malnutrition The inflammatory mass produces this type of constitutional symptoms and the clinician may suspect malignancy as the most likely diagnosis [4].
References
  1. GILLESPIE IE. Disease of the digestive system: duodenal ulcer. I. Br Med J [online] 1967 Nov 4, 4(5574):281-4 contd [viewed 05 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/4861387
  2. THORSEN K, SøREIDE JA, KVALøY JT, GLOMSAKER T, SøREIDE K. Epidemiology of perforated peptic ulcer: age- and gender-adjusted analysis of incidence and mortality. World J Gastroenterol [online] 2013 Jan 21, 19(3):347-54 [viewed 05 August 2014] Available from: doi:10.3748/wjg.v19.i3.347
  3. WILKINS T, KHAN N, NABH A, SCHADE RR. Diagnosis and management of upper gastrointestinal bleeding. Am Fam Physician [online] 2012 Mar 1, 85(5):469-76 [viewed 05 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22534226
  4. NEWTON EB, VERSLAND MR, SEPE TE. Giant duodenal ulcers. World J Gastroenterol [online] 2008 Aug 28, 14(32):4995-9 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18763280
  5. ETONYEAKU AC, AGBAKWURU EA, AKINKUOLIE AA, OMOTOLA CA, TALABI AO, ONYIA CU, KOLAWOLE OA, ALADESURU OA. A review of the management of perforated duodenal ulcers at a tertiary hospital in south western Nigeria. Afr H. Sci. [online] 2014 January [viewed 07 August 2014] Available from: doi:10.4314/ahs.v13i4.7
  6. CIENFUEGOS JA, ROTELLAR F, VALENTí V, ARREDONDO J, BAIXAULI J, PEDANO N, BELLVER M, HERNáNDEZ-LIZOAíN JL. [Giant duodenal ulcer perforation: a case of innovative repair with an antrum gastric patch]. Rev Esp Enferm Dig [online] 2012 Aug, 104(8):436-9 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23039806

Examination

Fact Explanation
Pulse may be normal or tachycardic It is usually normal in patients with duodenal ulcers but without upper GI bleeding. With severe bleeding patients become tachycardic[1]. In instances of perforated ulcers tachycardia is seen as well [4].
Blood pressure may be normal or hypotensive Normal in patients with duodenal ulcers but without upper GI bleeding. With severe bleeding and perforation of duodenal ulcer [4] a patient becomes hypotensive[1].
Pallor Patients with bleeding duodenal ulcers tend to develop anaemia [2].
Febrile This is a finding with perforated ulcer, particularly with late presentations. They develop septicemia, fluid & electrolyte imbalances, shock and/or Systemic Inflammatory Response Syndrome (SIRS) [3]. Patients appear to be very ill looking [4].
Epigastric tenderness and right hypochondrial guarding These are findings in possible ulcer perforation [4].
References
  1. WILKINS T, KHAN N, NABH A, SCHADE RR. Diagnosis and management of upper gastrointestinal bleeding. Am Fam Physician [online] 2012 Mar 1, 85(5):469-76 [viewed 05 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22534226
  2. NEWTON EB, VERSLAND MR, SEPE TE. Giant duodenal ulcers. World J Gastroenterol [online] 2008 Aug 28, 14(32):4995-9 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18763280
  3. ETONYEAKU AC, AGBAKWURU EA, AKINKUOLIE AA, OMOTOLA CA, TALABI AO, ONYIA CU, KOLAWOLE OA, ALADESURU OA. A review of the management of perforated duodenal ulcers at a tertiary hospital in south western Nigeria. Afr H. Sci. [online] 2014 January [viewed 07 August 2014] Available from: doi:10.4314/ahs.v13i4.7
  4. CIENFUEGOS JA, ROTELLAR F, VALENTí V, ARREDONDO J, BAIXAULI J, PEDANO N, BELLVER M, HERNáNDEZ-LIZOAíN JL. [Giant duodenal ulcer perforation: a case of innovative repair with an antrum gastric patch]. Rev Esp Enferm Dig [online] 2012 Aug, 104(8):436-9 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23039806

Differential Diagnoses

Fact Explanation
Functional dyspepsia[1] Patients with functional dyspepsia usually have a history of depression, anxiety and they tend to exhibit features of somatization [1].
Gastroesophageal Reflux Disease[1] Obesity, age, genetics, pregnancy, mechanical impairment of lower oesophageal junction contribute towards this[2].
Irritable Bowel Syndrome[1] Affects 5%- 20% of population. Symptoms range from diarrhea, constipation, abdominal pain and distention. Diagnosis is based on the Rome III criteria. [3].
Gastric ulcer[1] This also causes dyspeptic symptoms. Abdominal pain is exaggerated by food. Patients refuse food and lose weight.
Gastric cancer[1] Risk factors are: male gender, cigarette smoking, Helicobacter pylori infection, atrophic gastritis, partial gastrectomy, Menetrier's disease, genetic factors such as hereditary non polyposis colorectal cancer and familial adenomatous polyposis. [4].
References
  1. SPILLER RC. ABC of the upper gastrointestinal tract: Anorexia, nausea, vomiting, and pain. BMJ [online] 2001 Dec 8, 323(7325):1354-7 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11739225
  2. BOECKXSTAENS G., EL-SERAG H. B., SMOUT A. J. P. M., KAHRILAS P. J.. Symptomatic reflux disease: the present, the past and the future. Gut [online] December, 63(7):1185-1193 [viewed 06 August 2014] Available from: doi:10.1136/gutjnl-2013-306393
  3. EL-SALHY M. Irritable bowel syndrome: diagnosis and pathogenesis. World J Gastroenterol [online] 2012 Oct 7, 18(37):5151-63 [viewed 07 August 2014] Available from: doi:10.3748/wjg.v18.i37.5151
  4. JACKSON C., CUNNINGHAM D., OLIVEIRA J.. Gastric cancer: ESMO Clinical Recommendations for diagnosis, treatment and follow-up. Annals of Oncology [online] December, 20(Supplement 4):iv34-iv36 [viewed 08 August 2014] Available from: doi:10.1093/annonc/mdp122

Investigations - for Diagnosis

Fact Explanation
Upper GI endoscopy and biopsy These ulcers occur when there is a breech in GI tract mucosal barrier exposing it to the corrosive effects of gastric acid[1]. Endoscopy will show ulcerations in the duodenum, surrounded inflammation (edema, redness) and the size of the ulcer. Ulcers can be single or multiple [3]. Bleeding or perforation may be noted. It is necessary to take biopsies to exclude malignancy or any associated conditions such as: Coeliac disease.
Barium contrast radiography indications for this investigation are if endoscopy is unsuitable or not feasible such as in suspected gastric outlet obstruction [4].
References
  1. ETONYEAKU AC, AGBAKWURU EA, AKINKUOLIE AA, OMOTOLA CA, TALABI AO, ONYIA CU, KOLAWOLE OA, ALADESURU OA. A review of the management of perforated duodenal ulcers at a tertiary hospital in south western Nigeria. Afr H. Sci. [online] 2014 January [viewed 07 August 2014] Available from: doi:10.4314/ahs.v13i4.7
  2. ELTUMI M, BRUETON MJ, FRANCIS N. Ulceration of the small intestine in children with coeliac disease. Gut [online] 1996 Oct, 39(4):613-4 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8944575
  3. HUI WM, LAM SK. Multiple duodenal ulcer: natural history and pathophysiology. Gut [online] 1987 Sep, 28(9):1134-41 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3119434
  4. RAMAKRISHNAN K, SALINAS RC. Peptic ulcer disease. Am Fam Physician [online] 2007 Oct 1, 76(7):1005-12 [viewed 08 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17956071

Investigations - Fitness for Management

Fact Explanation
Hemoglobin Patients with bleeding duodenal ulcers tend to develop anaemia thus low hemoglobin levels[1].
Blood grouping and cross matching Bleeding duodenal ulcer patients may require urgent blood transfusions [2].
References
  1. NEWTON EB, VERSLAND MR, SEPE TE. Giant duodenal ulcers. World J Gastroenterol [online] 2008 Aug 28, 14(32):4995-9 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18763280
  2. LEE CW, SAROSI GA JR. Emergency ulcer surgery. Surg Clin North Am [online] 2011 Oct, 91(5):1001-13 [viewed 06 August 2014] Available from: doi:10.1016/j.suc.2011.06.008

Investigations - Screening/Staging

Fact Explanation
Helicobacter pylori testing with ELISA This is used for initial testing, but can not be used to confirm eradication. Sensitivity- 85%, specificity- 79%[1].
Urea breath test for H.pylori This is more expensive. Sensitivity- 95%- 100%, specificity- 91% - 98%, can be used to confirm eradication[1].
References
  1. RAMAKRISHNAN K, SALINAS RC. Peptic ulcer disease. Am Fam Physician [online] 2007 Oct 1, 76(7):1005-12 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17956071

Management - General Measures

Fact Explanation
Lifestyle modification: stop smoking and stress management Smoking delays the healing of ulcer and it increases the incidence of ulcer recurrence. Stress is also a cause; ulcers are seen after acute illness, multi organ failure, extensive burns and head illness. So education on stress management can be helpful. [2]
Dietary modification: increase dietary fibers and Vitamin A intake Additional dietary fiber intake reduces the risk of recurrence. Food types with high soluble fibers (orange, carrots, beans) are more effective reducing duodenal ulcer risk. Vitamin A intake has shown some benefit[ 1].There is evidence that fatty food, a high protein intake, consumption of alcohol and caffeine are possible etiological factors. [1]
References
  1. RYAN-HARSHMAN M, ALDOORI W. How diet and lifestyle affect duodenal ulcers. Review of the evidence. Can Fam Physician [online] 2004 May:727-32 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15171675
  2. RAMAKRISHNAN K, SALINAS RC. Peptic ulcer disease. Am Fam Physician [online] 2007 Oct 1, 76(7):1005-12 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17956071

Management - Specific Treatments

Fact Explanation
Proton Pump Inhibitors (PPI) These drugs block the final path of gastric acid release. Though PPI has less side effects when use in short causes, long term use has side effects as hip fracture, iron deficiency anaemia, enteric infections and pneumonia. [1].
Eradication of Helicobacter pylori infection with triple therapy Duodenal ulcer is a H.pylori related illness; main causative factor is acid and pepsin load increase[4].
Management of bleeding duodenal ulcers initial management should be to obtain IV access, ensure availability of blood for possible transfusion, fluid resuscitation with crystalloid solutions or blood if there is evidence of significant blood loss. Usually this bleeding will stop on its own. Only 5%- 10% patients need surgery to overcome bleeding. Risk assessment scores like Blatchford score, Rockall score are used to decide on further interventions [2].
Endoscopic interventions: Upper GI endoscopy This is the most important step in managing bleeding ulcers. Via endoscope procedures can be done to achieve clotting such as clipping, sclerosant injection and thermal contact. [2]
Surgery: over sewing the ulcer plus truncal vagotomy and pyloroplasty If an ulcer causes recurrent bleeding, but it fails to respond endoscopic interventions then surgical or radiological treatment is indicated. [3].
Surgery: Duodenectomy In this procedure the surgical approach is to remove the bleeding part [3].
Surgery: Ligation of the bleeding vessel with non-absorbable suture This will arrest further bleeding [3].
Interventional angiography: TAE (Transarterial Embolisation) Before this intervention the bleeding location can be identified during endoscopy. Depending on this suspected location the responsible artery (coeliac artery, superior mesenteric or inferior mesenteric artery) can be filled with contrast. Once the bleeding site is precisely identified a vasoconstrictive (vasopressin) medication is infused or else embolisation is done. Material used are gelatin sponges, poly vinyl alcohol or liquid agents like N-butyl 2 cyanoacrylate (NBCA)[3].
Management of perforated duodenal ulcer This is a common surgical emergency. Mortality and morbidity rates are high. Surgical repair is done either laparoscopically or as an open surgery. Techniques used to repairing are: primary closure, primary suture with pedicled omental flap, pedicled omental flap sutured into the perforation -Cellan- Jones repair, free omental plug sutured into perforation- Graham patch, use of three long tailed sutures to close perforation & buttress with an omental flap, use of tracking sutures around the perforation[6].
Supportive treatment for perforated duodenal ulcers Following the diagnosis antibiotics should be started after taking blood cultures. Do not stop antibiotics soon after surgery. Sometimes vagotomy is performed during surgery , so eradication of H.pylori is necessary. Long term antacid treatments are also needed as perforation recurrence in known to occur in 12%of patients [6].
References
  1. AMENT PW, DICOLA DB, JAMES ME. Reducing adverse effects of proton pump inhibitors. Am Fam Physician [online] 2012 Jul 1, 86(1):66-70 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22962914
  2. LEE CW, SAROSI GA JR. Emergency ulcer surgery. Surg Clin North Am [online] 2011 Oct, 91(5):1001-13 [viewed 06 August 2014] Available from: doi:10.1016/j.suc.2011.06.008
  3. CRAENEN EM, HOFKER HS, PETERS FT, KATER GM, GLATMAN KR, ZIJLSTRA JG. An upper gastrointestinal ulcer still bleeding after endoscopy: what comes next? Neth J Med [online] 2013 Sep, 71(7):355-8 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24167833
  4. LEE SW, CHANG CS, LEE TY, YEH HZ, TUNG CF, PENG YC. Risk factors and therapeutic response in Chinese patients with peptic ulcer disease. World J Gastroenterol [online] 2010 Apr 28, 16(16):2017-22 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20419840
  5. ABLES AZ, SIMON I, MELTON ER. Update on Helicobacter pylori treatment. Am Fam Physician [online] 2007 Feb 1, 75(3):351-8 [viewed 06 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17304866
  6. SøREIDE K., THORSEN K., SøREIDE J. A.. Strategies to improve the outcome of emergency surgery for perforated peptic ulcer. Br J Surg [online] December, 101(1):e51-e64 [viewed 09 August 2014] Available from: doi:10.1002/bjs.9368