Duodenal ulcer

What is a duodenal ulcer?

A duodenal ulcer is an open sore that forms in the lining of the duodenum, the first part of your small intestine, just beyond your stomach. It's one of two types of peptic ulcer (the other being a stomach, or gastric, ulcer), and it usually causes pain in the upper tummy, just below the breastbone.

Symptoms of a duodenal ulcer

Pain in the upper tummy is the main symptom. It tends to come and go, and is often eased by eating or taking an antacid, though it can return 2–3 hours later or wake you up at night. Some people find certain foods make the pain worse instead.

You might also notice:

• bloating, or feeling unusually full after eating
• burning indigestion (dyspepsia) in your upper abdomen
• nausea, retching, or occasionally being sick
• weight loss, or, in some people, weight gain from eating more often to ease the pain.

If an ulcer bleeds or bursts through the wall of the duodenum (a perforation), it can cause sudden, severe pain, vomiting blood, or black or bloody stools. These are medical emergencies and need immediate treatment.

Causes of a duodenal ulcer and who's at risk

Most duodenal ulcers happen when the layer of mucus that protects the duodenum is worn down, allowing stomach acid to damage the tissue underneath. In the UK, a bacterial infection called Helicobacter pylori (H. pylori) is thought to cause around 19 in 20 cases. More than one in four people in the UK become infected with H. pylori at some point in their lives, though most won't go on to develop an ulcer.

Anti-inflammatory painkillers, also called NSAIDs, such as ibuprofen, aspirin and diclofenac, are the other main cause.

You may be more likely to develop a duodenal ulcer if you:

• smoke, or drink a lot of alcohol
• are under a lot of stress, although this is rarely the underlying cause on its own
• have Crohn's disease or cystic fibrosis
• are having treatment for cancer
• have blood group O
• have a rare condition called Zollinger-Ellison syndrome, which causes your stomach to produce too much acid.

Are there different types of duodenal ulcer?

A duodenal ulcer is different from a gastric (stomach) ulcer, even though both are types of peptic ulcer. Gastric ulcer pain tends to start 30–60 minutes after eating and can lead to weight loss, whereas duodenal ulcer pain is usually eased by food but returns a few hours later or overnight. Gastric ulcers are also more often linked to an underlying cancer risk, which is one reason they're usually biopsied during endoscopy.

How is a duodenal ulcer diagnosed?

Your doctor will ask about your symptoms and medical history, including any painkillers you take. They'll usually arrange a test for H. pylori, using a breath test, a stool sample, or a blood test.

You may also be referred for a gastroscopy (also called an endoscopy), where a specialist passes a thin, flexible tube with a camera down your throat to examine your stomach and duodenum directly. They can take a small tissue sample (biopsy) at the same time, to confirm the diagnosis and test for H. pylori. A blood test may also be taken to check for anaemia caused by bleeding.

How is a duodenal ulcer treated?

Most duodenal ulcers are treated with medicines rather than surgery.

Non-surgical treatment

If you have H. pylori, the usual treatment is a one-week course of two antibiotics alongside a proton pump inhibitor (PPI), a medicine that reduces the amount of acid your stomach makes. This is often called triple therapy, and it clears the infection in most people, which usually stops the ulcer coming back.

If your ulcer is linked to an anti-inflammatory painkiller, you'll usually be advised to stop taking it if possible. You may need to continue to take PPI for 4–8 weeks to allow the ulcer to heal fully.

Alongside medicine, some lifestyle changes can help ease your symptoms and support healing, such as stopping smoking, cutting down on alcohol, losing weight if you're overweight, eating smaller and more frequent meals, having your evening meal a few hours before bed, managing stress, and avoiding foods that trigger your symptoms, such as coffee, fatty food, spicy food or tomato-based food.

Surgical treatment

Surgery is only usually needed if a complication develops, such as heavy bleeding that can't be controlled another way, a perforation, or scarring that narrows the passage between your stomach and duodenum and blocks food from passing through. These situations need emergency treatment.

When should I see a doctor?

See a GP if you have ongoing indigestion-type pain, feel nauseous, or are losing weight without trying.

Call 999 or go to A&E immediately if you have sudden, severe abdominal pain that doesn't go away, or if you vomit blood or pass black or bloody stools, since these can be signs of a serious complication.