Clinical Features

Burning epigastric pain is the most classic symptom of peptic ulcer disease. Ihe pain may also be described as sharp, dull, an ache, or an "empty" or "hungry" feeling. Pain may be relieved by milk, food, or antacids, presumably due to buffering and/or dilution of acid. Pain recurs as the gastric contents empty, and the recurrent pain may classically awaken the patient at night. Pain tends to occur daily for weeks, resolve, and then reoccur in weeks to months. Although no symptoms allow complete discrimination, in a study by Ialley et al, peptic ulceration was more likely than nonulcer dyspepsia or cholelithiasis in the presence of night pain; pain relieved by food, milk, or antacids; and a shorter duration of pain.7 Postprandial pain, food intolerance, nausea, retrosternal pain, and belching are not related to peptic ulcer disease."12 Atypical presentations are common in those over age 65, including no pain, epigastric pain not relieved by eating, nausea, vomiting, anorexia, weight loss, and bleeding.13

A change in the character of the patient's typical pain may herald a complication. Abrupt onset of severe or generalized pain may indicate perforation with spillage of gastric or duodenal contents and resulting peritonitis. Rapid onset of mid-back pain may be due to posterior penetration into the pancreas, with the development of pancreatitis. Nausea and vomiting may indicate gastric outlet obstruction from scarring or edema. Vomiting bright red blood or coffee-ground emesis, or passing tarry or melanotic stool or hematochezia indicates ulcer bleeding.

On physical examination, the only positive finding in patients with uncomplicated peptic ulcer disease may be epigastric tenderness. Ihis finding is neither sensitive nor specific for the diagnosis.7 Other physical findings may be indicative of complications: a rigid abdomen consistent with peritonitis in perforation; abdominal distention or a succussion splash due to obstruction; occult or gross blood per rectum or nasogastric tube with ulcer bleeding.

Epigastric pain, nausea, and vomiting may be present with acute gastritis, but the most common presentation is gastrointestinal bleeding, ranging from occult blood loss in the stool to massive upper gastrointestinal hemorrhage. Physical findings may be normal, may reflect only the gastrointestinal bleeding, or may reflect a severe underlying associated illness (as listed above).

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