Duodenal ulcer

Epidemiology

Duodenal ulcer is 4-10 times more frequent than 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 about 10% of the population develops a duodenal ulcer during their life.

Causes

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

Many patients with duodenal ulcer have impaired gastric emptying. In these cases, if the passage of acid chyme into the duodenum occurs too rapidly, the local buffering capacity can be overcome and the duodenal mucosa is excessively exposed to acid. This is aggravated by the fact that in patients with duodenal ulcer the secretion of bicarbonate in the duodenal mucus is considerably reduced. 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 corticosteroids can play an important role, with a mechanism not yet fully understood. Cigarette smoking is associated not only with a higher incidence of duodenal ulcer, but also with a reduced response to therapy, for example. a greater number of distant relapses and a higher mortality in case of complications. There is however no evidence of a relationship between alcohol consumption and the appearance of duodenal ulcer. The importance of psychological factors is controversial; however, it seems that anxious personalities are more exposed to the risk of ulcer also at the duodenal level. The role of family predisposition appears particularly important. This occurs with a triple frequency in first-degree relatives of ulcerative subjects compared to the general population and, as in the case of gastric ulcer, subjects of blood group 0 are particularly exposed. 85% of subjects with duodenal ulcer. The inflammatory alterations induced by this bacterium could make the duodenal mucosa more sensitive to the acid insult, thus predisposing to the onset of the ulcer.

Form and localization of the ulcerative lesion

95% of duodenal ulcers are located in the duodenal bulb, within 3 cm of the pylorus. The anterior wall of the bulb is the site most frequently affected; the posterior wall and the upper and lower margins of the bulb follow in order of frequency. The average diameter of duodenal ulcers is about 1 cm. The morphology is similar to that of gastric ulcer. Complications are haemorrhage, perforation and stenosis (occlusion); the possibility of evolution into 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 easily perforate.
The ulcers of the posterior wall of the bulb, on the other hand, tend to penetrate 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 bleeding complications of duodenal ulcer can be fatal, because the deepening of the ulcer can lead to the erosion of important arterial branches

Symptoms and Diagnosis

For further information: Duodenal Ulcer Symptoms

Although some patients with active duodenal ulcer are symptom-free, the presence of the ulcer is usually characterized by epigastric pain, sometimes referred to as a sense of discomfort or hunger, but more often referred to as dull and constricting. In some cases the pain is localized. to the right of the mid-abdominal line, and may radiate to the right shoulder or to the dorsal and lumbar region.
This last irradiation is often a sign of the "deepening" of the duodenal ulcer in the head of the pancreas. Pain typically appears 1.5 to 3 hours after eating (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 leads to the resolution of pain in a short time. There may be episodes of nausea and vomiting. Symptoms tend to be episodic and recurrent.
Typical is its seasonal flare-up in spring and autumn. Symptomatic periods lasting a few days or weeks alternate with remissions that can last several months or years.
Patients with simultaneous gastric and duodenal ulcer usually present symptoms mainly referable to that of duodenal ulcer.

Diagnosis

The differential diagnosis should be made 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 barium swallow.