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.
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.