GI Pain Relieved by Eating: Duodenal Ulcer

Why does food relieve the pain?

• Food acts as a chemical buffer, neutralizing gastric acid
• This reduces the acid load reaching the duodenal ulcer
• The pain therefore eases after eating

Classic Pain Pattern of Duodenal Ulcer:

Contrast with Gastric Ulcer:

One Special Case - Zollinger-Ellison Syndrome:

How to Diagnose Duodenal Ulcer

1. Clinical History (Symptoms)

• Epigastric burning/gnawing pain - midepigastric, sometimes radiating to the back
• Pain relieved by food, milk, or antacids (hunger pain)
• Nocturnal pain - waking the patient at night (2-4 AM)
• Periodic pattern - weeks of pain followed by pain-free intervals
• Absent weight loss (unlike gastric ulcer or malignancy)

• Unintentional weight loss
• Dysphagia or persistent vomiting
• GI bleeding (hematemesis, melena, iron-deficiency anaemia)
• Epigastric mass
• Failure to respond to PPI therapy
• Family history of GI cancer

2. Physical Examination

• Mild epigastric tenderness on deep palpation
• Signs of complications: board-like rigidity (perforation), pallor (bleeding)

3. Investigations

A. Endoscopy (Gold Standard - EGD/OGD)

• Esophagogastroduodenoscopy (EGD) is the definitive investigation
• Provides direct visualization of the ulcer in the duodenum (usually first part/D1)
• Allows tissue biopsy for H. pylori testing and to exclude malignancy
• Identifies complications (bleeding, deformity)
• Sensitivity and specificity are very high

B. H. pylori Testing

Note: PPIs can suppress H. pylori tests - stop PPIs 2 weeks before testing where possible.

C. Barium Meal (Upper GI Series)

• Older technique, still used if endoscopy is not tolerated or fails
• Barium within an ulcer crater is diagnostic
• Secondary changes (edema, scarring, deformity) may also be seen
• Less sensitive than endoscopy; cannot biopsy

D. CT Scan

• Not the test of choice for duodenal ulcer
• Occasionally demonstrates ulceration but is much less sensitive
• Useful for detecting complications like perforation (free air under diaphragm)

4. Summary Diagnostic Approach

Suspect Duodenal Ulcer (classic history)
         |
         ↓
Any ALARM features?
   YES → Urgent EGD
   NO  → Age < 60 with no alarm features?
              ↓
      Test & Treat strategy:
      Non-invasive H. pylori test (UBT or stool antigen)
      If positive → treat
      If no response → EGD

Treatment of Duodenal Ulcer

1. Lifestyle Modifications

• Stop NSAIDs/aspirin - a major causative factor; if aspirin is essential for cardiovascular protection, co-prescribe a daily PPI
• Smoking cessation - smoking doubles the risk and delays ulcer healing
• Avoid alcohol - irritates the mucosa
• Dietary changes - avoid foods that worsen symptoms (spicy food, caffeine)

2. Acid Suppression (Antisecretory Therapy)

A. Proton Pump Inhibitors (PPIs) - First-Line

• Irreversibly block H⁺/K⁺-ATPase (proton pump) on parietal cells
• Healing rates: 85% at 4 weeks, 96% at 8 weeks
• Duodenal ulcers are treated for 8 weeks (gastric ulcers need 12 weeks)
• Examples: Omeprazole, Esomeprazole, Pantoprazole, Lansoprazole, Rabeprazole

• Large ulcers (>2 cm)
• Refractory or frequently recurring PUD
• Failed H. pylori eradication
• Patients who cannot stop NSAID/aspirin use

B. H2 Receptor Antagonists (H2RAs) - Second-line

• Block histamine H2 receptors on parietal cells
• Less potent than PPIs - largely replaced by PPIs
• Still useful when PPIs are not tolerated
• Examples: Famotidine (most potent), Ranitidine, Cimetidine
• Dose adjustment needed in renal insufficiency

C. Antacids

• Oldest form of therapy; neutralize gastric acid chemically
• Used for symptomatic relief, not definitive treatment
• Types: Aluminum hydroxide, Magnesium trisilicate, Calcium carbonate
• Do not combine with PPIs - an alkaline environment prevents PPI activation

D. Sucralfate

• Mucosal protective agent; forms a protective coating over the ulcer
• Adjunct therapy to promote healing

3. H. pylori Eradication (Core of Treatment)

First-Line Regimens (14-day course recommended)

Note: Clarithromycin resistance is rising globally (20-35% worldwide). Bismuth quadruple therapy is now preferred in many regions as first-line.

Second-Line (if first-line fails)

• Bismuth quadruple therapy (if not used first-line)
• Levofloxacin triple therapy
• Always avoid repeating antibiotics that were used in the failed first-line regimen

Third-Line / Salvage

• Culture and sensitivity-guided therapy
• Rifabutin-based regimens
• Multidrug regimens guided by a gastroenterologist

Confirm Eradication

• Urea Breath Test (UBT) - preferred
• Stool H. pylori antigen test
• Do NOT use serology - antibodies persist for up to 18 months

4. Surgical Treatment

Vagotomy reduces acid secretion by denervating parietal cells - historically the mainstay of surgical PUD management, but now rarely performed.

Treatment Summary Flow

Confirmed Duodenal Ulcer
        |
        ↓
Test for H. pylori
   Positive → PPI + Antibiotics (eradication regimen x14 days)
              + Confirm eradication at 4-6 weeks
   Negative → PPI alone x 8 weeks
              + Stop NSAIDs + lifestyle changes
        |
        ↓
Complications? → Endoscopic or surgical intervention

How to Identify Peptic Ulcers

1. Clinical Identification (History & Symptoms)

• Unexplained weight loss
• Dysphagia (difficulty swallowing)
• Persistent vomiting
• GI bleeding (hematemesis, melena, iron-deficiency anaemia)
• Palpable epigastric mass
• Failure to respond to PPI after 4-6 weeks
• Age >55 with new dyspepsia

2. Physical Examination

• Mild epigastric tenderness on deep palpation
• Succussion splash - suggests gastric outlet obstruction
• Signs of complications: board-like rigidity (perforation), pallor/tachycardia (bleeding)

3. Definitive Investigation - Endoscopy (Gold Standard)

• Provides direct visualization of the ulcer
• Identifies the location (stomach vs. duodenum), size, depth, and edges
• Allows biopsy - mandatory for all gastric ulcers to exclude malignancy
• Simultaneous H. pylori testing via rapid urease (CLO) test or histology
• Identifies active bleeding and stigmata of hemorrhage (Forrest classification)

Endoscopic Appearance - Benign vs. Malignant Gastric Ulcer

The visual appearance of benign and malignant gastric ulcers may be identical - differentiation can only be confirmed by biopsy. Multiple biopsies from the perimeter of the lesion + brushings increase diagnostic accuracy to ~95%.

4. H. pylori Testing

5. Barium Meal (Upper GI Series)

• Barium within an ulcer crater is diagnostic
• Benign gastric ulcer appears as a round/ovoid barium collection with smooth radiating folds projecting beyond the gastric wall contour
• Malignant ulcer projects inside the lumen within a tumor mass, with nodular folds and acute angles at the wall
• Secondary changes from edema, scarring, or deformity may also be visible

Barium meal image - Benign Gastric Ulcer:

6. CT Scan

• Not the primary test for peptic ulcer identification
• Much less sensitive than endoscopy or barium studies
• Useful for detecting complications: free air (perforation), abscesses, fistulas

Summary: Identification Approach

Dyspepsia / epigastric symptoms
            |
    Alarm features present?
    YES → Urgent EGD (endoscopy)
    NO  → Age < 55?
              YES → Non-invasive H. pylori test
                    Positive → Test & Treat
                    Negative → Trial of PPI
                    No response → EGD
              NO  → EGD (higher cancer risk)

Peptic Ulcer vs. Duodenal Ulcer: Symptom Comparison

First, an Important Clarification

Shared Symptoms (Present in All Peptic Ulcers)

• Epigastric (upper abdominal) burning/gnawing pain - the hallmark symptom
• Nausea
• Vomiting
• Bloating and belching
• Relief with antacids
• Episodic pattern - weeks of pain, then pain-free intervals
• Nocturnal pain - waking the patient at night
• Silent/asymptomatic presentation - common in both

Key Differences: Gastric Ulcer vs. Duodenal Ulcer

The Classic Pain Pattern - Side by Side

GASTRIC ULCER                    DUODENAL ULCER
──────────────────────           ──────────────────────
Eat meal                         Eat meal
   ↓                                ↓
Pain STARTS or WORSENS           Pain RELIEVED (food buffers acid)
   ↓                                ↓
Avoids food → loses weight       2-4 hours later: stomach empties
                                    ↓
                                 Acid hits ulcer → Pain RETURNS
                                    ↓
                                 Eats again → Pain relieved again
                                 (cycle repeats, gains/maintains weight)

Important Caveats

1. Symptom overlap is high - distinguishing gastric from duodenal ulcer on symptoms alone is unreliable; endoscopy is needed
2. Elderly patients (>65 yrs) often have no symptoms at all or only atypical symptoms (nausea, weight loss, bleeding) regardless of ulcer type
3. Asymptomatic "silent" ulcers are common in both types, especially in NSAID users
4. Alarm symptoms (unexplained weight loss, vomiting, bleeding, dysphagia, epigastric mass) in either type require urgent endoscopy to rule out malignancy