PEPTIC ULCER: DUODENITIS AND ULCER OF DUODENAL BULB
Duodenitis refers to an inflammation of the mucosa in the duodenal bulbar region. Duodenitis is usually diagnosed endoscopically, often when it is performed for abdominal pain or evidence of acute or chronic gastrointestinal bleeding. The diagnosis may be supported in radiologic contrast studies when the mucosa of the most proximal part of the duodenum appears somewhat mottled and when, fluoroscopically, spasms and an increased motility of the duodenal cap can be observed. The inflamed duodenal mucosa has a relatively strong tendency to bleed, even in the absence of an actual ulcerative process. At times, however, duodenitis may be associated with multiple superficial erosions. On the other hand, diffuse duodenitis may also be present in association with a characteristic chronic peptic ulcer. Duodenitis is usually confined to the most proximal parts of the duodenum, but, occasionally, the antral mucosa as well may participate in the inflammatory reaction. Medical treatment for duodenitis is the same as that for peptic ulcer. Massive hemorrhages from duodenitis with erosion may, in rare cases, make exploration necessary, although, as a matter of general principle, surgical intervention is not recommended unless the source of the bleeding has been determined.
More common,
and clinically more important, is the chronic duodenal ulcer. With rare
exceptions, this lesion is seated within the duodenal bulb. It develops with
essentially the same frequency on the anterior or posterior wall. The average
size of a duodenal ulcer is 0.5 cm, but the ulcers on the posterior wall are usually larger than
those on the anterior wall, mainly because the former, walled off by the
pancreas lying below the ulcer, can increase in size without free perforation.
Causes of these duodenal ulcers include H. pylori infection and side
effects from NSAIDs.
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The duodenal
peptic ulcer is usually round and has a punched-out appearance, but as a small
ulcer it may sometimes be slitlike, crescent shaped, or triangular. The chronic
ulcer, in contrast to an acute ulcer that stops at the submucosa, involves all
layers. It penetrates to the muscular coat and at times more deeply. An ulcer
on the anterior wall may show a moderate amount of proliferation, whereas that
on the posterior wall will give evidence of considerable edema and fibrosis.
Healing may proceed just as it does with a gastric ulcer, with disappearance of
the crater and bridging of the gap by formation of fibrous tissue covered by
new mucous membrane, but healing becomes more difficult once the destruction of
the muscular layer has gone too far.
The symptoms
of a chronic duodenal ulcer are, as a rule, typical and are characterized by
periodic episodes of gnawing pain, usually located in the epigastrium. The pain
occurs 1 to 2 hours after meals and may be relieved by food.
Roentgen
examination reveals the classic features of deformity: (1) a niche
corresponding to the actual ulcer crater, (2) a shortening of the upper
curvature of the bulb, and (3) contraction of the opposite side, which probably
is the result of spasms of the circular muscle fibers in the plane of the ulcer
or of edema and cicatrization (the process of healing to produce scar
tissue). Radiating folds due to puckering from scar formation are sometimes
demonstrable at the edge of the niche.
