Peptic ulcer disease

Case history

A 40-year-old man presents to his primary care physician with a 2-month history of intermittent upper abdominal pain. He describes the pain as a dull, gnawing ache. The pain sometimes wakes him at night, is relieved by food and drinking milk, and is helped partially by famotidine. He had a similar but milder episode about 5 years ago, which was treated with omeprazole. Physical examination reveals a fit, apparently healthy man in no distress. The only abnormal finding is mild epigastric tenderness on palpation of the abdomen.

Other presentations

Duodenal ulcers may penetrate posteriorly into the pancreas, causing severe abdominal pain radiating through to the back. Gastric and duodenal ulcers may cause occult blood loss and iron deficiency anaemia. Rarely, patients may develop pyloric stenosis from an ulcer of the pyloric channel and present with nausea, vomiting, early satiety, and a succussion splash on physical examination (caused by gastric outlet obstruction). The combination of peptic ulcer symptoms with diarrhoea may indicate Zollinger-Ellison syndrome.

Importantly, peptic ulcers may cause no symptoms (especially in older people and those taking non-steroidal anti-inflammatory drugs). Then presentation may be sudden, with the signs of bleeding (haematemesis and/or melaena and shock) or perforation with peritonitis.