The duodenum is the first part of the small intestines and is in direct continuity with the stomach. Ulcers in the duodenum usually cause a burning pain in the upper abdomen along with some nausea and vomiting. The treatments available for duodenal ulcers can be divided into surgical and non-surgical. Due to advances in medications available to treat ulcers, surgery is reserved for complicated duodenal ulcers.
Non-Surgical Therapy
The non-surgical therapies for duodenal ulcers are aimed at the causes of the ulcer. There are protective mechanisms in place to prevent damage to the lining of the duodenum from the acidic fluid that leaves the stomach after one consumes a meal. When there is an imbalance between the protective mechanisms and the stomach acid production, an ulcer results. The primary cause of this imbalance is the presence of the bacterium H. pylori. This bacterium produces a substance that destroys the lining of the duodenum, making it more susceptible to damage by stomach acid.
There are many medications available to reduce or neutralize the acid produced by the stomach. Acid inhibitors include Zantac, Tagamet, Nexium, Prilosec and Pantecta. Most of these medications are available in low dose form without a prescription, while higher doses need to be prescribed by a doctor. They act at the level of the cells in the stomach to decrease their production of stomach acid.
Acid neutralizers like Tums, Rolaids, Maalox and Milk of Magnesia interact with stomach acid to reduce its effects on the duodenum. Both acid reducers and neutralizers relieve the symptoms associated with duodenal ulcers, but do not address all the underlying causes and as such must be combined with antibiotics to adequately treat the problem.
Antibiotics are added to the treatment regime to eradicate H.pylori. Two antibiotics, amoxicillin and clarithromycin are usually combined to treat the infection. For persons who are allergic to penicillins, the antibiotic metronidazole is used instead.
The current recommendation by the American Gastroenterological Association for treatment of uncomplicated duodenal ulcers is a 7 to 10 day course of amoxicillin and clarithomycin, along with a four week course of an acid reducer such as Nexium, and a medication that contains bismuth.
Surgical therapy is reserved for complicated ulcers. Complications of ulcers include perforation, bleeding, intractable pain and obstruction. Perforation occurs when the ulcer erodes the entire thickness of the duodenum wall, resulting in leakage of the stomach contents into the abdomen. Intractable pain results from long-standing ulcers, which do not heal with medical therapy. Obstruction can occur if longstanding ulcers heal with excessive scar tissue. This scar tissue may obstruct the flow of stomach contents into the small intestines. All these complications require immediate surgical correction, as well as direct treatment of the underlying cause of the ulcer; therefore, surgery will involve destroying the segment of the nerve supply responsible for the production of acid. This procedure does not completely eliminate stomach acid, but reduces it significantly, allowing the ulcer to heal and preventing further ulcers.
Bleeding ulcers are treated via a minimally invasive procedure called endoscopy. In endoscopy a doctor uses a small flexible camera to visualize the bleeding ulcer. He may employ various methods via the endoscope to stop the bleeding, the most common of which is using heat to close the lumen of the bleeding vessel. This is called cautery.
References
- "Sabiston Textbook of Surgery"; Townsend Jr., C., et al.; 2008
- "Washington Manual of Surgery"; Doherty, G.M.; et al.; 2002
- American Gastroenterological Association
