HISTORY. Epigastric pain is the major symptom. Assess pain by obtaining a history of the onset, duration, and characteristics in relation to food intake and medications. Patients may describe pain as sharp, burning, or gnawing, or it may be achy and perceived as abdominal pressure. Pain with duodenal ulcer occurs from 90 minutes to 3 hours after eating, is relieved with food or

Peptic Ulcer Disease 711

antacids, and may awaken a person at night. It is located to the right of the midline epigastrium with duodenal ulcers and to the left of the midline with gastric ulcers. Gastric ulcer pain is precipitated by food and is not relieved by antacid use to the same extent as duodenal ulcer pain is. Some patients have constant pain or no clear pattern of discomfort. As a result of the pain, weight loss and anorexia may occur with gastric ulcers. Weight gain may result with duodenal ulcers because food relieves the pain.

Question the patient about a family history of ulcer disease; smoking and alcohol habits; presence of other symptoms, such as nausea and vomiting; and changes in stool color, level of energy, appetite, and body weight. Review the patient's medication profile, both prescribed and over the counter (OTC). Ask about the amounts of caffeinated beverages taken daily. Determine the foods that aggravate the symptoms. Assess the patient's level of stress and coping skills.

PHYSICAL EXAMINATION. On inspection, you may note pale mucous membranes and skin because of anemia from acute or chronic blood loss. Some patients have black or tarry stools. Currant-colored or bright red stools occur only with massive bleeding. During auscultation, you may note that bowel sounds are hyperactive initially but diminish because of a paralytic ileus with ulcer perforation and peritonitis. Palpation in the midline may reveal epigastric tenderness.

PSYCHOSOCIAL. Researchers have not been able to establish a characteristic duodenal ulcer personality. Chronic stress and anxiety, however, are believed to increase gastric secretions and may be factors in exacerbating ulcer recurrence. Assess the patient's response to the disease, and note any unusual stressors that have an effect on the patient's or significant other's life.

Diagnostic Highlights


Normal Result

Abnormality with Condition


Barium radiographic studies

Esophagogastroduo-dendoscopy (EGD)

Normal gastrointestinal tract

Normal gastrointestinal mucosa

Presence of ulcers often as a protrusion on radiographic examination

Presence of mucosal ulcerations in the stomach or duodenum

Barium study highlights presence of ulcer in stomach or duodenum

Flexible endoscopy to allow visualization of mucosa

Other Tests: Serum gastrin levels, hemoglobin, hematocrit, complete blood count (CBC); tests for H. pylori: (1) antibody detection (immunoglobulin G [IgG]) to H. pylori is measured in serum, plasma, or whole blood; (2) urea breath tests detect active H. pylori infection by identifying enzymatic activity of bacterial urease; and (3) fecal antigen testing to detect presence of H. pylori antigens in stools.

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