Duodenal ulcer

　　The duodenal mucosa has a series of defensive and reparative mechanisms that are sufficient to resist the erosion of gastric acid/pepsin. It is only when certain factors damage this mechanism that gastric acid/pepsin can erode the mucosa and lead to the formation of ulcers. Helicobacter pylori and nonsteroidal anti-inflammatory drugs are the most common causes of damage to the duodenal mucosal barrier, leading to the onset of peptic ulcer disease. Excessive gastric acid secretion far exceeding the defensive and reparative effects of the mucosa may also lead to the occurrence of peptic ulcer disease.

　　(1) Helicobacter pylori (H. pylori)

　　Helicobacter pylori is an important cause of peptic ulcer, with an incidence rate of about 90% in patients with duodenal ulcer. After successful eradication of Helicobacter pylori, the recurrence rate of ulcers is significantly reduced.

　　(2) Nonsteroidal anti-inflammatory drugs (NSAIDs)

　　NSAIDs are another common cause of peptic ulcer. NSAIDs cause peptic ulcer disease by weakening the defensive and reparative functions of the mucosa, and the risk of developing peptic ulcer and its complications in patients taking NSAIDs is significantly higher than that in the general population. About 10% to 25% of patients taking NSAIDs for a long time can be found to have gastric or duodenal ulcers, and about 1% to 4% of patients may develop complications such as bleeding and perforation. The risk of ulcer formation and the occurrence of complications are related not only to the type, dose, and duration of NSAID administration, but also to factors such as age, concomitant use of anticoagulant drugs, and glucocorticoids.

　　(3) Gastric acid and pepsin

　　The ultimate formation of duodenal ulcer is due to the autodigestion of the mucosa by gastric acid/pepsin. The decisive role of gastric acid in the formation process of duodenal ulcer is the direct cause of ulcer formation. About 1/3 of duodenal ulcer patients have an increased maximum acid output (MAO) stimulated by gastrin pentapeptide, while the MAO of the other patients is mostly within the normal high range.

　　(4) Other Factors

　　Smoking, heredity, stress, and abnormal duodenal motility are also pathogenic factors for duodenal ulcers.

　　The common complications of duodenal ulcers include:

　　(1) Bleeding

　　The erosion of the ulcer around the surrounding blood vessels can cause bleeding. Bleeding is the most common complication of peptic ulcers and the most common cause of upper gastrointestinal bleeding (accounting for about 50% of all causes).

　　(2) Perforation

　　If the ulcer lesion penetrates the serosal layer, perforation may occur. Clinically, ulcer perforation can be divided into three types: acute, subacute, and chronic, with the acute type being most common. The ulcers that commonly perforate are usually located on the anterior wall of the duodenum, and after perforation, the contents of the gastrointestinal tract leak into the peritoneal cavity, causing acute peritonitis.

　　(3) Pyloric Stenosis

　　Acute attacks of ulcers can cause temporary obstruction due to inflammation, edema, and pyloric spasm, which can be relieved as the inflammation improves; chronic obstruction is mainly due to scar contraction and is persistent. Further gastroscopy or X-ray barium meal examination can be used to confirm the diagnosis.

　　Upper abdominal pain is the main symptom of duodenal ulcers, but some patients may be asymptomatic or have mild symptoms that are not noticed by the patient, and symptoms such as bleeding or perforation may be the first symptoms. Typical clinical characteristics of duodenal ulcers include: ① A chronic process, with a history of several years to several decades; ② Periodic recurrence, alternating between attacks and spontaneous remission, with attack periods of several weeks or months, and remission periods of varying lengths, from a few weeks to several years; attacks are often seasonal, mostly occurring in autumn and winter or winter and spring, and can be triggered by poor mental and emotional conditions or overwork; ③ During attacks, upper abdominal pain is rhythmic, manifested as empty stomach pain, which occurs 2 to 4 hours after meals or (and) at midnight, and the pain is usually relieved by eating or taking antacid drugs.

　　The pain of duodenal ulcers is usually located in the upper middle abdomen or slightly to the right. The pain range is generally limited, with local tenderness, but the site of pain is not necessarily the location of the ulcer. When the ulcer penetrates the serosal layer or becomes a penetrating ulcer, the pain can spread to other parts of the body such as the chest, upper left abdomen, upper right abdomen, or back. Since each person's tolerance to pain varies, there is no objective standard for the degree of pain in ulcer disease, and its nature is determined by the patient's sense, usually described as a feeling of hunger, dull pain, belching, pressure, burning pain, or severe pain and pricking.

　　The occurrence of duodenal ulcers is closely related to lifestyle, which seriously affects the physical health of patients and has a certain impact on their normal life and work. The preventive measures for duodenal ulcers include:

　　(1) Regular Diet: Eating regularly, at fixed times and in appropriate quantities, helps the secretion of digestive glands, which is more conducive to digestion. Avoiding hunger or overeating is important. The temperature of the food should be suitable.

　　(2) Avoid stimulation: Quit smoking and avoid alcohol, eat less spicy foods such as chili and pepper.

　　(3) Eat less fried foods: Because these foods are not easy to digest, they will increase the burden on the digestive tract, and eating too much will cause indigestion. They will also increase blood lipids, which is harmful to health.

　　(4) Eat less preserved foods: These foods contain a lot of salt and certain carcinogens, and should not be eaten in large quantities.

　　(5) Eat less cold and刺激性 foods: Cold and刺激性 foods have a strong stimulating effect on the digestive tract mucosa and are easy to cause damage to the gastrointestinal tract.

　　The common laboratory examination items for duodenal ulcer include:

　　(1) Gastroscopy

　　Gastroscopy is the preferred examination method for diagnosing duodenal ulcer. Gastroscopy not only allows direct observation and imaging of the duodenal mucosa but also can take biopsies for pathological examination and Helicobacter pylori detection under direct vision, and can also detect complications such as early canceration of ulcers. Duodenal ulcers under gastroscopy are mostly round or elliptical, and there are also linear ones, with smooth edges, covered with grayish yellow or grayish white exudates at the bottom. The surrounding mucosa may have congestion and edema, and the folds may converge towards the ulcer.

　　(2) Barium meal X-ray examination

　　Barium meal X-ray examination is suitable for those who have contraindications to gastroscopy or do not want to undergo gastroscopy. The X-ray signs of duodenal ulcer include ulcers, irritation of the duodenal bulb, and malformation of the bulb.

　　(3) Helicobacter pylori detection

　　Helicobacter pylori detection is a routine examination item for the diagnosis of duodenal ulcer. The detection methods are divided into invasive and non-invasive two major categories. The former requires the collection of gastric mucosal tissue through gastroscopy for detection, mainly including rapid urease test, histological examination, and Helicobacter pylori culture; the latter mainly includes 13C or 14C urea breath test, fecal Helicobacter pylori antigen detection, and serological examination (qualitative detection of serum Helicobacter pylori IgG antibody). The rapid urease test is the preferred method for invasive examination, which is simple to operate and low in cost.

　　(4) Gastric juice analysis and serum gastrin determination

　　It is generally used for differential diagnosis when there is a suspicion of gastrinoma.

　　Patients with duodenal ulcer should maintain an optimistic attitude, develop good living habits, have a reasonable diet, actively cooperate with treatment, and only in this way can the occurrence of duodenal ulcer be prevented to the greatest extent.

　　Foods that patients with duodenal ulcer should eat include:

　　(1) Prefer soft and easily digestible foods, avoid foods with large volume, hardness, and a lot of rough fiber to reduce mechanical stimulation to the ulcer surface.

　　(2) Choose fruits and vegetables with less fiber, such as tender cucumbers, tender eggplants, tender cabbage leaves, tomatoes (without skin and seeds), winter melon, carrots, and ripe apples, peaches, and pears.

　　Foods that patients with duodenal ulcer should avoid include:

　　(1) Avoid foods that can strongly stimulate the secretion of gastric juice, such as coffee, strong tea, cocoa, chocolate, strong meat soup, chicken soup, overly sweet foods, alcohol, sweet potatoes, etc.; various spices and strong seasonings such as monosodium glutamate, wasabi, pepper, chili, fennel, and Sichuan pepper should also be controlled.

　　(2) Foods rich in rough fiber, such as corn flour, sorghum, coarse grains, dried soybeans, lotus stems, bamboo shoots, celery, lotus root, chives, soybean sprouts, etc., should be limited. Hard foods, such as preserved pork, ham, sausages, clam meat, peanuts, etc., should not be eaten.

　　(3) Foods rich in gas-producing substances, such as scallions, garlic, radishes, onions, garlic sprouts, etc., are detrimental to ulcer disease.

　　(4) Avoid overly sweet, salty, hot, and cold foods.

　　The aim of Western medicine in treating duodenal ulcers is to eliminate the cause, alleviate symptoms, heal the ulcer, prevent recurrence, and prevent complications. Treatment aimed at the cause, such as eradicating Helicobacter pylori, may completely cure the ulcer disease.

　　(1) General Treatment

　　Live a regular life, avoid overwork and mental stress. Pay attention to dietary regularity, quit smoking and alcohol. NSAID users should try to discontinue use, and even if they have not used them, they should warn patients to be cautious in the future.

　　(2) Medications for Treating Peptic Ulcers and Their Applications

　　Medications for treating peptic ulcers can be divided into two major categories: drugs that inhibit gastric acid secretion and drugs that protect the gastric mucosa. They mainly play a role in alleviating symptoms and promoting ulcer healing and are often used in conjunction with eradication treatment of Helicobacter pylori.

　　(3) Eradication Treatment of Helicobacter pylori

　　For peptic ulcers caused by Helicobacter pylori infection, eradicating Helicobacter pylori not only promotes ulcer healing but also prevents recurrence, thereby completely curing the ulcer. Therefore, for all peptic ulcers with Helicobacter pylori infection, whether they are primary or recurrent, active or inactive, with or without complications, eradication treatment of Helicobacter pylori should be administered. Antibiotics that have a bactericidal effect on Helicobacter pylori include clarithromycin, amoxicillin, metronidazole (or tinidazole), tetracycline, furazolidone, and some quinolones such as levofloxacin. PPIs and colloidal bismuth can inhibit Helicobacter pylori in the body and have a synergistic bactericidal effect with the aforementioned antibiotics.

　　(4) Indications for Surgery

　　Due to the progress of internal medicine treatment, at present, surgical operations are mainly limited to a few patients with complications, including: ①Massive bleeding that is ineffective after internal medicine treatment; ②Acute perforation; ③Scarring pyloric stenosis; ④Cancerous transformation of gastric ulcer; ⑤Intractable ulcers that are ineffective after strict internal medicine treatment.