Duodenal Ulcer

General Considerations

•     2-3 times more frequent than gastric ulcers

•     3:1 male:female ratio

Pathophysiology

•     Excessive acidity in duodenum from

      • Abnormally high gastric secretion

      • Inadequate neutralization

Predisposing factors

•     Steroids

•     Severe head injury

•     Post-surgical

•     COPD

Location

•     Bulbar (95%)

      • Anterior wall–            50%

      • Posterior wall–           23%

      • Inferior fornix–           22%

      • Superior fornix–           5%

•     Postbulbar (3-5%)

      • Majority on medial wall just proximal to ampulla

      • Tendency for hemorrhage in 66%

      • Male:female ration 7:1

X-ray

•     Small round, ovoid or linear crater

•     Kissing ulcers–ulcers opposite from each other on the anterior and posterior walls

•     Giant duodenal ulcer–>3cm (rare) with higher morbidity and mortality

            • May be mistaken for the duodenal bulb itself and missed

•     Clover-leaf deformity–healed central ulcer of the bulb with four-leaf clover-like deformity remaining

Complications

•     Hemorrhage      15%           melena>hematemesis   

•     Perforation      <10%         anterior>posterior /may fistulize to GB

•     Obstruction        5%

•     Penetration        <5%           walled-off perforation

Duodenal Ulcer. There is a collection of barium on the dependent surface of the duodenal bulb (white arrows) on this double contrast (air-contrast) upper GI examination. This represent barium in an ulcer crater.