Duodenal Ulcer

What is Duodenal Ulcer?

A duodenal ulcer is a break in the surface lining of the duodenum, the first part of the small intestine. It is one type of peptic ulcer disease, a group of conditions in which the lining of the stomach or duodenum is damaged beyond its superficial layer.^[1] Because it can cause bleeding or a hole in the bowel wall, it needs medical care, and our role is limited to supportive care once you are under a physician's care for it.

Common symptoms

Most duodenal ulcers cause indigestion or upper abdominal pain. Pain from a duodenal ulcer tends to start 2 to 3 hours after a meal, and many people also have bloating, nausea, vomiting, loss of appetite or weight loss.^{[1, 2]}

Some ulcers first show up as complications, such as gastrointestinal bleeding, a blocked stomach outlet or perforation.^[1]

Causes and risk factors

The main causes of peptic ulcer disease are Helicobacter pylori infection, found in roughly 42% of patients in one review, and aspirin or NSAID use, found in about 36%.^[3] Critical illness can also cause stress-related ulcers, and some ulcers have no identified cause.^[4]

Smoking and heavy alcohol use are widely recognized contributors. Genetic studies also point to inherited susceptibility to H. pylori infection and to stomach acid and gut-movement genes.^[5]

How it is diagnosed and treated conventionally

Anyone diagnosed with a duodenal ulcer should be tested for H. pylori, and endoscopy confirms the diagnosis and is needed for some patients.^{[1, 2]} Most patients are treated with a proton pump inhibitor (PPI) combined with antibiotics if H. pylori is present.^[2]

Acid blockers heal most ulcers within about 4 weeks. Eradicating H. pylori sharply lowers the chance of recurrence, and stopping NSAIDs heals most NSAID-related ulcers.^[3] Complications are treated urgently in hospital.^[4]

Why Duodenal Ulcer calls for a whole-person approach

Infection and medicines are the main drivers of duodenal ulcers, so treatment starts there. Other factors still affect how a person feels and may influence the gut, including stress and mood.^{[5, 6]}

Supportive care focuses on these background factors and on symptoms such as discomfort, nausea and poor appetite. It does not replace testing for infection or acid-lowering treatment.

Helicobacter pylori and medicines

H. pylori infection and NSAIDs account for most peptic ulcers, and ulcers are less likely to return once H. pylori is cleared or NSAIDs are stopped.^[3] Please do not stop or change any prescribed medicine, including aspirin or NSAIDs, without your physician.

Stress and the brain-gut connection

A review of stress and the gut describes how stress changes gut movement, secretion, pain perception and mucosal blood flow, and lists peptic ulcer among the conditions linked with stress.^[6] This is general physiology, and stress alone is not considered the main cause of duodenal ulcers.

Mood and shared genetics

A genome-wide study of peptic ulcer disease found overlap with genetic risk for depression and other digestive conditions, but it does not show that depression causes ulcers.^[5]

Acupuncture as supportive care in Duodenal Ulcer

What the research shows

Research directly on duodenal ulcer is very limited. A meta-analysis of 16 trials with 1,570 patients with peptic ulcer, mostly from China, found acupuncture alone was not significantly different from Western medicine for response, ulcer healing or H. pylori clearance. Acupuncture added to Western medicine gave better response and healing rates than Western medicine alone. The authors graded the evidence as low or very low and called for better trials.^[7]

A small 1988 study of 21 patients with duodenal ulcer reported complete healing in 76% of patients after 3 weeks of acupuncture, but it had no control group, so it cannot show that acupuncture caused the healing.^[8]

Acupuncture has been studied more for related upper digestive symptoms. A meta-analysis of 22 trials in functional dyspepsia found that acupuncture added to medication improved symptom scores more than medication alone. The authors rated the quality of the studies as generally low and the evidence as very low to moderate.^[9]

How acupuncture may work

A review of acupuncture at the Zusanli point in animal models of stress-induced gastric ulcer describes anti-inflammatory and antioxidant effects, repair of the stomach lining and interaction with the brain-gut axis.^[10] These are proposed explanations from laboratory work. They have not been shown to heal duodenal ulcers in people.

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points on the abdomen, legs, arms and other areas, usually left in place for about 20 to 40 minutes. A course is typically several visits, and we reassess after a short course to see whether symptoms are changing.

In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[11] Tell the practitioner first if you have a bleeding disorder, take blood thinners or have had a bleeding ulcer, are pregnant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine as supportive care in Duodenal Ulcer

The Ayurvedic view

In Ayurveda, burning upper abdominal pain with acid reflux and sour belching is traditionally grouped under Amlapitta, described as an imbalance of Pitta, the principle linked with heat and digestion. Ulcer-type pain after meals is traditionally described as Parinama Shula. These are traditional categories used to choose care, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Regular meals, avoiding very spicy, sour, fried and fermented foods, and avoiding alcohol and tobacco, which also fits standard medical advice for ulcers
• Cooling, soothing herbs used traditionally for Pitta, prescribed individually
• Stress-reduction practices such as gentle breathing and a steady sleep routine

Panchakarma, including purgation and medicated enema, is not appropriate during pregnancy, acute illness or frailty, and it is generally not considered appropriate with an active or bleeding ulcer or before the ulcer has been medically assessed.

What the research shows

We found no clinical trials of Ayurvedic treatment for duodenal ulcer or peptic ulcer, so the evidence for the ulcer itself is none. Studies exist for Amlapitta, a traditional term closer to acid dyspepsia. One trial of 30 patients compared two plant-ash preparations with placebo for 30 days. It reported that both reduced symptoms, but it was very small, and ulcers had been excluded.^[12] A 30-patient study with no comparison group, using individually chosen herbo-mineral preparations for 28 days, also reported symptom relief.^[13]

These studies cannot tell us whether Ayurvedic treatment helps people who have a duodenal ulcer. Because herbo-mineral preparations can contain metals, product quality matters.^[14]

Herbal medicine as supportive care in Duodenal Ulcer

Herbs and formulas that have been studied

Most research is on Chinese patent medicines taken together with standard ulcer drugs. One meta-analysis covered Kangfuxin, a Chinese patent medicine, used with the PPI rabeprazole in peptic ulcer.^[15] A network meta-analysis compared 11 Chinese patent medicines added to Western medicine in H. pylori-related gastric ulcer.^[16] For dyspepsia, a Cochrane review assessed non-Chinese herbs such as peppermint and caraway oil, turmeric and licorice.^[17]

What the research shows

The evidence is limited. A meta-analysis of 25 trials with 2,555 patients found that Kangfuxin added to rabeprazole improved ulcer healing and symptoms and lowered recurrence compared with rabeprazole alone, without more adverse events. Every treatment group also received standard acid-lowering medicine.^[15] A network meta-analysis of 35 trials in H. pylori-related gastric ulcer, which is a stomach rather than duodenal ulcer, likewise found combination treatment more effective than Western medicine alone, with the authors calling for larger multicenter trials.^[16]

For functional dyspepsia, which is not ulcer disease, a Cochrane review of 41 trials found that some herbs may improve symptoms, but the certainty of evidence ranged from moderate to very low.^[17] None of these studies shows that an herb heals duodenal ulcers or replaces H. pylori treatment.

Safety and herb-drug interactions

Herbs can interact with medicines, and people with ulcers often take NSAIDs, aspirin, blood thinners or PPIs. Reported interactions include enhanced anticoagulation or bleeding when danshen, garlic or ginkgo were combined with warfarin, and bleeding when ginkgo was combined with aspirin.^[18] A history of ulcer bleeding makes this especially relevant, so a practitioner needs your full medication list.

Licorice is traditionally used for ulcers, but its main adverse effects are high blood pressure and low potassium, and it needs caution in pregnancy.^[19] In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[14] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding or have liver or kidney disease. Herbs that irritate the stomach should be avoided with an active ulcer.

Translating traditional medicine into modern biological language

This section is interpretation, not equivalence. Chinese medicine often describes stomach and upper abdominal pain as disharmony between the stomach and liver, or as cold or heat in the stomach. Researchers studying acupuncture for ulcers look at inflammation, repair of the stomach lining and the brain-gut axis, which loosely parallel this picture.^[10]

Ayurveda's aggravated Pitta describes burning and acid symptoms. In modern terms, acid secretion, infection and mucosal defense are the targets of ulcer treatment.^[1] No study has shown that these traditional concepts correspond to specific biological processes.

How this care fits with your medical care

Supportive care here is complementary. Keep your physician or gastroenterologist, finish any H. pylori antibiotic course, and do not stop or change PPIs, antibiotics, aspirin or NSAIDs without your prescriber. We do not diagnose ulcers or manage the disease. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care.

Please bring your diagnosis, any endoscopy or H. pylori test results, a full list of medicines and supplements, and details of any past ulcer bleeding.

When to seek urgent medical care

Duodenal ulcers can cause bleeding or perforation, which are emergencies.^{[1, 3]}

• Vomiting blood or material that looks like coffee grounds
• Black, tarry or bloody stools
• Sudden, severe abdominal pain, or a rigid, very tender abdomen
• Dizziness, fainting, a racing heart or pale skin, which can signal blood loss
• Repeated vomiting, or being unable to keep food or fluids down

If any of these occur, call 911 or go to the nearest emergency department. Tell your physician promptly about unexplained weight loss or trouble swallowing.