Stomach and duodenal ulcer: symptoms

It should be understood that the anamnestic data on the previously identified Helicobacter pylori infection and long-term admission to patients with NSAIDs can not be a decisive factor in establishing the diagnosis of peptic ulcer. Anamnestic identification of risk factors for peptic ulcer disease in patients taking NSAIDs may be useful in establishing evidence for conducting FGDS.

[1], [2], [3], [4], [5]

The main symptoms of peptic ulcer

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

Pain is the most common symptom of peptic ulcer of the stomach and duodenum. It is necessary to find out the nature, periodicity, time of occurrence and disappearance of pains, the connection with the reception of food.

To pain in the upper half of the abdomen (more often in the epigastric region) up to 75% of patients complain. Approximately 50% of patients experience pain of low intensity, and about a third of patients have severe pain. The pain may appear or intensify with physical activity, eating spicy food, a long break in eating, drinking alcohol. In the typical course of peptic ulcer, the pains have a clear connection with the intake of food, they occur when the disease worsens and are seasonal, more often in the spring and autumn. In addition, a rather characteristic decrease or even disappearance of pain after taking soda, food, antisecretory (omez, famotidine, etc.) and antacid (Almagel, Gastal, etc.) drugs.

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 lesions are affected, pain occurs immediately after eating.

Late pains occur 1.5-2 hours after a meal, gradually increase as evacuation of contents from the stomach; are characteristic for ulcers of the pyloric part of the stomach and the bulb of the duodenum.

"Hungry" (night) pains occur after 2.5-4 hours after eating, disappear after another intake; are characteristic of ulcers of the duodenum and pyloric part of the stomach. The combination of early and late pains is observed with combined or multiple ulcers.

The intensity of pain can depend on the age (more pronounced - in young people), the presence of complications.

The most typical projection of pain, depending on the location of the ulcerative process, is as follows:

• with ulcers of the cardiac and subcardial parts of the stomach - the area of the xiphoid process;
• with ulcers of the body of the stomach - the epigastric region to the left of the median line;
• with pyloric and duodenal ulcers, the epigastric region to the right of the median line.

Palpation of the epigastric region may be painful.

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

Dyspeptic syndrome is characterized by heartburn, eructation, nausea, vomiting, stool disorder, as well as changes in appetite, a feeling of overflow or bloating, a feeling of discomfort in the epigastric region. Heartburn is noted in 30-80% of patients, it can be persistent and appears, as a rule, 1.5-3 hours after eating. At least 50% of patients complain of burp. 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. Constipation affects almost 50% of patients, which is more often observed with exacerbation of the process. Diarrhea is not typical. The expressed disturbances of appetite at a peptic ulcer, as a rule, are not observed. The patient can limit himself in nutrition with severe pain, which happens when exacerbating.

It is necessary to clarify the patient the presence of episodes of vomiting blood or black stool (melena). Additionally, in case of physical examination, it is necessary to try to identify signs of a possible malignant character of ulceration or the presence of complications of peptic ulcer disease.

With a favorable course of the disease occurs without complications, with alternating periods of exacerbation lasting from 3 to 8 weeks, and remission periods, the duration of which can range from several months to several years. There may also be an asymptomatic course of the disease: the diagnosis of peptic ulcer during life is not established in 24.9-28.8% of cases.

Symptoms of peptic ulcer depending on localization of the ulcer

Symptoms of cardiac and subcardial ulcer ulcers

These ulcers are localized either directly in the esophageal-gastric transition or distal to it, but not more than 5-6 cm.

Characteristic for cardiac and subcardial ulcers are the following features:

• men are more often ill at the age of over 45;
• pains occur early, 15-20 minutes after eating and are localized high in the epigastrium near the xiphoid process;
• pains are often irradiated to the heart area and can be mistakenly regarded as stenocardic. In differential diagnosis, it should be borne in mind that pain in coronary heart disease occurs when walking, at the height of physical activity and disappear at rest. Pain in the cardiac and subcardial ulcer is clearly associated with food intake and does not depend on physical activity, walking, calms down not after taking nitroglycerin under the tongue, as with angina pectoris, and after taking antacids, milk;
• characterized by a mild degree of pain syndrome;
• pains are often accompanied by heartburn, eructation, vomiting due to a lack of cardiac sphincter and the development of gastroesophageal reflux;
• often ulcers of the cardial and subcardial parts of the stomach are combined with hernia of the esophagus of the diaphragm, reflux-esophagitis;
• The most characteristic complication is bleeding, perforation of the ulcer is very rare.

Symptoms of small gastric ulcers

Small curvature is the most frequent localization of gastric ulcers. Characteristic features are the following:

• the age of patients usually exceeds 40 years, often these ulcers occur in the elderly and the elderly;
• pain localized in the epigastric region (somewhat to the left of the median line), arise 1-1.5 hours after eating and cease after evacuation of food from the stomach; sometimes there are late, "night" and "hungry" pains;
• pains are usually noisy, their intensity is moderate; However, in the phase of exacerbation, very intense pain can occur;
• heartburn, nausea, and rarely vomiting;
• gastric secretion is usually normal, but it is also possible in some cases to increase or decrease the acidity of gastric juice;
• in 14% of cases are complicated by bleeding, rarely - by perforation;
• in 8-10% of cases malignant ulcers are possible, and it is commonly believed that malignancy is most characteristic of ulcers located at the bend of low curvature. Ulcers localized in the upper part of the small curvature are mostly benign. 

Symptoms of ulcers of great curvature of the stomach

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

• are rare;
• among patients, older men predominate;
• The symptomatology differs little from the typical clinical picture of a stomach ulcer;
• in 50% of cases the ulcers of the large curvature of the stomach turn out to be malignant, therefore the doctor should always consider the ulcer of such localization as potentially malignant and do repeated multiple biopsies from the edges and bottom of the ulcer.

Symptoms of anthrax ulcer

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

• are found mainly in young people;
• symptomatology is similar to that of duodenal ulcers, late, "nocturnal", "hungry" epigastric pains are characteristic; heartburn; vomiting with acidic contents; high acidity of gastric juice; positive symptom of Mendel on the right in epigastrium;
• it is always necessary to carry out differential diagnostics with a primary ulcerative form of cancer, especially in the elderly, since the antrum department is the preferred location of stomach cancer;
• in 15-20% of cases are complicated by gastric bleeding.

Symptoms of pyloric canker ulcers

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

• the persistent course of the disease;
• characterized by severe pain syndrome, pains are paroxysmal, last about 30-40 minutes, in 1/3 of the pain patients are late, nightly, "hungry", but in many patients they are not associated with eating;
• pain often accompanied by vomiting of acidic contents;
• characteristic stubborn heartburn, paroxysmal excessive saliva separation, feeling of bursting and fullness in the epigastrium after eating;
• with perennial recurrence, pyloric canal ulcers are complicated by the pyloric stenosis; other frequent complications are bleeding (the pyloric canal is copiously vascularized), perforation, penetration into the pancreas; Malignancy is observed in 3-8%.

Symptoms of ulcers of the bulb of the duodenum

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

• the age of patients is usually less than 40 years;
• more sick men;
• pain vepigastrii (more right) appear 1.5-2 hours after eating, often there are nocturnal, early morning, and also "hungry" pain;
• vomiting is rare;
• typical seasonality of exacerbations (mainly in spring and autumn);
• the positive symptom of Mendel in the epigastrium on the right is determined;
• The most frequent complication is perforation of the ulcer. 

When the ulcer is located on the back wall of the bulb of the duodenum, the following manifestations are most typical in the clinical picture:

• the main symptomatology is similar to the above-described symptoms, typical for localization of the ulcer on the anterior wall of the bulb of the duodenum;
• often spasm of the sphincter of Oddi, dyskinesia of the gallbladder of the hypotonic type (a feeling of heaviness and dull pain in the right hypochondrium with irradiation into the right subscapular region);
• the disease is often complicated by the penetration of the ulcer into the pancreas and the hepatic duodenal ligament, the development of reactive pancreatitis.

Ulcers of the duodenum, unlike gastric ulcers, are not malignant.

Symptoms of extra-bulbous (postbulbarnye) ulcers

Vnutrikulichnymi (postbulbarnymi) ulcers called ulcers, located distal to the bulb of the duodenum. They account for 5-7% of all gastroduodenal ulcers and have the characteristic features:

• most common in men aged 40-60 years, the disease begins 5-10 years later compared with duodenal ulcers;
• in the phase of exacerbation, intense pains in the right upper quadrant of the abdomen, radiating to the right subscapular region and back, are very characteristic. Often the pains are paroxysmal and may resemble an attack of urolithic or cholelithiasis;
• pains appear 3-4 hours after eating, and eating, in particular milk, stops 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;
• perforation of the ulcer, in contrast to the localization on the anterior wall of the bulb of the duodenum, is observed much less often;
• in some patients, it is possible to develop mechanical (subhepatic) jaundice, which is caused by compression of the common bile duct with an inflammatory periulcerous infiltrate or connective tissue.

Symptoms of combined and multiple gastroduodenal ulcers

Combined ulcers occur in 5-10% of patients with peptic ulcer. Initially, the ulcer of the duodenal ulcer develops, and a few years later - a stomach ulcer. The presumptive mechanism of this sequence of ulceration is the following.

With an ulcer of the duodenal ulcer, edema of the mucosa, spasm of the intestine, and often cicatricial stenosis of the primary part of the duodenum develop. All this complicates the evacuation of gastric contents, there is a stretching of the aspiral department (antral stasis), which stimulates gastric hyperestimation and, accordingly, causes gastric hypersecretion. As a result, the prerequisites for the development of a secondary gastric ulcer are created, which is more often localized in the region of the stomach angle. The development of an ulcer initially in the stomach, and then in the 12 duodenum is extremely rare and is considered an exception. Perhaps also their simultaneous development.

The combined gastroduodenal ulcer has the following characteristic clinical features:

• the attachment of a gastric ulcer rarely worsens the course of the disease;
• pains in the epigastrium become intense, along with late, nocturnal, "hungry" pains, early pains (arising soon after eating) appear;
• the zone of pain localization in epigastrium becomes more common;
• after eating, there is a painful feeling of overflow of the stomach (even after taking a small amount of food), severe heartburn, often worried about vomiting;
• in the study of the secretory function of the stomach, pronounced hypersecretion is observed, while the production of hydrochloric acid may become even higher than the values that existed with an isolated duodenal ulcer;
• characterized by the development of complications such as cicatricial stenosis of the pylorus, pilorospasm, gastrointestinal bleeding, perforation of the ulcer (often duodenal);
• in 30-40% of cases, the attachment of a gastric ulcer to a duodenal ulcer does not significantly change the clinical picture of the disease and a gastric ulcer can be detected only when gastroscopy. 

Multiple ulcers are called 2 or more ulcers, simultaneously localized in the stomach or duodenum. For multiple ulcers, the following features are characteristic:

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

Symptoms of ulcers of giant gastric and duodenal ulcers

According to ES Riss and Yu. I. Fiszon-Riss (1995), giant ulcers having a diameter of more than 2 cm are called giant AS Loginov (1992) to gigantic ulcers with a diameter greater than 3 cm.

Giant ulcers are characterized by the following features:

• are located mainly on the small curvature of the stomach, less often in the subcardial region, on a large curvature and very rarely in the duodenum;
• pains are much pronounced, their frequency often disappears, they can become almost constant, which requires differential diagnostics with stomach cancer; In rare cases, the pain syndrome may be mild;
• characterized by rapid onset of depletion;
• complications often develop - massive gastric bleeding, penguin penguin, less often - perforation of the ulcer;
• A careful differential diagnosis of a giant ulcer with a primary-ulcerative form of stomach cancer is required; It is possible malignancy of giant gastric ulcers.

Symptoms of long-lasting non-healing ulcers

According to AS Loginov (1984), VM Mayorov (1989), long-term non-healing are called ulcers that do not cicatrize within 2 months. The main reasons for the dramatic lengthening of the healing times of an ulcer are:

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

For long-term non-healing ulcers is characterized by erased symptoms, against the background of therapy acuity of pain decreases. However, quite often such ulcers are complicated by perivisceritis, penetration, and then the pain becomes stubborn, constant, monotonous. There may be a progressive drop in the body weight of the patient. These circumstances dictate the need for careful differential diagnosis of long-term healing ulcers with a primary-ulcerative form of stomach cancer.

Peptic ulcer in senile and old age

Under senile understand ulcers, first developed at the age after 60 years. Ulcers in the elderly or elderly people are called ulcers, first appeared at a young age, but retaining an active course until old age.

Features of peptic ulcer in these age groups are:

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

Features of peptic ulcer disease in women

With the saved normal menstrual cycle, the peptic ulcer proceeds relatively easily, the remission occurs quickly, the ulceration of the ulcer occurs at regular intervals, the long-term non-healing ulcers are not characteristic. Pain syndrome with ulcer disease in women is less pronounced than in men, complications are less frequent. Pregnancy usually causes remission or contributes to its rapid onset.

When the menstrual cycle is violated and in the menopausal period, the course of the peptic ulcer becomes more severe.

[6], [7], [8]

Features of the course of peptic ulcer in adolescence and adolescence

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

• the incidence of gastric and duodenum ulcers in these age groups is significantly higher than in older people;
• the disease often occurs latent or atypical, the pain syndrome is mild and can be masked by significant neurovegetative manifestations (sweating, arterial hypotension, increased irritability);
• the ulcer, as a rule, is localized in the duodenum;
• complications develop rarely;
• the study of functional ability reveals a pronounced gastric hypertension;
• healing of ulcers occurs relatively quickly;
• complications of peptic ulcer develop rarely.

[9], [10], [11], [12], [13], [14]

Atypical course of peptic ulcer disease

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

• pains are often localized mainly in the right hypochondrium or right iliac region and then patients are usually diagnosed with chronic cholecystitis (often calculous), chronic or acute appendicitis ("cholecystitis" or "aphedictic" mask of peptic ulcer). It should be emphasized that at present not everyone agrees with the existence of chronic appendicitis;
• possible atypical localization of pain: in the region of the heart (with ulcer of small curvature of the stomach - "heart" mask); in the lumbar region ("radiculitis" mask);
• in a number of cases, there are "mute" ulcers, not manifested by pain, dyspeptic syndrome. Such "dumb" ulcers can suddenly manifest as gastric bleeding, perforation. Sometimes "mute" ulcers gradually lead to the development of cicatricial stenosis of the pylorus. However, a carefully collected history does not reveal indications for any dyspeptic disorders or pain in the premorbital period. Patients with cicatrical stenosis of the pylorus address to the doctor only when the subjective symptomatology of the stenosis begins to manifest itself. The causes of the "silent" course of peptic ulcer are unknown.

[15], [16], [17], [18], [19], [20]