Gastric and duodenal ulcer - Symptoms

It should be understood that anamnestic data on previously identified Helicobacter pylori infection and long-term use of NSAIDs by the patient cannot be a decisive factor in establishing the diagnosis of peptic ulcer disease. Anamnestic identification of risk factors for peptic ulcer disease in patients taking NSAIDs may be useful in establishing indications for FGDS.

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The main symptoms of peptic ulcer disease

The main symptoms of a stomach ulcer (peptic ulcer disease) are pain and dyspeptic syndromes (a syndrome is a stable set of symptoms characteristic of a given disease).

Pain is the most typical symptom of gastric ulcer and duodenal ulcer. It is necessary to determine the nature, frequency, time of occurrence and disappearance of pain, and its connection with food intake.

Up to 75% of patients complain of pain in the upper abdomen (usually in the epigastric region). About 50% of patients experience pain of low intensity, and about a third of patients experience severe pain. Pain may appear or intensify during physical exertion, eating spicy food, a long break from eating, or drinking alcohol. In the typical course of peptic ulcer disease, pain is clearly associated with food intake, it occurs during an exacerbation of the disease and is characterized by seasonality - more often in spring and autumn. In addition, a decrease or even disappearance of pain after taking soda, food, antisecretory (omez, famotidine, etc.) and antacid (almagel, gastal, etc.) drugs is quite typical.

Early pains occur 0.5-1 hour after eating, gradually increase in intensity, persist for 1.5-2 hours, decrease and disappear as the gastric contents move into the duodenum; characteristic of ulcers of the body of the stomach. When the cardiac, subcardial and fundal sections are affected, pain sensations occur immediately after eating.

Late pain occurs 1.5-2 hours after eating, gradually increasing as the contents of the stomach are evacuated; it is typical for ulcers of the pyloric part of the stomach and the duodenal bulb.

"Hunger" (night) pains occur 2.5-4 hours after eating, disappear after the next meal; are typical for ulcers of the duodenum and pyloric part of the stomach. A combination of early and late pains is observed in combined or multiple ulcers.

The intensity of pain may depend on age (more pronounced in young people) and the presence of complications.

The most typical projection of pain depending on the localization of the ulcerative process is considered to be the following:

• for ulcers of the cardiac and subcardial sections of the stomach - the area of the xiphoid process;
• for ulcers of the body of the stomach - the epigastric region to the left of the midline;
• for ulcers of the pyloric region and duodenum - the epigastric region to the right of the midline.

Palpation of the epigastric region may be painful.

The absence of a typical character of pain does not contradict the diagnosis of peptic ulcer disease.

Dyspeptic syndrome is characterized by heartburn, belching, nausea, vomiting, bowel movements, as well as changes in appetite, a feeling of fullness or bloating in the stomach, and a feeling of discomfort in the epigastric region. Heartburn is observed in 30-80% of patients, it can be persistent and usually appears 1.5-3 hours after eating. At least 50% of patients complain of belching. Nausea and vomiting are common in peptic ulcer disease, most often vomiting develops at the height of pain and brings relief to the patient, so patients can induce vomiting artificially. Almost 50% of patients suffer from constipation, which is more often observed during an exacerbation of the process. Diarrhea is not typical. Expressed appetite disorders in peptic ulcer disease, as a rule, are not observed. The patient can limit himself in nutrition with severe pain, which happens during an exacerbation.

It is essential to check with the patient for episodes of vomiting blood or black stool (melena). Additionally, during the physical examination, one should specifically try to identify signs of a possible malignant nature of the ulcer or the presence of complications of peptic ulcer disease.

In a favorable course, the disease proceeds without complications, with alternating periods of exacerbation lasting from 3 to 8 weeks, and periods of remission, the duration of which can vary from several months to several years. An asymptomatic course of the disease is also possible: the diagnosis of peptic ulcer disease is not established during life in 24.9-28.8% of cases.

Symptoms of peptic ulcer disease depending on the location of the ulcer

Symptoms of ulcers of the cardiac and subcardial parts of the stomach

These ulcers are localized either directly at the esophagogastric junction or distal to it, but no more than 5-6 cm.

The following features are characteristic of cardiac and subcardial ulcers:

• men over 45 years of age are more likely to get sick;
• pain occurs early, 15-20 minutes after eating and is localized high in the epigastrium near the xiphoid process;
• pains quite often irradiate to the heart area and can be mistakenly assessed as angina. In differential diagnostics, it should be taken into account that pains in ischemic heart disease appear when walking, at the height of physical activity and disappear at rest. Pains in cardiac and subcardial ulcers are clearly associated with food intake and do not depend on physical exertion, walking, and subside not after taking nitroglycerin under the tongue, as in angina, but after taking antacids, milk;
• characterized by a weak expression of pain syndrome;
• pain is often accompanied by heartburn, belching, vomiting due to insufficiency of the cardiac sphincter and the development of gastroesophageal reflux;
• Often ulcers of the cardiac and subcardial parts of the stomach are combined with a hernia of the esophageal opening of the diaphragm, reflux esophagitis;
• The most typical complication is bleeding; ulcer perforation is very rare.

Symptoms of a gastric ulcer of the lesser curvature

The lesser curvature is the most common location for gastric ulcers. The characteristic features are as follows:

• the age of patients usually exceeds 40 years, often these ulcers occur in the elderly and old people;
• the pain is localized in the epigastric region (slightly to the left of the midline), occurs 1-1.5 hours after eating and stops after the food is evacuated from the stomach; sometimes there are late, “night” and “hunger” pains;
• the pain is usually of a nagging nature, its intensity is moderate; however, in the acute phase, very intense pain may occur;
• heartburn, nausea, and, less commonly, vomiting are often observed;
• gastric secretion is usually normal, but in some cases an increase or decrease in the acidity of gastric juice is also possible;
• in 14% of cases they are complicated by bleeding, rarely by perforation;
• In 8-10% of cases, ulcer malignancy is possible, and it is generally accepted that malignancy is most characteristic of ulcers located at the bend of the lesser curvature. Ulcers localized in the upper part of the lesser curvature are mostly benign.

Symptoms of ulcer of the greater curvature of the stomach

Ulcers of the greater curvature of the stomach have the following clinical features:

• are rare;
• older men predominate among patients;
• the symptoms differ little from the typical clinical picture of a stomach ulcer;
• In 50% of cases, ulcers of the greater curvature of the stomach are malignant, so the physician should always consider an ulcer in this location as potentially malignant and perform repeated multiple biopsies from the edges and bottom of the ulcer.

Symptoms of antral ulcer

Ulcers of the antral part of the stomach ("prepyloric") account for 10-16% of all cases of peptic ulcer disease and have the following clinical features:

• are found mainly in young people;
• the symptoms are similar to those of a duodenal ulcer, characterized by late, "night", "hunger" pains in the epigastrium; heartburn; vomiting of sour contents; high acidity of gastric juice; positive Mendel's symptom on the right in the epigastrium;
• It is always necessary to carry out differential diagnostics with the primary ulcerative form of cancer, especially in the elderly, since the antral region is a favorite localization of gastric cancer;
• in 15-20% of cases they are complicated by gastric bleeding.

Symptoms of Pyloric Ulcer

Pyloric canal ulcers account for approximately 3-8% of all gastroduodenal ulcers and are characterized by the following features:

• persistent course of the disease;
• a pronounced pain syndrome is characteristic, the pain is paroxysmal, lasts about 30-40 minutes, in 1/3 of patients the pain is late, at night, “hunger-related”, however, in many patients it is not associated with food intake;
• pain is often accompanied by vomiting of acidic contents;
• characterized by persistent heartburn, paroxysmal excessive salivation, a feeling of distension and fullness in the epigastrium after eating;
• With long-term recurrence of pyloric canal ulcers, they are complicated by pyloric stenosis; other common complications include bleeding (the pyloric canal is highly vascularized), perforation, and penetration into the pancreas; malignancy is observed in 3-8%.

Symptoms of duodenal ulcer

Ulcers of the duodenal bulb are most often localized on the anterior wall. The clinical picture of the disease has the following features:

• the age of patients is usually under 40 years;
• men get sick more often;
• epigastric pain (more on the right) appears 1.5-2 hours after eating, often at night, early in the morning, and also “hunger” pains;
• vomiting is rare;
• seasonality of exacerbations is typical (mainly in spring and autumn);
• a positive Mendel's symptom is determined in the epigastrium on the right;
• The most common complication is ulcer perforation.

When the ulcer is located on the posterior wall of the duodenal bulb, the following manifestations are most characteristic in the clinical picture:

• the main symptoms are similar to the symptoms described above, characteristic of the localization of the ulcer on the anterior wall of the duodenal bulb;
• spasm of the sphincter of Oddi, hypotonic dyskinesia of the gallbladder (a feeling of heaviness and dull pain in the right hypochondrium radiating to the right subscapular region) are often observed;
• The disease is often complicated by ulcer penetration into the pancreas and hepatoduodenal ligament, and the development of reactive pancreatitis.

Ulcers of the duodenum, unlike gastric ulcers, do not become malignant.

Symptoms of extrabulbar (postbulbar) ulcers

Extrabulbar (postbulbar) ulcers are those located distal to the duodenal bulb. They account for 5-7% of all gastroduodenal ulcers and have the following characteristic features:

• most often found in men aged 40-60 years, the disease begins 5-10 years later than duodenal ulcer;
• in the acute phase, intense pain in the right upper quadrant of the abdomen, radiating to the right subscapular region and back, is very typical. Often the pain is paroxysmal and may resemble an attack of urolithiasis or cholelithiasis;
• pain appears 3-4 hours after eating, and eating food, in particular milk, relieves the pain syndrome not immediately, but after 15-20 minutes;
• the disease is often complicated by intestinal bleeding, the development of perivisceritis, perigastritis, penetration and stenosis of the duodenum;
• ulcer perforation, in contrast to localization on the anterior wall of the duodenal bulb, is observed much less frequently;
• In some patients, mechanical (subhepatic) jaundice may develop, which is caused by compression of the common bile duct by inflammatory periulcerous infiltrate or connective tissue.

Symptoms of combined and multiple gastroduodenal ulcers

Combined ulcers occur in 5-10% of patients with peptic ulcer disease. In this case, a duodenal ulcer develops initially, and after several years, a gastric ulcer. The presumed mechanism of such a sequence of ulcer development is as follows.

In case of a duodenal ulcer, mucosal edema, intestinal spasm, and often cicatricial stenosis of the initial section of the duodenum develop. All this complicates the evacuation of gastric contents, the ashral section (antral stasis) stretches, which stimulates hyperproduction of gastrin and, accordingly, causes gastric hypersecretion. As a result, prerequisites are created for the development of a secondary gastric ulcer, which is most often localized in the area of the angle of the stomach. The development of an ulcer initially in the stomach and then in the duodenum is extremely rare and is considered an exception. Their simultaneous development is also possible.

Combined gastroduodenal ulcer has the following characteristic clinical features:

• the addition of a gastric ulcer rarely worsens the course of the disease;
• pain in the epigastrium becomes intense, along with late, night, “hunger” pains, early pains appear (arising soon after eating);
• the area of pain localization in the epigastrium becomes more widespread;
• after eating, there is a painful feeling of fullness in the stomach (even after eating a small amount of food), severe heartburn, and vomiting is often a concern;
• when examining the secretory function of the stomach, pronounced hypersecretion is observed, while the production of hydrochloric acid can become even higher compared to the values that were present in an isolated duodenal ulcer;
• the development of such complications as cicatricial pyloric stenosis, pylorospasm, gastrointestinal bleeding, ulcer perforation (usually duodenal) is characteristic;
• In 30-40% of cases, the addition of a gastric ulcer to a duodenal ulcer does not significantly change the clinical picture of the disease and a gastric ulcer can only be detected by gastroscopy.

Multiple ulcers are 2 or more ulcers located simultaneously in the stomach or duodenum. The following features are characteristic of multiple ulcers:

• tendency to slow scarring, frequent recurrence, development of complications;
• In some patients, the clinical course may not differ from the course of a single gastric or duodenal ulcer.

Symptoms of giant ulcers of the stomach and duodenum

According to E. S. Ryss and Yu. I. Fishzon-Ryss (1995), giant ulcers are those with a diameter of over 2 cm. A. S. Loginov (1992) classifies ulcers with a diameter of over 3 cm as giant.

Giant ulcers are characterized by the following features:

• are located mainly on the lesser curvature of the stomach, less often in the subcardial region, on the greater curvature and very rarely in the duodenum;
• the pain is very pronounced, its periodicity often disappears, it can become almost constant, which requires differential diagnosis with stomach cancer; in rare cases, the pain syndrome may be mild;
• characterized by rapidly developing exhaustion;
• very often complications develop - massive gastric bleeding, penetration into the pancreas, less often - ulcer perforation;
• A careful differential diagnosis of giant ulcers with primary ulcerative form of gastric cancer is required; malignancy of giant gastric ulcers is possible.

Symptoms of long-term non-healing ulcers

According to A. S. Loginov (1984), V. M. Mayorov (1989), ulcers that do not scar within 2 months are called long-term non-healing. The main reasons for a sharp prolongation of ulcer healing time are:

• hereditary burden;
• age over 50 years;
• smoking;
• alcohol abuse;
• the presence of severe gastroduodenitis;
• cicatricial deformation of the stomach and duodenum;
• persistence of Helicobacter infection.

Long-term non-healing ulcers are characterized by erased symptoms, and the severity of pain decreases with therapy. However, such ulcers are often complicated by perivisceritis, penetration, and then the pain becomes persistent, constant, monotonous. Progressive weight loss of the patient may be noted. These circumstances dictate the need for careful differential diagnostics of a long-term non-healing ulcer with the primary ulcerative form of gastric cancer.

Peptic ulcer in old and elderly people

Senile ulcers are those that first developed after the age of 60. Ulcers in old people or elderly people are those that first appeared at a young age but remain active until old age.

The characteristics of peptic ulcer disease in these age groups are:

• an increase in the number and severity of complications, primarily bleeding, compared to the age when the ulcer first formed;
• tendency to increase the diameter and depth of the ulcer;
• poor ulcer healing;
• the pain syndrome is mild or moderate;
• acute development of "senile" ulcers, their predominant localization in the stomach, frequent complication of bleeding;
• the need for careful differential diagnosis with gastric cancer.

Peculiarities of the course of peptic ulcer disease in women

With a normal menstrual cycle, ulcer disease is relatively mild, remission occurs quickly, ulcer scarring occurs within the usual time frame, and long-term non-healing ulcers are not typical. Pain syndrome in ulcer disease in women is less pronounced than in men, complications are observed less frequently. Pregnancy usually causes remission or promotes its rapid onset.

With menstrual cycle disorders and during menopause, the course of peptic ulcer disease becomes more severe.

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Peculiarities of the course of peptic ulcer disease in adolescence and adolescence

Peptic ulcer disease in adolescence and adolescence is characterized by the following features:

• the incidence of gastric and duodenal ulcers in these age groups is significantly higher than in older people;
• the disease often proceeds latently or atypically, the pain syndrome is weakly expressed and can be masked by significant neurovegetative manifestations (sweating, arterial hypotension, increased irritability);
• the ulcer is usually localized in the duodenum;
• complications develop rarely;
• functional capacity testing reveals severe gastric hypertension;
• ulcer healing occurs relatively quickly;
• Complications of peptic ulcer disease develop rarely.

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Atypical course of peptic ulcer disease

Deviations from the typical course of peptic ulcer disease (atypical forms) are as follows:

• pain is often localized predominantly in the right hypochondrium or in the right iliac region, and then patients are usually diagnosed with chronic cholecystitis (often calculous), chronic or acute appendicitis ("cholecystitis" or "appeudicitis" masks of peptic ulcer disease). It should be emphasized that at present, not everyone agrees with the existence of chronic appendicitis;
• atypical localization of pain is possible: in the heart region (with ulcers of the lesser curvature of the stomach - "heart" mask); in the lumbar region ("radiculitis" mask);
• In some cases, there are "silent" ulcers that do not manifest themselves with pain or dyspeptic syndrome. Such "silent" ulcers can suddenly manifest themselves with gastric bleeding and perforation. Sometimes "silent" ulcers gradually lead to the development of cicatricial pyloric stenosis. In this case, a carefully collected anamnesis does not reveal any indications of dyspeptic disorders or pain in the premorbid period. Patients with cicatricial pyloric stenosis consult a doctor only when subjective symptoms of the stenosis itself begin to manifest. The reasons for the "silent" course of peptic ulcer disease are unknown.

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