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 "Approach to 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".)
- Barkun A, Leontiadis G. Systematic review of the symptom burden, quality of life impairment and costs associated with peptic ulcer disease. Am J Med 2010; 123:358.
- Earlam R. A computerized questionnaire analysis of duodenal ulcer symptoms. Gastroenterology 1976; 71:314.
- Kang JY, Yap I, Guan R, Tay HH. Acid perfusion of duodenal ulcer craters and ulcer pain: a controlled double blind study. Gut 1986; 27:942.
- Gururatsakul M, Holloway RH, Talley NJ, Holtmann GJ. Association between clinical manifestations of complicated and uncomplicated peptic ulcer and visceral sensory dysfunction. J Gastroenterol Hepatol 2010; 25:1162.
- Lu CL, Chang SS, Wang SS, et al. Silent peptic ulcer disease: frequency, factors leading to "silence," and implications regarding the pathogenesis of visceral symptoms. Gastrointest Endosc 2004; 60:34.
- Matthewson K, Pugh S, Northfield TC. Which peptic ulcer patients bleed? Gut 1988; 29:70.
- Wilcox CM, Clark WS. Features associated with painless peptic ulcer bleeding. Am J Gastroenterol 1997; 92:1289.
- Hilton D, Iman N, Burke GJ, et al. Absence of abdominal pain in older persons with endoscopic ulcers: a prospective study. Am J Gastroenterol 2001; 96:380.
- Ng CY, Squires TJ, Busuttil A. Acute abdomen as a cause of death in sudden, unexpected deaths in the elderly. Scott Med J 2007; 52:20.
- Laosebikan AO, Govindasamy V, Chinnery G, et al. Giant gastric ulcer: an endoscopic roller coaster. Gut 2005; 54:468, 509.
- Graham DY. Ulcer complications and their nonoperative treatment. In: Gastrointestinal Disease, 5th ed, Sleisenger M, Fordtran J (Eds), WB Saunders, Philadelphia 1993. p.698.
- Soybel DI, Kestenberg A, Brunt EM, Becker JM. Gastrocolic fistula as a complication of benign gastric ulcer: report of four cases and update of the literature. Br J Surg 1989; 76:1298.
- Ranschaert E, Rigauts H. Confined gastric perforation: ultrasound and computed tomographic diagnosis. Abdom Imaging 1993; 18:318.
- Odze RD, Bégin LR. Peptic-ulcer-induced aortoenteric fistula. Report of a case and review of the literature. J Clin Gastroenterol 1991; 13:682.
- Ford GA, Simpson AH, Gear MW, Wilkinson SP. Duodenal ulceration into the cystic artery. Postgrad Med J 1990; 66:144.
- Van Steenbergen W, Ponette E, Marchal G, et al. Distal common bile duct stenosis secondary to benign duodenal ulceration: report of a case. Gastrointest Radiol 1990; 15:215.
- Merrill JR. Fistulation to the pancreatic duct complicating duodenal peptic ulcer. Gastroenterology 1984; 87:957.
- Behrman SW. Management of complicated peptic ulcer disease. Arch Surg 2005; 140:201.
- Gunshefski L, Flancbaum L, Brolin RE, Frankel A. Changing patterns in perforated peptic ulcer disease. Am Surg 1990; 56:270.
- Moayyedi P, Talley NJ, Fennerty MB, Vakil N. Can the clinical history distinguish between organic and functional dyspepsia? JAMA 2006; 295:1566.
- Cotton PB, Shorvon PJ. Analysis of endoscopy and radiography in the diagnosis, follow-up and treatment of peptic ulcer disease. Clin Gastroenterol 1984; 13:383.
- Dooley CP, Larson AW, Stace NH, et al. Double-contrast barium meal and upper gastrointestinal endoscopy. A comparative study. Ann Intern Med 1984; 101:538.
- Graham DY, Schwartz JT, Cain GD, Gyorkey F. Prospective evaluation of biopsy number in the diagnosis of esophageal and gastric carcinoma. Gastroenterology 1982; 82:228.
- Levine MS. Role of the double-contrast upper gastrointestinal series in the 1990s. Gastroenterol Clin North Am 1995; 24:289.
- Glick SN. Duodenal ulcer. Radiol Clin North Am 1994; 32:1259.
- Gisbert JP, Esteban C, Jimenez I, Moreno-Otero R. 13C-urea breath test during hospitalization for the diagnosis of Helicobacter pylori infection in peptic ulcer bleeding. Helicobacter 2007; 12:231.
- Lin HJ, Lo WC, Perng CL, et al. Helicobacter pylori stool antigen test in patients with bleeding peptic ulcers. Helicobacter 2004; 9:663.
- van Leerdam ME, van der Ende A, ten Kate FJ, et al. Lack of accuracy of the noninvasive Helicobacter pylori stool antigen test in patients with gastroduodenal ulcer bleeding. Am J Gastroenterol 2003; 98:798.
- Malfertheiner P, Megraud F, O'Morain C, et al. Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report. Gut 2007; 56:772.
- Cappell MS. Profound spatial clustering of simultaneous peptic ulcers. Gut 1989; 30:1329.
- Meko JB, Norton JA. Management of patients with Zollinger-Ellison syndrome. Annu Rev Med 1995; 46:395.
- 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