Peptic Ulcer Disease Clinical Presentation

Updated: Jan 29, 2017
  • Author: BS Anand, MD; Chief Editor: Julian Katz, MD  more...
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Presentation

History

Obtaining a medical history, especially for peptic ulcer disease, H pylori infection, ingestion of nonsteroidal anti-inflammatory drugs (NSAIDs), or smoking, is essential in making the correct diagnosis. Gastric and duodenal ulcers usually cannot be differentiated based on history alone, although some findings may be suggestive.

Epigastric pain is the most common symptom of both gastric and duodenal ulcers. It is characterized by a gnawing or burning sensation and occurs after meals—classically, shortly after meals with gastric ulcer and 2-3 hours afterward with duodenal ulcer. Food or antacids relieve the pain of duodenal ulcers but provide minimal relief of gastric ulcer pain.

Duodenal ulcer pain often awakens the patient at night. About 50-80% of patients with duodenal ulcers experience nightly pain, as opposed to only 30-40% of patients with gastric ulcers and 20-40% of patients with nonulcer dyspepsia (NUD). Pain typically follows a daily pattern specific to the patient. Pain with radiation to the back is suggestive of a posterior penetrating gastric ulcer complicated by pancreatitis.

Patients who develop gastric outlet obstruction as a result of a chronic, untreated duodenal ulcer usually report a history of fullness and bloating associated with nausea and emesis that occurs several hours after food intake. A common misconception is that adults with gastric outlet obstruction present with nausea and emesis immediately after a meal.

Other possible manifestations include the following:

  • Dyspepsia, including belching, bloating, distention, and fatty food intolerance
  • Heartburn
  • Chest discomfort
  • Hematemesis or melena resulting from gastrointestinal bleeding. Melena may be intermittent over several days or multiple episodes in a single day.
  • Rarely, a briskly bleeding ulcer can present as hematochezia.
  • Symptoms consistent with anemia (eg, fatigue, dyspnea) may be present
  • Sudden onset of symptoms may indicate perforation.
  • NSAID-induced gastritis or ulcers may be silent, especially in elderly patients.
  • Only 20-25% of patients with symptoms suggestive of peptic ulceration are found on investigation to have a peptic ulcer.

Alarm features that warrant prompt gastroenterology referral [1] include the following:

  • Bleeding or anemia
  • Early satiety
  • Unexplained weight loss
  • Progressive dysphagia or odynophagia
  • Recurrent vomiting
  • Family history of gastrointestinal cancer
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Physical Examination

In uncomplicated peptic ulcer disease (PUD), the clinical findings are few and nonspecific and include the following:

  • Epigastric tenderness (usually mild)
  • Right upper quadrant tenderness may suggest a biliary etiology or, less frequently, PUD.
  • Guaiac-positive stool resulting from occult blood loss
  • Melena resulting from acute or subacute gastrointestinal bleeding
  • Succussion splash resulting from partial or complete gastric outlet obstruction

Patients with perforated PUD usually present with a sudden onset of severe, sharp abdominal pain. Most patients describe generalized pain; a few present with severe epigastric pain. As even slight movement can tremendously worsen their pain, these patients assume a fetal position. Abdominal examination usually discloses generalized tenderness, rebound tenderness, guarding, and rigidity. However, the degree of peritoneal findings is strongly influenced by a number of factors, including the size of perforation, amount of bacterial and gastric contents contaminating the abdominal cavity, time between perforation and presentation, and spontaneous sealing of perforation.

These patients may also demonstrate signs and symptoms of septic shock, such as tachycardia, hypotension, and anuria. Not surprisingly, these indicators of shock may be absent in elderly or immunocompromised patients or in those with diabetes. Patients should be asked if retching and vomiting occurred before the onset of pain.

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