Small intestine & ampulla
Inflammatory disorders
Duodenal peptic ulcer
Authors: Ahmed Afifi, M.B.B.Ch., Raul S. Gonzalez, M.D.
Editorial Board Member: Claudio Luchini, M.D., Ph.D.
Deputy Editor-in-Chief: Aaron R. Huber, D.O.
Last author update: 26 September 2023
Last staff update: 26 September 2023
Copyright: 2003-2024, PathologyOutlines.com, Inc.
PubMed Search: Duodenal peptic ulcer
Table of Contents
Definition / general | Essential features | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Laboratory | Radiology description | Prognostic factors | Case reports | Treatment | Clinical images | Gross description | Gross images | Microscopic (histologic) description | Microscopic (histologic) images | Videos | Sample pathology report | Differential diagnosis | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Afifi A, Gonzalez RS. Duodenal peptic ulcer. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/smallbowelduodenalpepticulcer.html. Accessed April 20th, 2024.
Definition / general
- Corrosive lesion caused by excessive gastric acid secretion, leading to defects in the mucosal surface of the duodenum
Essential features
- Often results from heavy nonsteroidal anti-inflammatory drug (NSAID) use, Helicobacter pylori infection, gastric acid hypersecretion or stress
- Typically presents with epigastric pain but may be asymptomatic
- Histology shows ulceration and background foveolar metaplasia
ICD coding
- ICD-10: K26 - duodenal ulcer
- Subcodes based on hemorrhage, perforation and chronicity
Epidemiology
- Incidence is 1 case per 1,000 person years (Pharmacoepidemiol Drug Saf 2011;20:718)
- 4 times more common than gastric ulcers (StatPearls: Peptic Ulcer Disease [Accessed 1 September 2023])
- M > F (StatPearls: Peptic Ulcer Disease [Accessed 1 September 2023])
- Incidence worldwide is decreasing in recent decades (Transl Res 2021;232:115)
Sites
- Most commonly involves the first part of the duodenum (bulb) (> 95%) (StatPearls: Duodenal Ulcer [Accessed 1 September 2023])
- Involvement of other parts of the duodenum is rare, particularly the fourth part
Pathophysiology
- Duodenal ulcers develop due to a disruption in the equilibrium between aggressive factors (gastric acid) and protective factors (mucus and bicarbonate [HCO3-]) (StatPearls: Duodenal Ulcer [Accessed 1 September 2023])
- Erosion of the mucosal barrier exposes submucosal layers to gastric acid and enzymes
- Most patients have a history of H. pylori infection or heavy NSAID use
- H. pylori (StatPearls: Peptic Ulcer Disease [Accessed 1 September 2023])
- Inhibits somatostatin secretion, leading to increased gastrin secretion, which in turn increases hydrogen ion (H+) secretion and delivery to the duodenum
- Direct spread of H. pylori to the duodenum inhibits duodenal HCO3- secretion, leading to increased acid without adequate neutralization
- NSAIDs (StatPearls: Peptic Ulcer Disease [Accessed 1 September 2023])
- Inhibit COX1 and COX2, which decrease prostaglandin production, leading to erosion of the gastric mucosa (prostaglandins may have a protective effect, supporting blood flow and helping to maintain integrity of the mucosa)
- Decrease mucosal blood flow and mucosal cell proliferation
Etiology
- H. pylori and NSAID use (see above) promote ulcer formation by interacting with additional risk factors such as smoking, heavy alcohol use, glucocorticoids and caffeine (StatPearls: Duodenal Ulcer [Accessed 1 September 2023])
- Diet, stress and genetic factors also play a role (StatPearls: Peptic Ulcer Disease [Accessed 1 September 2023])
- Rare causes of peptic ulcers include acid hypersecretory states (e.g., gastrinoma), non-NSAID medications (e.g., bisphosphonates), infections (e.g., cytomegalovirus [CMV]) or systemic inflammatory disease (StatPearls: Peptic Ulcer Disease [Accessed 1 September 2023])
Clinical features
- Up to 70% of patients with peptic ulcer disease are asymptomatic (StatPearls: Duodenal Ulcer [Accessed 1 September 2023])
- Characteristic symptoms include
- Dyspepsia: postprandial heaviness, early satiety and epigastric pain
- Epigastric pain described as burning or gnawing, often peaking during fasting periods and improving after meals
- Nausea and vomiting
- Abdominal bloating
- Weight gain due to improved symptoms after a meal
- Can cause occult blood in stool or signs of internal bleeding (e.g., anemia, hematemesis, melena)
- Presentation can vary based on the location and severity of the ulcer, including gastrointestinal bleeding, obstructions, perforation or fistula development
Diagnosis
- Suspected in patients with dyspepsia and upper abdominal symptoms with a previous H. pylori diagnosis or a history of NSAID use
- Clinical guidelines for diagnosis exist (Am J Gastroenterol 2017;112:988)
- Patients < 60 years of age without red flags for dyspepsia begin with noninvasive testing for H. pylori (test and treat strategy) as successful eradication reduces unnecessary esophagogastroduodenoscopies (EGDs) and prolonged trials of acid suppression
- Urea breath test
- Stool antigen test
- Patients > 60 years of age, patients with red flags for dyspepsia or patients unresponsive to medical therapy are referred directly to EGD
- Red flags indicating the need for EGD in a younger patient include dysphagia, persistent vomiting, gastrointestinal (GI) bleeding, rapid weight loss and a family history of GI malignancy
- Barium endoscopy is an alternative for patients with contraindications to EGD
Laboratory
- Testing for rare causes is considered in cases of recurrent ulcers or unclear etiology (J Clin Endocrinol Metab 2022;107:e2110)
- Fasting serum gastrin
- Secretin stimulation test
- High levels in gastrinoma
- Parathyroid hormone (PTH) level (Gastroenterol Rep (Oxf) 2018;6:231)
- Testing for systemic inflammatory diseases
Radiology description
- Upper gastrointestinal (UGI) series: well defined, round or oval, lucent area with a crater-like appearance, often surrounded by edema (Insights Imaging 2021;12:94)
- Endoscopy (EGD): ulcer with a smooth base, rounded and regular edges, typically located on the anterior or posterior wall of the duodenal bulb, often accompanied by regular surrounding mucosa
- Double contrast barium meal: provides enhanced visibility of ulcer margins, especially for smaller ulcers (Insights Imaging 2021;12:94)
Prognostic factors
- Variable depending on the severity of the disease at the time of diagnosis
- Duodenal ulcers caused by H. pylori require treatment to eradicate the infection, with rates of resolution varying
- Duodenal ulcers caused by heavy NSAID use are treated by discontinuing the drug, with a generally favorable prognosis
- Patients with ulcer complications, such as perforation, gastric outlet obstruction and severe ulceration, experience high mortality rates
- Reference: StatPearls: Duodenal Ulcer [Accessed 1 September 2023]
Case reports
- 12 year old boy with atypical perforated duodenal ulcer (BMJ Case Rep 2014;2014:bcr2014204716)
- 53 year old man with leukemia and perforated duodenal ulcer (J Med Case Rep 2013;7:257)
- 54 year old man with perforation of gastric and duodenal ulcers (J Med Case Rep 2010;4:272)
Treatment
- Treatment is based on the severity of disease at time of diagnosis
- Lifestyle modifications
- Smoking cessation
- Avoid NSAIDs
- Alcohol reduction
- Stress management
- Acid suppression with proton pump inhibitors (PPIs) or histamine type 2 (H2) receptor antagonists
- Eradication of H. pylori infection using antibiotic regimens
- Triple therapy: 2 antibiotics (amoxicillin and clarithromycin) and 1 PPI (e.g., pantoprazole)
- Effective management involves addressing underlying causes and promoting mucosal healing
- Reference: StatPearls: Duodenal Ulcer [Accessed 1 September 2023]
Clinical images
Contributed by Raul S. Gonzalez, M.D.
Endoscopy
Images hosted on other servers:
Acute duodenal ulceration
Gross description
- Benign peptic ulcer (StatPearls: Peptic Ulcer Disease [Accessed 1 September 2023])
- Smooth base
- Rounded, regular edges
- Regular surrounding mucosa
- Usually located on the anterior or posterior wall of the duodenal bulb
- Malignant ulcer (for comparison) (Radiology 2009;252:410)
- Base reveals an ulcerated mass protruding into the lumen
- Overhanging, irregular edges
- Nodular, irregular mucosa
- Atypical location
Gross images
Contributed by Raul S. Gonzalez, M.D.
Gastroduodenal junction resection
Microscopic (histologic) description
- Fibrinopurulent debris and granulation tissue at site of ulceration, extending at least into lamina propria if not into muscularis mucosae and submucosa
- Underlying inflammatory changes
- Severe examples may involve full thickness of wall
- Adjacent duodenal mucosa may show changes of peptic injury, such as foveolar metaplasia, villous blunting and Brunner gland hyperplasia
- H. pylori infection is rare within the duodenum itself and usually occurs in foveolar metaplasia (J Clin Pathol 2021;74:537)
Microscopic (histologic) images
Contributed by Raul S. Gonzalez, M.D.
Granulation tissue
Adjacent mucosa
Fibrinous ulcer
Helicobacter infection in duodenum
Videos
Severe duodenal peptic ulcer
Sample pathology report
- Duodenum, ulcer, biopsy:
- Fibrinopurulent debris and granulation tissue, consistent with ulceration
- Background duodenal mucosa with foveolar metaplasia, consistent with peptic injury
- Negative for malignancy
Differential diagnosis
- Celiac disease:
- Duodenal mucosa shows villous blunting, which may also occur in the setting of ulceration
- Duodenal mucosa shows increased intraepithelial lymphocytes, which should not occur in the setting of ulceration
- Peptic duodenitis:
- This change can be seen in the background of an ulcer but fibrinopurulent debris and granulation tissue should be absent
- Malignancy:
- Duodenal adenocarcinoma can also cause ulceration
- Microscopic examination reveals malignant glands or single cells
- Endoscopic appearance is also different (see above)
- Crohn's disease:
- May also cause severe duodenal injury, including ulceration
- Lower gastrointestinal involvement should occur
- Duodenal granulomas may be present
Board review style question #1
Which of the following is a major cause of duodenal peptic ulcers?
- Celiac disease
- Cytomegalovirus (CMV) infection
- Gastrinoma
- Heavy nonsteroidal anti-inflammatory drug (NSAID) use
- Stress
Board review style answer #1
D. Heavy NSAID use. Helicobacter pylori and heavy NSAID use are known to be the 2 main causes of duodenal peptic ulcers. Answers B, C and E are incorrect because CMV infection, gastrinoma elsewhere and stress are minor / uncommon causes of peptic ulcers. Answer A is incorrect because celiac disease does not generally cause peptic ulcers.
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Board review style question #2
Which of the following gross features suggests a duodenal ulcer is benign and peptic in nature, rather than malignant in nature?
- Atypical / unusual location within the duodenum
- Nodular, irregular mucosa
- Overhanging, irregular edges
- Smooth base
- Ulcerated mass protruding into the lumen
Board review style answer #2
D. Smooth base. Benign ulcers usually have a smooth base. Answer A is incorrect because benign ulcers have a typical location, generally the anterior or posterior wall of the duodenal bulb. Answers B and C are incorrect because benign ulcers usually have rounded, regular edges with normal surrounding mucosa. Answer E is incorrect because a mass lesion should not be seen in a benign ulcer.
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