Duodenal ulcer

Classification according to ICD-10
K26.-	Duodenal ulcer
ICD-10 online (WHO version 2019)

The duodenal ulcer (Germanized also duodenal ulcer , or duodenal ulcer ) is an ulcer ( ulcus ) in the duodenum ( duodenum ). The criterion for classification as an ulcer is a substance defect that affects the lamina muscularis mucosae , i.e. H. the muscle layer lying under the actual mucous membrane . More superficial lesions are called erosion .

Duodenal ulcer has been known since 1824.

Epidemiology

Duodenal ulcers (from Latin duodenal ulcer ) are about four times more common than gastric ulcers . They occur more frequently in younger to middle age, mainly in people of the male sex (more than twice as often as in women) and in people with blood group 0. The occurrence is observed increasingly in spring and autumn. Around one in ten people will develop a duodenal ulcer during their lifetime. The incidence is 0.1–0.2% and has fallen slightly overall.

causes

Several factors appear to be involved in the development of a duodenal ulcer. Generally speaking, every duodenal ulcer is based on a disparity between the factors protecting the mucous membrane (mucus, bicarbonate , prostaglandin ) and aggressive factors such as gastric acid , proteases and inflammatory reactions. Chronic infection with the Helicobacter pylori bacterium has been confirmed as one of the most important triggers since the 1980s. Further mechanisms that have an additive effect are hyperacidity (pH value too low), circulatory disorders in the intestinal wall and the long-term use of drugs that inhibit prostaglandin synthesis (e.g. acetylsalicylic acid ). Also psychosomatic factors play a role. Atypically localized, multiple (multiple) and recurrent (recurring after healing) ulcers indicate Zollinger-Ellison syndrome . In the Holy Seven , Franz Alexander describes duodenal ulcer as a psychosomatic disease.

morphology

The area (about 2 cm) immediately adjacent to the gastric outlet ( pylorus ) is preferably affected. Acute ulcers are usually circular, lie at the level of the mucous membrane and have drawn-in edges. Chronic ulcers are sharply defined, and often show after oral (mouth Windwärts) an overhanging edge, while the edge to aboral is worn stair-like.

Symptoms

General symptoms such as nausea , vomiting , feeling of pressure and fullness as well as irregular bowel movements are often at the beginning. Unwanted weight loss can often be observed. In contrast to gastric ulcer, duodenal ulcer is typical of " fasting pain ", which only becomes noticeable about two hours after ingestion or at night and is indicated in the middle upper abdominal region ( epigastric ) or around the navel ( periumbilical ). The symptoms are not specific; other disease processes in the abdominal cavity must be ruled out. Sometimes a manifest ulcer does not cause any symptoms at all and is only discovered during routine examinations or when other questions arise.

therapy

In the case of Helicobacter pylori infection, which is found in most cases, eradication therapy is carried out, which consists of three to four drugs (two antibiotics , a proton pump inhibitor to inhibit gastric acid production and possibly bismuth ) that are taken over a period of seven to ten days become.

It is also of central importance to eliminate triggering factors, which include in particular peripherally effective painkillers such as acetylsalicylic acid (ASA, aspirin) and so-called nonsteroidal anti-inflammatory drugs (NSAIDs, e.g. ibuprofen). The other conservative treatment tries to restore the balance of mucosal protective and aggressive factors. In addition to diet, abstinence from nicotine and alcohol and avoiding stress, proton pump inhibitors such as omeprazole or pantoprazole are prescribed today , which, depending on the dosage, reduce or completely prevent acid production in the stomach. The indication for long-term therapy with proton pump inhibitors should, however, be viewed critically due to the potential for side effects.

Today, ulcers that cannot be treated satisfactorily with conservative methods are rarely operated on, since in most cases a cure can be achieved with Helicobacter eradication. The vagotomy , in which, depending on the variant, different parts of the stomach-innervating part of the vagus nerve are severed, is only rarely performed . A gastric resection is also only rarely required , in which the ulcer is healed by removing the parts of the stomach that are mainly responsible for gastric acid production.

Complications

Duodenal ulcer is a major cause of upper gastrointestinal bleeding , accounting for a quarter to a third of cases. The perforation , which can lead to life-threatening purulent peritonitis , is rare . The ulcer bleeding can also be caused by NSAIDs . Statutory health insurance funds spend almost EUR 125 million annually on the treatment of gastrointestinal side effects of NSAIDs. 1,100 to 2,200 people die in Germany every year from gastrointestinal complications, including duodenal bleeding (estimates). The number of unreported cases is likely to be significantly higher.

literature

Yvonne Syha, Laura Popescu, Mario Wurglics, Manfred Schubert-Zsilavecz: History of Ulcer Therapy . In: Pharmacy in our time . Science, education, further education , vol. 34 (2005), issue 3, pp. 188–192, ISSN 0048-3664 .
Hans Adolf Kühn: Ulcus ventriculi and duodeni (Ulcus pepticum, Ulcus rotundum, Anglo-Saxon "Peptic ulcer", French "ulcère"). In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition, ibid. 1961, pp. 786-795.

Individual evidence

^ G. Lindell et al .: On the natural history of peptic ulcer. In: Scandinavian Journal of Gastroenterology. Vol. 29 (1994), No. 11, pp. 979-982, ISSN 0085-5928 . PMID 7871377 .
↑ Gotthard Schettler, Heiner Greten : Internal medicine. Understand, learn, apply. 9th edition. Thieme, Stuttgart 1998, ISBN 3-13-552209-1 .
↑ If PPIs are taken for too long. February 16, 2017, accessed January 4, 2019 .
↑ Peter Schemmer et al .: The vital threat of an upper gastrointestinal bleeding. Risk factor analysis of 121 consecutive patients . In: World Journal of Gastroenterology , Vol. 12 (2006), Issue 22, pp. 3597-3601, ISSN 1007-9327 . PMID 16773718 .
^ Gregorios A. Paspatis et al .: An epidemiological study of acute upper gastrointestinal bleeding in Crete, Greece . In: European Journal of Gastroenterology and Hepatology , Vol. 12 (2000), Issue 11, pp. 1215-1220, ISSN 0954-691X . PMID 11111778 .
↑ Quoted after Reduces the pain, protects the organs . In: Der Allgemeinarzt , vol. 28 (2007), issue 9, p. 39, ISSN 0172-7249 .
↑ Quoted from tNSAR versus Coxibe: What is certain? - Around 2,200 deaths annually due to complications in the GI tract. In: Ärztliche Praxis , Vol. 22 of May 29, 2007, ISSN 1867-125X , p. 8.

[1] G. Lindell et al .: On the natural history of peptic ulcer. In: Scandinavian Journal of Gastroenterology. Vol. 29 (1994), No. 11, pp. 979-982, ISSN 0085-5928 . PMID 7871377 .

[2] Gotthard Schettler, Heiner Greten : Internal medicine. Understand, learn, apply. 9th edition. Thieme, Stuttgart 1998, ISBN 3-13-552209-1 .

[3] If PPIs are taken for too long. February 16, 2017, accessed January 4, 2019 .

[4] Peter Schemmer et al .: The vital threat of an upper gastrointestinal bleeding. Risk factor analysis of 121 consecutive patients . In: World Journal of Gastroenterology , Vol. 12 (2006), Issue 22, pp. 3597-3601, ISSN 1007-9327 . PMID 16773718 .

[5] Gregorios A. Paspatis et al .: An epidemiological study of acute upper gastrointestinal bleeding in Crete, Greece . In: European Journal of Gastroenterology and Hepatology , Vol. 12 (2000), Issue 11, pp. 1215-1220, ISSN 0954-691X . PMID 11111778 .

[6] Quoted after Reduces the pain, protects the organs . In: Der Allgemeinarzt , vol. 28 (2007), issue 9, p. 39, ISSN 0172-7249 .

[7] Quoted from tNSAR versus Coxibe: What is certain? - Around 2,200 deaths annually due to complications in the GI tract. In: Ärztliche Praxis , Vol. 22 of May 29, 2007, ISSN 1867-125X , p. 8.