The following video demonstrates the endoscopic view of a duodenal ulcer and a look at its pathogenesis by reviewing The leaking roof concept by C. S. Goodwin.
The most important causative factor for a duodenal ulcer is Helicobacter pylori.
Endoscopic view of a DU. The endoscope is in the duodenum. Retracting the scope from the second part of the duodenum slowly into the duodenal bulb showed an ulcer in the first part of the duodenum. Biopsies taken from this ulcer were positive for H pylori infection.
C. S. Goodwin published the Leaking roof concept explaining the pathogenesis of a DU in The Lancet in 1988. He compared the duodenum to a house with an intact roof. Any breech in the roof allows the leakage of acid rain resulting in the formation of an ulcer.
We will now look in detail the series of events leading to the formation of a DU according to the leaking roof concept. Gastric hypermotility along with the hyperacidity are the initiative factors which lead to the gastric metaplasia of the duodenum. H pylori which normally infects the gastric antrum producing antral gastritis invades the gastric metaplasia of the duodenum to produce duodenitis. H pylori damages the microvilli and the cytoskelatal webs and also disrupts the intercellular bridges. It also depletes the mucin by producing a protease and a lipase. Acid and pepsin leak through this damaged mucin roof and precipitate erosions and ulcerations leading to the formation of a DU. Other mucin disrupting factors also contribute to this.
The principles of management of a patient with DU is therefore based on the precipitating causes. To repair the roof by treating H pylori and to prevent the acid rain by using proton pump inhibitors.
Chandra S. Dasari, MD, MD Anderson Cancer Center
Gottumukkala S. Raju, MD, MD Anderson Cancer Center