Duodenal ulcer

Duodenal ulcer--- Definition

A circumscribed ulceration of the
duodenal mucosa occurring in
areas exposed to acid and pepsin
and most often caused by
Helicobacter pylori infection.
 Normally acid/pepsin attack is
balanced by mucosal defences
Increased attack by hyperacidity
1. H Pylori Weakened mucosal defence – food,
infections alkaline duodenal fluid, mucus
2. Alcohol
3. Smoking
1. Drugs (Aspirin,
4. Diet
2. NSAIDs,
3. corticosteroids).
4. Stress
5. Genetic factors-blood group O
6. Diseases (Zollinger Ellison
Syndrome).
 Duodenal Ulcers
 Duodenal ulcers are 4 times as common as
gastric ulcer
 most common in middle age
 peak 30-50 years

 Male to female ratio—4:1

 Genetic link: 3 times more common in 1st degree
relatives
 Duodenal Ulcers
 More common in patients with blood group O
 Associated with increased serum pepsinogen &
Gastrin
 H. pylori infection common up to 95%
 Smoking is twice as common
 Duodenal ulcer-Pathology
 Duodenal ulcer usually lies in first part of
duodenum its floor formed by muscular
layer
 Anteriorly may penetrate liver or perforate.
 Posteriorly may penetrate into pancreas
 Bleeding due to erosion of gastro duodenal
vessels
 Duodenal ulcer
Clinical feratures

1. Localized and right hypochondriac pain.

2. Pain in empty stomach
3. Early morning pain
4. Pain is relieved on taking food
 Characteristic pain of
Duodenal ulcer
5. Relieved by antacids
6. Relieved by vomiting (spontaneous or
induced later by duodenal obstruction)
7. Periodicity. symptom free interval 2-
6 months, often seasonal variation,
8. Hematamesis or melena,(40%-
60%)
9. Initially appetite is good and weight
gain later weight loss due to
vomiting caused by obstruction.
 Duodenal ulcer
Abdominal examination

Duodenal point

1. Abdominal examination is usually normal

2. Sometimes tenderness in duodenal point
3. Sometimes signs of complications
 Duodenal ulcer
Symptoms of complications

 Bleeding
 Overt haematemesis and/or melaena

 Black tarry stools

 Hypotension/tachycardia if acute
bleeding
 Pallor due to anaemia (iron deficiency

 anaemia) if chronic bleed

 Duodenal ulcer
Symptoms of complications

 Obstruction
 Abdominal pain not related to food and
continuous pain
 Projectile vomiting of undigested food,

 VGP,

 Succession splash
 Duodenal ulcer
Symptoms of complications

 Perforation
 Sudden onset of acute abdominal pain

 Liver dullness obliterated

 Signs of peritonitis

 surgical emergency
OUTLINE OF MANAGEMENT:

•INVESTIGATIONS.
•TREATMENT
Duodenal ulcer-Investigations

 Investigations to diagnose ulcer

1. Gastric function tests
2. Barium meals series
3. Upper GI endoscopy
Gastric function tests
1. Pentagastrin test
2. Key’s augmented histamine test
3. Hollander insulin test(insulin test)
4. The Diagnex-Blue Test
5. 24 hours gastric pH monitorng
6. Serum gastrin level estimation
7. Fractional test meal
8. Radio isotope labeled gastric emptying
study
 Histalog or pentagastrin
test:
• Basal acid output (BAO) is determined by
measurement of acid in 2-4 specimens
collected 15 minute interval before
stimulation.
• Maximal acid output (MAO) is determined
by measurement of acid in 4 specimens
collected at 30 minute interval after
stimulation.
 Pentagastrin test
 Pentagastrin test, (for gastric function) a test
comparing basal acid output with a peak acid
output.
 After the patient fasts overnight,
 a nasogastric tube is inserted under fluoroscopy
so that the tip lies in the antrum of the stomach
 a basal acid output and its pH are obtained for
secretion of stomach acid.
 Histalog or pentagastrin (6 microgram/kg body
weight injected subcutaneously /IM.)
 Serum gastrin,
Gastric juice volume & pH

Condition serum gastrin volume acid

(pg/ml) ml/12 hours output/ pH
Normal < 500 (pg/ml) 20-100 . 15-25 mEq/lt 2
Duodenal ulcer 300 - 500 (pg/ml) >400 40-80mEq/lt <2
Gastric ulcer 300 - 60,000 (pg/ml) 50-100 5-15mEq/lt >2

Z.E. syndrome 3,500 - 60,000 (pg/ml) >1500 100-3000mEq/lt <1

Duodenal ulcer -Investigations
 For complications
 Hb
 Faecal occult blood
 Investigations for H. Pylori infection
 Serology, biopsy, urease breath test
 Investigations to rule out other possible
diagnoses
 Liver ultrasound
 Important investigations
 Upper Gastro-intestinal radiography.
 With double contrast 80-90% can be
diagnosed.
 Upper gastrointestinal endoscopy
 Upper gastrointestinal
endoscopy
 Diagnose duodenal ulcer
 To see complications like
hemorrhage
 To stop bleeding using laser
 Barium meal series
Duodenal ulcer
 Duodenal cap deformity
(Trifoliate appearance
Clover shaped deformity)
 Duodenal stenosis
 Duodenal ulcer
 Diagnosis of h.pylori infection
 Urease breath test,(NH4+CO2)
 IgG.IgA
 Brush cytology of gastric mucosa,
 Biopsy of gastric mucossa.
 Duodenal ulcer
 Investigations for
perforation
 CHEST X Ray (erect),
gas under diaphram
 ABDOMEN.(supine/later
al view)
 Duodenal ulcer
hemorrhage

 Coelic artery
angiography-
embolisation.
 radio-isotope scan
Duodenal ulcer

 Stop
 smoking,
 alcohol,
 NSAID’s
 Other interventions
 Diet modification ??
 Stress modification ??
 Duodenalulcer – Drug Therapy
Raising gastric pH

Antacids Inhibitors of acid secretion

oxethazaine 20 mg
aluminium hydroxide 250 mg,
magnesium trisilicate 250 mg,

H2 antagonists Proton pump inhibitors

Ranitidine 150 mg BD before Pantaprozole 40mg / BD before
meals x 14 days meals x14 days

Mucosal protection
1.Bismuth subcitrate 240 mg bid or 120 mg qid/4wk
2.Sucralfate 1 gm QID x 28 days
3.Misoprostol H.Pylori eradication
NSAID-associated ulceration800 mcg/day HP-KIT Combi-kit: 1BD for 14 days
in 2-4 divided doses for 4-8 wk. omeprazole (EC) 20 mg,
amoxicillin 750 mg,
tinidazole 500 mg.
Duodenal ulcer ---STENOSIS.

••TREATMENT
 Doudenal Ulcer :
indications for elective operation

 Failure to heal on optimal medical therapy

 Distal gastric obstruction
 Hematamesis
 Perforation
 SURGICAL TREATMENT

 OPERATIONS FOR UNCOMPLICATED

DUODENALULCERS –
1. Highly Selective Vagotomy,
2. Truncal vagotomy with drainage procedure
(gastro jejunostomy, Pyloroplasty.
3. Truncal vagotomy with antrectomy with
Billroth I anastamosis
 Types of vagotomy

1.Truncal Vagotomy
2.Selective Vagotomy
Hepatic division preserved

Nerve of Letarjet is preserved

“Crow’s foot”

3.Highly selective Vagotomy

 Vagotomy with Antrectomy &
Billroth I Gastro duodenostomy

Rarely Billroth II / Polya gastrectomy

 Drainage procedures :pyloroplasty
Finney
Heineke-Mikulicz
Duodenal Ulcer : indications for operation

 Intractability
 Perforation
 Obstruction
 Hemorrhage
 Bleeding duodenal ulcer :
operative procedures

 Endoscopic clip application or laser

 Simple over sewing with
 TV and antrectomy
 Drainage procedure with or without
truncal vagotomy
 Duodenal ulcer -- Perforation

Most often chronic ulcer

50%: sealed off X-chest / abdomen in
Site:most often anterior, juxtapyloric upright position
Mean diameter: 5mm (>1cm=giant If negative:CT with oral
ulcer: rare) contrast
Clinical features ; perforated duodenal
ulcer

 Symptoms ;
 sudden onset of severe epigastric pain
spreading throughout the abdomen,
 variable degree of shock
 Signs ;
 abdominal tenderness, rigidity
 Liver dullness obliterated
 Plain X-ray ; gas under diaphragm
 Duodenal ulcer –perforation surgery

1.Simple closure with Graham’s patch

2.Simple closure with Graham’s patch with

definitive surgery
a) parietal cell vagotomy
b) truncal vagotomy and pyloroplasty
c) truncal vagotomy and antrectomy
 Duodenal ulcer –perforation surgery
1.Simple closure with Graham’s patch
Duodenal ulcer –perforation surgery

2.Simple closure with Graham’s patch

with definitive surgery
a) parietal cell vagotomy
b) truncal vagotomy and pyloroplasty
c) truncal vagotomy and antrectomy
Complications of treatment
 Complications of vagotomy.
1.post-vagotomy diarrhoea.
2.delayed gastric emptying.
3.gallstones (truncal vagotomy).
 Complications of gastrectomy.
1.dumping syns (both early &late).
2.bilious vomitting (afferent loop syn)
3.small stomach syn.nutritional defficiencies (wt. loss,
iron, vitamin B12, osteoporosis).
4.gastric stump malignancy