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Gastro Intestinal Diseases

Duodenal Ulcer


This is more classical and common. The ulcer penetrates deep into the mucosa. More than 95% occur in the first part of the duodenum. About 60% of ulcers recur within one year and 90% within two years.



Causative factors

These are not known for sure. The number of acid-secreting cells is high, with greater outpouring of acid. Excessive acid flow is consequential, in comparison to gastric ulcer where defective mucosal resistance is the cause. Genetic factors appear to be important. Alcohol and cigarettes are potent causative and aggravating factors. Others are chronic usage of painkiller drugs, poor lifestyle, a bacteria known as helicobacter pylori found in a number of patients with DU, skipping meals (which allows acid to irritate the lining, the outflow being aggravated by stress on an empty stomach) and, most important, the mind. Stress produces and aggravates duodenal ulcer in any situation. Of this there is no doubt. All patients experience increase in pain with stress.



Symptoms

The classic symptom is pain in the epigastric area present two to three hours after a meal. It is a burning, painful, gnawing or aching sensation, with fullness or bloating, even awakening the patient from sleep. It is relieved by intake of food or antacids. The severity of the pain varies, and recurrence is common with periods of remission. Any change in the pattern of the pain may herald complications — constant pain unrelieved by any agent may suggest perforation, or adherence to the pancreas behind. Many patients with DU have no symptoms. There is often poor correlation between symptoms and healing. Surprisingly, duodenal ulcers never turn malignant. Complications are similar to gastric ulcer.



Diagnosis

Pain in the epigastric region and a little to the right side and below it, if relieved by food or antacids, is in favour of DU. Double contrast barium and endoscopy are helpful in diagnosis. Small ulcers missed by barium can be picked up by endoscopy.



Medical Management

Healing of ulcers and relief of pain are the two objectives. Antacids like aluminium hydroxide and magnesium hydroxide are most commonly used. The former produces constipation, and the latter diarrhoea in some patients. Antacids could be taken one hour after each meal and at bedtime. Agents preventing the binding of histamine to receptors are very helpful. Acid secretion is lowered. They are taken with meals. Side effects are minimal, though they include rash, gynaecomastia, mental confusion and increasing the action of other drugs. Ranitidine, nizatidine and famotidine are effective. Omperazole is a promising drug. Prostaglandins, which are chemicals present in the body, help ulcers. They reduce acid secretion, enhance mucosal resistance, stimulate blood flow, increase bicarbonate secretion and stimulate cellular regeneration. Other important measures include cessation of smoking and drinking, lifestyle changes to reduce stress (which is probably the most important) and avoidance of painkiller drugs. Within four to six weeks of therapy, most duodenal ulcers heal.

If surgical procedures are undertaken, the area is resected and the remainder sutured for gastric ulcers. In duodenal ulcers, the duodenum is bypassed and the stomach joined with the small intestine (gastro-jejunostomy). There are many side effects: diarrhoea, as the vagus nerve is cut to reduce acid secretion (the vagus nerve controls gastric emptying), nausea, alteration in blood glucose due to the altered anatomy, and anaemia due to malabsorption. The frequency of surgery for both conditions has decreased after advances in medicine.




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