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Duodenal ulcer – Symptoms and causes

Publisher/Author : Pacific Cross

Duodenal ulcer - Symptoms and causes


What is duodenal ulcer?

A duodenal ulcer is an open sore in the lining of the duodenum, the first part of the small intestine, that lies immediately distal (after) the stomach. The broad term for ulceration in the stomach or duodenal lining is peptic ulcer disease. Most of the causes of stomach ulcers are also responsible for the development of duodenal ulcers.

The duodenum has an inner epithelial lining, known as the mucosa. It is made up of simple columnar cells and also contains specialized cells that produce mucus and a few digestive enzymes.

With duodenal ulcers, the mucosa is eroded revealing the underlying layers like the submucosa and in severe cases, an ulcer may perforate the duodenal wall.

The duodenum has its own protective mechanisms against gastric acid in addition to a mucus barrier like the stomach. When acidity is detected in the duodenum, the pancreatic ducts secrete a combination of water and bicarbonate ions to neutralize the gastric acid in the duodenum.

Digestive hormones like secretin are also released into the blood stream to slow down gastric emptying thereby allowing the duodenum to cope with smaller quantities of gastric acid. The epithelial cells can also actively pump out hydrogen ions from the duodenal lumen, further reducing the acid content.

How common is duodenal ulcer?

Duodenal ulcers are more common than stomach ulcers and are usually a solitary (single) ulcer. The ulcer usually forms close to the pyloric valve and more often occurs on the anterior duodenal wall. Please discuss with your doctor for further information.


What are the symptoms of duodenal ulcer?

The common symptoms of duodenal ulcer are:

  • Abdominal pain usually centrally in the upper abdomen
  • Anaemia usually showing Iron deficiency
  • Indigestion
  • Vomiting
  • Vomiting blood (haematemesis)
  • Black stools (melaena)
  • Collapse and shock


When should I see my doctor?



What causes duodenal ulcer?

A duodenal ulcer arises when the protective mechanisms that protect the epithelial lining are compromised. The incoming acidic chyme from the stomach can erode the lining of the duodenum.

The most common causes of duodenal ulcers, like stomach ulcers, include H.pylori infection and the use of NSAIDs.

  • Helicobacter pylori (H.pylori) Infection
  • H. pylori is a type of bacteria that infects the stomach lining but may also extend to the duodenum especially if the duodenal mucosa is altered in a manner that it resembles the stomach lining (gastric metaplasia).
  • H. pylori increases gastric acid secretion in the stomach and also degrades the mucus barrier.
  • This allows gastric acid to make contact with the duodenal lining, leading to inflammation and eventually ulceration.
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • NSAIDs are widely available drugs used to reduce inflammation and ease pain.
  • These drugs impair the mucus barrier of the duodenum thereby allowing gastric acid to make contact with the duodenal lining.
  • Chronic use of NSAIDs are more likely to lead duodenal ulceration.

Risk factors

What increases my risk for duodenal ulcer?

There are many risk factors for duodenal ulcer, such as:

  • Cigarette smoking
  • Alcohol misuse
  • Advancing age, especially if there is a history of H.pylori infection
  • Severe illness and debilitated patients
  • Ingestion of caustic agents
  • Hyperacidity conditions like Zollinger-Ellison syndrome
  • Epstein-Barr virus (EBV), cytomegalovirus (CMV) or herpes simplex virus-1 (HSV-1)
  • Family history
  • Chemotherapy and radiation therapy in cancer patients

Diagnosis & treatment


How is duodenal ulcer diagnosed?

Gastroscopy (endoscopy) is the test that can confirm a duodenal ulcer. In this test a doctor or nurse looks inside your stomach and the first part of your small intestine (duodenum). They do this by passing a thin, flexible telescope down your gullet (oesophagus). They can see any inflammation or ulcers.

A test to detect the H. pylori germ (bacterium) is usually done if you have a duodenal ulcer. If H. pylori is found then it is likely to be the cause of the ulcer.

Briefly, it can be detected in a sample of stools (faeces), or in a breath test, or from a blood test, or from a biopsy sample taken during an endoscopy. See separate leaflet called Helicobacter Pylori and Stomach Pain for more details.

How is duodenal ulcer treated?

Acid-suppressing medication

A 4- to 8-week course of a medicine that greatly reduces the amount of acid your stomach makes is usually advised. The most commonly used medicine is a proton pump inhibitor (PPI). These are a group (class) of medicines that work on the cells that line the stomach, reducing the production of acid.

They include esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole, and come in various brand names. Sometimes another class of medicines called H2 blockers is used. They are also called histamine H2-receptor antagonists but are commonly called H2 blockers.

H2 blockers work in a different way on the cells that line the stomach, reducing the production of acid. They include cimetidine, famotidine, nizatidine and ranitidine, and come in various brand names. As the amount of acid is greatly reduced, the ulcer usually heals. However, this is not the end of the story.

If your ulcer was caused by H. pylori


In addition, you need to take an acid-suppressing medicine to reduce the acid in the stomach. This is needed to allow the antibiotics to work well. You need to take this combination therapy (sometimes called triple therapy) for a week.

One course of combination therapy clears H. pylori infection in up to 9 in 10 cases. If H. pylori is cleared, the chance of a duodenal ulcer returning is greatly reduced. However, in a small number of people, H. pylori infection returns at some stage in the future.

After treatment, a test to check that H. pylori has gone may be advised. If it is done, it needs to be done at least four weeks after the course of combination therapy has finished. In most cases, the test is negative meaning that the infection has gone. If it has not gone then a repeat course of combination therapy with a different set of antibiotics may be advised.

Some doctors say that for people with a duodenal ulcer, this confirmation test is not necessary if symptoms have gone. The fact that symptoms have gone usually indicates that the ulcer and the cause (H. pylori) have gone.

But, some doctors say it is needed to play safe. Your own doctor will advise if you should have it. (Note: a test to confirm that H. pylori has gone is usually always recommended if you have a stomach ulcer.)

If your ulcer was caused by an anti-inflammatory medicine

If possible, you should stop the anti-inflammatory medicine. This allows the ulcer to heal. You will also normally be prescribed an acid-suppressing medicine for several weeks (as mentioned above). This stops the stomach from making acid and allows the ulcer to heal.



In the past, surgery was commonly needed to treat a duodenal ulcer. This was before it was discovered that H. pylori was the cause of most duodenal ulcers, and before modern acid-suppressing medicines became available. Surgery is now usually only needed if a complication of a duodenal ulcer develops such as severe bleeding or a hole (perforation).

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Lifestyle changes & home remedies

What are some lifestyle changes or home remedies that can help me manage duodenal ulcer?

The following lifestyles and home remedies might help you cope with duodenal ulcer:

  • Make changes to your diet, such as eating smaller amounts of food more frequently. This change may improve your symptoms, but it won’t help your ulcer heal.
  • Drink alcohol only in moderation, or not at all. Limit alcohol to 14 units a week and try to have 2 completely alcohol free days in that week. Drinking too much alcohol may make an ulcer heal more slowly and may make your symptoms worse.



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