Understanding your gut and digestion

Food
passes down the oesophagus (gullet) into the stomach. The stomach makes
acid which is not essential, but helps to digest food. After being
mixed in the stomach, food passes into the duodenum (the first part of
the small intestine). In the duodenum and the rest of the small
intestine, food mixes with enzymes (chemicals). The enzymes come from
the pancreas and from cells lining the intestine. The enzymes break
down (digest) the food which is absorbed into the body.

Some terms explained

• Peptic inflammation
  is inflammation caused by stomach acid. Inflammation may be in the
  stomach, the duodenum (as acid flows in with food), or the lower
  oesophagus (if acid splashes up to cause reflux oesophagitis).
• A peptic ulcer
  is an ulcer caused by stomach acid. An ulcer is where the lining of the
  gut is damaged and the underlying tissue is exposed. If you could see
  inside your gut, an ulcer looks like a small, red crater on the inside
  lining of the gut.
• The duodenum is the most common site for a peptic ulcer. This leaflet deals only with duodenal ulcers. There are separate leaflets called 'Stomach (Gastric) Ulcers' and 'Acid Reflux and Oesophagitis'.

What causes duodenal ulcers?

Your
stomach normally produces acid to help with the digestion of food and
to kill bacteria. This acid is corrosive so some cells on the inside
lining of the stomach and duodenum produce a natural mucous barrier
which protects the lining of the stomach and duodenum. There is
normally a balance between the amount of acid that you make and the
mucus defence barrier. An ulcer may develop if there is an alteration
in this balance, allowing the acid to damage the lining of the stomach
or duodenum. Causes of this include the following:

Infection with Helicobacter pylori

Infection with Helicobacter pylori (commonly just called H. pylori) is the cause in about 19 in 20 cases of duodenal ulcer. More than a quarter of people in the UK become infected with H. pylori
at some stage in their life. Once you are infected, unless treated, the
infection usually stays for the rest of your life. In many people it
causes no problems and a number of these bacteria just live harmlessly
in the lining of the stomach and duodenum. However, in some people this
bacterium causes an inflammation in the lining of the stomach or
duodenum. This causes the defence mucus barrier to be disrupted (and in
some cases the amount of acid to be increased) which allows the acid to
cause inflammation and ulcers.

Anti-inflammatory medicines - including aspirin

Anti-inflammatory
medicines are sometimes called non-steroidal anti inflammatory drugs
(NSAIDs). There are various types and brands. For example: aspirin,
ibuprofen, diclofenac, etc. Many people take an anti-inflammatory
medicine for arthritis, muscular pains, etc. Aspirin is also used by
many people to protect against blood clots forming. However, these
medicines sometimes affect the mucus barrier of the duodenum and allow
acid to cause an ulcer. About 1 in 20 duodenal ulcers are caused by
anti-inflammatory medicines.

Other causes and factors

Other causes are
rare. For example, the Zollinger-Ellison syndrome. In this rare
condition, much more acid than usual is made by the stomach. Other
factors such as smoking, stress, and drinking heavily may possibly
increase the risk of having a duodenal ulcer. However, these are not
usually the underlying cause of duodenal ulcers.

What are the symptoms of a duodenal ulcer?

• Pain
  in the upper abdomen just below the sternum (breastbone) is the common
  symptom. It usually comes and goes. It may occur most before meals, or
  when you are hungry. It may be eased if you eat food, or take antacid
  tablets. The pain may wake you from sleep.
• Other symptoms
  which may occur include: bloating, retching, and feeling sick. You may
  feel particularly full after a meal. Sometimes food makes the pain
  worse.
• Complications occur in some cases, and can be serious. These include:
  • Bleeding ulcer. This can range from a trickle to a life-threatening bleed.
  • Perforation.
    This is where the ulcer goes right through (perforates) the wall of the
    duodenum. Food and acid in the duodenum then leak into the abdominal
    cavity. This usually causes severe pain and is a medical emergency.

What tests may be done?

• Endoscopy
  is the test that can confirm a duodenal ulcer. In this test a doctor or
  nurse looks inside your stomach and duodenum by passing a thin,
  flexible telescope down your oesophagus. They can see any inflammation
  or ulcers.
• A test to detect the H. pylori bacterium is usually done if you have a duodenal ulcer. If H. pylori is found then it is likely to be the cause of the ulcer. See separate leaflet called Helicobacter Pylori and Stomach Pain
  for more detail and how it can be diagnosed. Briefly, it can be
  detected in a sample of faeces (bowel motions), or in a breath test, or
  from a blood test, or from a biopsy sample taken during an endoscopy.

What are the treatments for a duodenal ulcer?

Acid suppressing medication

A 4-8 week
course of a medicine that greatly reduces the amount of acid that your
stomach makes is usually advised. The most commonly used medicine is a
proton pump inhibitor (PPI). These are a class (group) of medicines
that work on the cells that line the stomach, reducing the production
of acid. They include: esomeprazole, lansoprazole, omeprazole,
pantoprazole and rabeprazole, and come in various brand names.
Sometimes another class of medicines called H2 blockers is used. They
are also called histamine H2-receptor antagonists but are commonly
called H2 blockers. H2 blockers work in a different way on the cells
that line the stomach, reducing the production of acid. They include:
cimetidine, famotidine, nizatidine and ranitidine, and come in various
brand names. As the amount of acid is greatly reduced, the ulcer
usually heals. However, this is not the end of the story ...

If your ulcer was caused by H. pylori

Nearly all duodenal ulcers are caused by infection with H. pylori.
Therefore, a main part of the treatment is to clear this infection. If
this infection is not cleared, the ulcer is likely to return once you
stop taking acid-suppressing medication. Two antibiotics are needed. In
addition, you need to take an acid-suppressing medicine to reduce the
acid in the stomach. This is needed to allow the antibiotics to work
well. You need to take this combination therapy (sometimes called
triple therapy) for a week.

One course of combination therapy clears H. pylori infection in up to 9 in 10 cases. If H. pylori is cleared, the chance of a recurrence of a duodenal ulcer is greatly reduced. However, in a small number of people, H. pylori infection returns at some stage in the future.

After treatment, a test to check that H. pylori
has gone may be advised. If it is done, it needs to be done at least
four weeks after the course of combination therapy has finished. In
most cases, the test is negative meaning that the infection has gone.
If it has not gone, then a repeat course of combination therapy with a
different set of antibiotics may be advised. Some doctors say that for
people with a duodenal ulcer, this confirmation test is not necessary
if symptoms have gone. The fact that symptoms have gone usually
indicates that the ulcer and the cause (H. pylori) have gone. But, some doctors say it is needed to play safe. Your own doctor will advise if you should have it. (Note: a test to confirm that H. pylori has gone is usually always recommended if you have a stomach ulcer.)

If your ulcer was caused by an anti-inflammatory medicine

If
possible, you should stop the anti-inflammatory medicine. This allows
the ulcer to heal. You will also normally be prescribed an
acid-suppressing medicine for several weeks (as mentioned above). This
stops the stomach from making acid and allows the ulcer to heal.

However,
in many cases the anti-inflammatory medicine is needed to ease symptoms
of arthritis or other painful conditions, or aspirin is needed to
protect against blood clots. In these situations, one option is to take
an acid-suppressing medicine each day indefinitely. This reduces the
amount of acid made by the stomach, and greatly reduces the chance of
an ulcer forming again.