Peptic ulcer disease: Clinical manifestations and diagnosis
- Nimish B Vakil, MD, AGAF, FACP, FACG, FASGE
Nimish B Vakil, MD, AGAF, FACP, FACG, FASGE
- Clinical Professor of Medicine
- University of Wisconsin School of Medicine and Public Health
A peptic ulcer is a defect in the gastric or duodenal mucosa that extends through the muscularis mucosa into the deeper layers of the wall. Peptic ulcers may present with dyspeptic or other gastrointestinal symptoms, or may be asymptomatic and present with complications such as hemorrhage or perforation. This topic will review the clinical manifestations and diagnosis of peptic ulcer disease. The etiology, complications, and management of peptic ulcer disease are discussed in detail, separately. (See "Epidemiology and etiology of peptic ulcer disease" and "Overview of the complications of peptic ulcer disease" and "Peptic ulcer disease: Management" and "Refractory or recurrent peptic ulcer disease" and "Surgical management of peptic ulcer disease".)
Dyspepsia — Upper abdominal pain or discomfort is the most prominent symptom in patients with peptic ulcers. Approximately 80 percent of patients with endoscopically diagnosed ulcers have epigastric pain . Occasionally the discomfort localizes to the right or left upper quadrants of the hypochondrium . Radiation of pain to the back may occur, but back pain as the primary symptom is atypical. Although ulcer pain is often burning, gnawing, or hunger-like in quality, the discomfort can be vague or crampy. In untreated patients, symptoms can occur in clusters lasting a few weeks followed by symptom-free periods of weeks or months. The "classic" pain of duodenal ulcers occurs two to five hours after a meal when acid is secreted in the absence of a food buffer and at night (between about 11 PM and 2 AM) when the circadian stimulation of acid secretion is maximal .
Patients with peptic ulcers, and particularly pyloric channel ulcers, may have food-provoked symptoms due to visceral sensitization and gastroduodenal dysmotility . These symptoms include epigastric pain that worsens with eating, postprandial belching and epigastric fullness, early satiety, fatty food intolerance, nausea, and occasional vomiting [1,4].
Asymptomatic — Approximately 70 percent of peptic ulcers are asymptomatic . Patients with silent peptic ulcers may later present with ulcer related complications. Between 43 and 87 percent of patients with bleeding peptic ulcers present without antecedent dyspepsia or other heralding gastrointestinal symptoms [4,6,7]. Older adults and individuals on nonsteroidal anti-inflammatory drugs (NSAIDs) are more likely to be asymptomatic and later present with ulcer complications [1,6,8,9].
Ulcer complications — Complications may be heralded by new ulcer symptoms or a change in symptoms or may occur in the absence of typical symptoms. (See "Overview of the complications of peptic ulcer disease".)
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- CLINICAL MANIFESTATIONS
- Ulcer complications
- - Bleeding
- - Gastric outlet obstruction
- - Penetration and fistulization
- - Perforation
- Associated symptoms
- LABORATORY FINDINGS
- Upper endoscopy
- ESTABLISHING THE ETIOLOGY
- Test for Helicobacter pylori
- Assessment of NSAID use
- Additional evaluation
- DIFFERENTIAL DIAGNOSIS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS