Peptic Ulcer symptoms,signs, investigations and complications

This article to discuss the clinical picture of Peptic ulcer ( symptoms and signs ) , the routine investigations and complications in order to achieve a good approach to diagnosis of the disease.

Symptoms of Peptic ulcer 

1. Epigastric pain :
- Character :.burning, stabbing, or dull ache .
- Site : patient points to the epigastrium .  The patient can indicate its site with two or three fingers (the pointing sign). Back pain suggests penetrating ulcer .

- Relation to meals :
Duodenal ulcer: it is worse when the patient is hungry & at night.
Gastric ulcer: It occurs 0.5-1 hr after meals .

- Night pain : Pain wakes the patient from sleep suggests DU.
- Pain relief : 
Duodenal ulcer: Food, antacids and vomiting.
Gastric ulcer: fasting, antacids and vomiting.
2. Nausea : may accompany the pain.

3. Vomiting : It is infrequent but often relieves the pain. Some patients learn to induce vomiting for pain relief.

4. G.I bleeding : 
- It may be manifested by hematemesis or melena. Also chronic undetected blood loss may occur leading to anemia.

5. Appetite is variable :
-  Duodenal ulcer: It increases in most cases. Also the patient may identify the pain as hunger pain and obtains relief by eating, weight gain may occur.

- Gastric ulcer: Patient suffers from sitophobia for fear of pain, weight loss may occur.

6. Heart burn : It occurs due to acid regurgitation. Water brash also may occur .

7. Episodic pain ( Periodicity ) :
This will occur especially in duodenal ulcer. The pain occurs in (on again/off again) episodes lasting 2-3 weeks at a time, three or four times in a year. Between episodes the patient feels well.

8. Manifestations of Complications 
In some patients the ulcer is completely silent, presenting for the first time with complication .

Signs of Peptic ulcer 

( May be negative )
Tender epigastrium .
Signs of anemia.
Signs of peritonitis with perforation.

Investigations :

1. Upper Endoscopy :
- For exclusion of GERD or malignancy & to differentiate between benign & malignant gastric ulcers.
- All gastric ulcers should be biopsied .

2. Barium meal  : less commonly used 
Gastric ulcer : Ulcer niche on the lesser curvature with serial films.Notch on the greater curvature opposite the niche .
Duodenal ulcer :deformity of the duodenal cap with serial films.

3. Investigations for Helicobacter pylori :
1. Serum antibodies: detect IgG antibodies (sensitive and specific) but are not useful for eradication.
2. Urease test: biopsies are added to a urea solution; in positive cases the urease splits urea to release ammonia giving color change in the indicator, as ammonia raises the pH of the solution .
3. Culture: biopsies obtained can be cultured.
4. Histology: H. pylori can be detected histologically by (Giemsa) stained sections of gastric mucosa obtained by biopsy.

Non invasive method to diagnose H. pylori is 13C urea breath test by measuring of the breath after ingestion of  C13 urea. It is a quick, easy screening test.

Complications of Peptic ulcer
1. Hemorrhage, hematemesis, melena or anemia .
2. Fibrosis and obstruction 
- a) Gastric outlet obstruction.      b) Hour-glass stomach.

3. Perforation (common in duodenal ulcer) 
This causes generalized peritonitis, or subphrenic abscess. Plain chest X ray showing pneumoperitoneum. 

4. Penetration : Pain usually is sudden and radiates to the back, with rise of serum amylase.

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