Duodenal Ulcer

R. Brooke Jeffrey, MD

Key Facts

Terminology

Mucosal erosion of duodenum

Imaging

Best diagnostic clue: Sharply marginated barium collection with folds radiating to edge of ulcer crater on fluoroscopic-guided double-contrast barium study
95% duodenal bulbar ulcers, 5% postbulbar ulcers
Persistent, small, round, ovoid or linear ulcer niche (barium collection)
Smooth, radiolucent ulcer mound of edematous mucosa
Radiating folds converge centrally at edge of ulcer crater
Ring shadow: Barium coating rim of unfilled anterior wall ulcer crater (air-contrast view)

Top Differential Diagnoses

Duodenal inflammation
Duodenal stricture
Duodenal carcinoma

Clinical Issues

2-3x more frequent than gastric ulcers
Burning, gnawing, or aching pain at epigastrium 2-4 hours after meals, relieved by antacids/food
Pain episodes occurring in clusters of days to weeks followed by longer pain-free intervals

Diagnostic Checklist

Eradication of H. pylori is 1st step of treatment
Check for duodenal bulb deformity
Prone compression views necessary to evaluate anterior wall duodenal ulcers

(Left) Graphic illustrates a duodenal ulcer with a deformed bulb due to converging folds and spasm. (Right) Axial NECT in a 47-year-old man 10 days status post surgery for a small bowel obstruction. The patient now presents with severe upper abdominal pain and peritoneal signs of a perforated duodenal ulcer with ectopic gas and fluid in the subhepatic space

, as well as free air

(Left) Axial CECT in a 42-year-old man presenting with acute severe abdominal pain and guarding shows extensive free intraperitoneal gas

from a perforated duodenal ulcer. (Right) Axial CECT in the same patient demonstrates a thickened gastric wall

, probably due to gastritis. Ventral to the duodenal bulb and antrum are small collections of extraluminal gas and oral contrast medium

that confirm the source of perforation.

TERMINOLOGY

Synonyms

Peptic ulcer disease

Definitions

Mucosal erosion of duodenum

IMAGING

General Features

Best diagnostic clue
- Sharply marginated barium collection with folds radiating to edge of ulcer crater on fluoroscopic-guided double-contrast barium study
Location
- 95% duodenal bulbar ulcers, 5% postbulbar ulcers
  - Bulbar ulcers: Apex, central portion, or base of bulb
  - Postbulbar ulcers: Medial wall of proximal descending duodenum above papilla of Vater
- 50% of duodenal ulcers located on anterior wall
Size
- Most ulcers < 1 cm at time of diagnosis
Morphology
- Round/ovoid barium collections
- 5% of duodenal ulcers have linear configuration

Fluoroscopic Findings

Fluoroscopic-guided double-contrast barium studies
- Bulbar ulcers
  - Persistent, small, round, ovoid or linear ulcer niche
  - Smooth, radiolucent ulcer mound of edematous mucosa
  - Radiating folds converge centrally at edge of ulcer crater
  - Ring shadow: Barium-coating rim of unfilled anterior wall ulcer crater (air-contrast view)
  - Deformity of bulb (edema and spasm/scarring)
  - Residual depression of central portion of scar mimics active ulcer crater
  - Pseudodiverticula balloon out between areas of fibrosis and spasm
  - “Cloverleaf” deformity of pseudodiverticula
- Postbulbar ulcers
  - Smooth/rounded indentation on lateral wall opposite ulcer crater (edema and spasm)
  - “Ring stricture”: Eccentric narrowing (scarring)
- Giant duodenal ulcers (> 2 cm)
  - Always located in duodenal bulb
  - Virtually replaces bulb, mistaken for scarred or normal bulb
  - Key clue: Fixed or unchanging configuration
  - Focal narrowing → outlet obstruction (edema and spasm)