10.6: Peptic Ulcer Disease III: Clinical Manifestations and Diagnostic Studies

Peptic ulcer disease (PUD) presents with diverse symptoms depending on the location and severity of the ulcer. Clinical manifestations of peptic ulcer include dull pain and a burning sensation in the mid-epigastric region.

Few clinical manifestations differentiate gastric ulcers from duodenal ulcers. Distinctions in the location, timing, and pain relief are crucial for healthcare providers in differentiating between gastric and duodenal ulcers during clinical assessments.

1. Location of Pain: Gastric ulcers cause burning or gaseous discomfort in the epigastrium. Conversely, duodenal ulcers result in burning or cramp-like pain in the mid-epigastric region.
2. Timing of Pain: Gastric ulcer pain often occurs shortly after eating when the stomach is full, as food can increase the amount of acid in the stomach and exacerbate the pain. In contrast, pain from duodenal ulcers typically manifests when the stomach is empty, usually 2-3 hours after meals, particularly between meals or nighttime. This discomfort arises when stomach acid directly interacts with the ulcer, causing a sensation of pain.
3. Relief of Pain: Consuming antacids or having a meal can alleviate discomfort caused by duodenal ulcers. These actions aid in neutralizing stomach acid and promoting faster stomach emptying, thereby reducing irritation of the ulcer. However, in the case of gastric ulcers, eating might not provide relief and could potentially exacerbate the condition, as it stimulates increased acid production by the stomach.

Other nonspecific symptoms of PUD vary among individuals. These may include sour eructation or burping, bloating, early satiety, heartburn (pyrosis), constipation or diarrhea, and episodes of bleeding. Additionally, vomiting can result from gastric outlet obstruction caused by pyloric muscle spasms, mechanical obstruction from scarring, or acute swelling around the ulcer. The sudden onset of intense upper abdominal pain radiating to the shoulder, accompanied by extreme tenderness in the abdomen, can indicate a perforated peptic ulcer.

The diagnostic evaluation for PUD involves a multifaceted approach, including physical examination, endoscopy, barium contrast studies, and specific tests for identifying H. pylori infection and detecting gastrinoma (such as Zollinger-Ellison syndrome). A physical examination may reveal pain, tenderness in the upper abdomen (epigastric tenderness), or abdominal distention. Endoscopy is a valuable tool for directly visualizing inflammatory changes and identifying the location of the ulcer. In cases where endoscopy is not feasible, a barium contrast study can be used to diagnose gastric outlet obstruction or detect ulcers.

For H. pylori infection, a biopsy of the antral mucosa and rapid urease testing can be performed, as urea is a byproduct of the metabolism of the bacteria H. pylori. Various other tests are available for identifying H. pylori infection, including serologic testing for antibodies, stool antigen testing, and urea breath tests.