Treatment of Duodenal Ulcer

Most common symptom caused by duodenal ulcer is pain. Pain caused by duodenal ulcer is initially treated with medications. Rarely ulcer perforate in to surrounding peritoneal space. Occasionally following perforation of ulcer through the duodenal wall, the track is formed between one of the surrounding organ and duodenal lumen. The track is known as fistula. The pain become extremely severe because of fistula and peritonitis. The treatment of such complication often needs hospitalization and surgery. The cost of treatment of chronic non healing duodenal ulcer can be substantial. The out of pocket cost because of co-pays and deductible become unbearable for some families when surgical treatment and hospitalization is necessary. The complications of duodenal ulcer can be prevented by discontinuing smoking and chronic alcohol consumption. Preventive therapy is essential to prevent complications. Healing of duodenal ulcer is faster if individual stops smoking or drinking alcohol. The treatment of duodenal ulcer in most cases includes medication and in few cases invasive procedure is essential. Invasive procedures performed to treat duodenal ulcer and its complications are endoscopy and surgery.

Treatment of Duodenal Ulcer

Conservative Treatment for Duodenal Ulcer

Treatment of Helicobacter Pylori Infection-

Early initiation of antibiotics prevents severe gastric inflammation and duodenal ulcer formation caused by Helicobacter Pylori bacteria.

Antibiotics- H. Pylori bacteria often causes duodenal ulcer. The presence of H. Pylori infection is diagnosed by urea breath Test. Once the diagnosis is confirmed then the infection is treated with selective antibiotics. The most common antibiotics used are tetracycline, and amoxicillin. In few resistant cases culture and antibiotic sensitivity test are performed. Then the effective antibiotics selected are metronidazole (Flagyl) and levofloxacin (Levaquin).
 The course of treatment is 10 to 14 days.

Treatment of Chronic Pain Caused By Duodenal Ulcer

  1. Treatment to Neutralize Acid Content Of Gastric Juice

    Duodenal ulcer pain becomes predominant problem when pain interferes with sleep. In most cases duodenal ulcer pain becomes severe during the middle of sleep and patient is unable to sleep. Antacids helps to feel immediate pain relief. Immediate pain relief is observed after taking one to two pills of antacids. The long term pain relief and healing of duodenal ulcer is achieved by reducing the acid secretion.

    Antacids- Antacids are sold over the counter and does not need any prescription. Antacids are alkaline in nature and alkaline molecules neutralizes the acid content of gastric juice. The pain caused by duodenal ulcers subsides when acid content of stomach juice is neutralized within stomach prior to its contact with duodenal mucosa. Antacids are taken in liquid form or chewable pills. Antacids are sold as aluminum hydroxide, magnesium carbonate and magnesium tricilicate. Antacids also cover the mucosal lining of duodenum resulting in protection of mucosa. Antacids prescriptions are avoided during first trimester and children under 12 years' age. Side effects observed are bowel cramps, diarrhea or constipation.

  2. Treatment to Reduce Acid Secretion in Stomach-

    The two class of medications, which are effective in reducing acid secretions are H2 receptor blocker and proton pump inhibitors. H2 receptor inhibitors reduces the secretion of histamine and thus decreases secretion of hydrochloric acid by proton pump, which lies within the ECL cells. Decreased histamine secretion reduces hydrochloric acid secretion. Similarly, proton pump inhibitors stop the proton pump to secrete hydrochloric acid.

    Enterochromaffin-like cells or ECL cells secretes hydrochloric acid using proton pump. ECL cells are embedded within gastric (stomach) mucosal endothelial cells. The histamine is released from the vesicles situated within the gastric mucosal cells. Histamine then stimulates the ECL cells to secrete hydrochloric acids. The histamine is also released when hormone gastrin stimulates certain receptors over the surface of the gastric mucosal cell. Histamine release is also caused by vagal nerve stimulation.

  1. H2 receptor Inhibitors- H2 receptor stimulation of cells of gastric mucosa causes increase secretion of histamine. Histamine stimulates proton pump located within Enterochromaffin-like cells or ECL cells. Proton pump secretes hydrochloric acid. H2 receptors antagonist block these receptors, which triggers secretion of histamine. Decrease secretion of histamine follows decrease secretion of hydrochloric acid. H2 receptor inhibitors most often prescribed are famotidine (Pepcid), cimetidine (Tagamet HB) and nizatidine (Axid AR). Side effects that may observed are nausea, diarrheaheadache and dizziness. The medication is not prescribed during first trimester in pregnant mother and children under 12 years of age.
  2. Proton Pump Inhibitors 1- Cascade of enzyme system within ECL cells when activated causes secretion of hydrochloric acid. This enzyme system within the ECL cells is known as proton pump. Enzyme system is also known as hydrogen/potassium adenosine triphophatase or AT Pase proton pump. Deactivation of proton pump stops production of hydrochloric acid. The single prolong course of treatment often permanently stops secretion of hydrochloric acid by gastric mucosa. In few cases of patient suffering with duodenal ulcer treatment may need to be repeated on and off for long time. The most common proton pump inhibitors used are omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium) and pantoprazole (Protonix).


Surgical Treatment of Duodenal Ulcer

The choice of surgical treatment is endoscopic surgery, laparotomy and laparoscopic surgery. The endoscopic surgery involves passing of tubular camera through mouth into duodenum. Laparotomy surgery is performed by taking skin incision of length 4 to 6 cm over the skin lying above the duodenum next to umbilicus. The surgery is performed under direct vision. Laparotomy surgery is performed by very small incision less than 1 cm in length. The laparotomy tubular camera is passed through the incision into abdominal cavity. All the surgeries are performed under anesthesia and safe.

  1. Endoscopic Surgery: Less Invasive Treatment for Duodenal Ulcer

    Endoscopic procedure using endoscope is performed for diagnosis as well as treatment of duodenal ulcer. Endoscopic procedure is most preferred procedure for stoppage of bleeding duodenal ulcer. Sometime duodenal ulcer bleeding can be life threatening and endoscopic cauterization helps to stop bleeding. Endoscopic procedure is less invasive and safe.

    1. Endoscopic Surgery to Stop Bleeding from Duodenal Ulcer- The procedure is performed to stop mild or life threatening bleeding from duodenal ulcer. The tubular long camera passed through mouth into stomach and duodenum. The duodenal ulcer is identified either viewing the duodenal mucosa through eye piece or camera. The cauterizing electrode is passed along the endoscope following recognition of duodenal bleeding ulcer. The edges and body of ulcer is cauterized with precaution not to perforate the ulcer.
    2. Endoscopic Repair of Perforated Duodenal Ulcer 2- Recently several major teaching institution and hospitals are performing endoscopic surgery to close the perforated Duodenal Ulcer. The perforated ulcer is identified using endoscope. The bleeding is cauterized and the perforated duodenal ulcer wall is closed with absorbable sutures using special tubular suture tying equipment.
  2. Laparotomy Surgery

    Symptomatic multiple duodenal ulcer not responding to oral medication are treated with surgery. Surgical choice involves removal of acid producing stomach and ulcerated duodenum. Surgery is often also combined with removal of vegas nerve known as vagotomy. The indication for surgery is continuous duodenal ulcer pain not responding to conservative treatment and bleeding. The stomach is divided in 3 parts as lesser curvature, greater curvature and pylorus. The acid producing gastric cells are mostly present in lesser curvature of stomach. The pylorus is formed by thick bundle of muscles.

    1. Billroth I Gastrectomy 3- This surgery involves removal of part of lesser curvature and pylorus. Remaining stomach consist of greater curvature, which is anastomosed or connected to duodenum. Surgery helps to reduce acid secretion and also reduces gastric emptying time. The duodenal mucosa is now exposed to gastric acid containing food.
    2. Billroth II or Pólya gastrectomy 4- Billroth II is modified Billroth I surgery. Like Billroth I lesser curvature and pylorus is removed, the greater curvature of stomach is anastomosed to side of jejunum instead duodenum. The open end of duodenum is closed by sutures and duodenal stump is left attached to jejunum. The procedure removes acid producing stomach and pylorus. The acidic gastric content passes into jejunum and duodenum. The duodenal mucosa is now not exposed to acidic gastric content like following Billroth I surgery.
    3. Highly Selective Vagotomy- The hyperactive parasympathetic nervous system in patient suffering with anxiety or stress results in repeated stimulation ECL cells by vegas nerve. The parasympathetic stimulation of ECL nerve follows increased secretion of histamine, which activates proton pump to secretes hydrochloric acid. The removal of selective vegas nerve to stomach and duodenum eliminates the persistent secretion of hydrochloric acid by ECL helps. The decreased concentration of acid in gastric content helps to heal the duodenal ulcer and also prevent new peptic ulcer formation. The selective vagotomy involving removal of nerve to stomach, duodenum and part of jejunum is known as highly selective vagotomy.
    4. Truncal Vagotomy and Pyloroplasty- The contraction of muscles of pylorus of stomach closes the passage between stomach and duodenum for 2 to 3 hours to complete the initial digestion process by stomach. So gastric emptying time is delayed after food for 2 to 3 hours. Pyloroplasty surgery involves longitudinal incision of wall of pylorus muscles that excludes mucosa. The muscle wall is then closed with transverse suture so after wound is healed pylorus muscle contraction does not close the stomach lumen at pylorus, thus food can pass through pylorus into duodenum. The surgery is effective and prevents several side effects, which are observed after Billroth surgeries.
    5. Surgery involves removal of vegas nerve and cutting of pylorus muscles to eliminate sphincter function of pylorus. Vagotomy reduces acid production and pyloroplasty fastens gastric emptying of acidic food.
  3. Laparoscopic Surgery for Perforated Duodenal Ulcer5,6

    The perforated duodenal ulcer causes peritonitis and may result in fistula formation. The prompt diagnosis of perforation of duodenal ulcer and its closure as a treatment is very important to prevent fistula formation. Perforation is identified faster with laparoscopy. Laparoscopic surgery is performed using laparoscope. Laparoscope is a tubular camera just like endoscope often larger in diameter. The surgeon sees the organs and other structures within abdominal cavity through the eye piece or over the television screen when eyepiece of the camera is connected to television by monitor capturing device. The laparoscope is passed through the skin incision made over abdomen close to umbilicus. The tip of the laparoscope contains camera. The laparoscope is passed into abdominal cavity. The tip of the camera of laparoscope is moved within the abdominal cavity until the perforation of duodenum is identified and localized. Once the ulcer is located then various other equipment are used to isolate the ulcer from other abdominal organs and opening of the ulcer (perforation) is closed with sutures. Abdominal cavity irrigated with antibiotic solution to treat the peritonitis.

Alternative Therapy for Treating Duodenal Ulcer

Alternative therapy is effective in reducing acid production and histamine released. Alternative therapy is beneficial in patient who may suffer with mild form of ulcer. Stoppage of alcohol consumption and smoking helps in reducing frequency of ulcer formation. Some of the substances like honey, garlic, cranberry, turmeric, mastic and cabbage helps to cure ulcer when used with antacids and acid reducing medications.

Also Read:

Reference:

  1. The appropriate use of proton pump inhibitors (PPIs): Need for a reappraisal.
    Savarino V1, Dulbecco P2, de Bortoli N3, Ottonello A4, Savarino E5.
    Eur J Intern Med. 2016 Oct 23. pii: S0953-6205(16)30362-4.

  2. Endoscopic control of upper gastrointestinal bleeding.
    Himal HS., Can J Surg. 1985 Jul;28(4):305-8.
    https://www.ncbi.nlm.nih.gov/pubmed/3893665

  3. BILLROTH I RESECTION FOR DUODENAL ULCER.
    BARCLAY S. Aust N Z J Surg. 1964 Nov;34:147-51.
    https://www.ncbi.nlm.nih.gov/pubmed/14218949

  4. THE TREATMENT OF DUODENAL ULCER BY VAGOTOMY, ANTRECTOMY, AND BILLROTH I ANASTOMOSIS.
    MARTIN GH., J Miss State Med Assoc. 1963 Dec;4(12):523-9.
    https://www.ncbi.nlm.nih.gov/pubmed/14134091

  5. Laparoscopic surgical technique for perforated duodenal ulcer.
    Rebibo L1, Darmon I2, Regimbeau JM2., J Visc Surg. 2016 Apr;153(2):127-33.
    https://www.ncbi.nlm.nih.gov/pubmed/26972898

  6. Laparoscopic Surgery for Perforated Duodenal Ulcer Disease: Analysis of 70 Consecutive Cases From a Single Surgeon.
    Kim MG1. Surg Laparosc Endosc Percutan Tech. 2015 Aug;25(4):331-6.
    https://www.ncbi.nlm.nih.gov/pubmed/25799260

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: November 3, 2016

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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