Peptic ulcer disease produces no symptom of its own. Most people who have an ulcer are asymptomatic, and the disease is often recognised only when it bleeds, perforates or obstructs. When symptoms do appear they are those of dyspepsia — discomfort centred in the upper abdomen — which many other conditions also produce, so the history narrows the possibilities but rarely makes the diagnosis alone.
Symptoms of an uncomplicated ulcer
The usual symptom is a burning or gnawing pain in the epigastrium, sometimes with bloating, early fullness after eating, belching or nausea. The pain of a duodenal ulcer classically appears when the stomach is empty, about 2 or 3 hours after a meal and often at night, and eating or an antacid relieves it; the pain of a gastric ulcer is more often brought on by eating. This traditional separation is a weak guide, because many patients do not fit either pattern, and the classic fasting pain relieved by food is a poor predictor of the disease: more than 90% of patients with that pattern do not have peptic ulcer disease. Physical examination is usually normal; epigastric tenderness may be present but does not distinguish an ulcer from other causes of dyspepsia.
Because the pain is non-specific, the history matters less for confirming an ulcer than for identifying the features that make a serious lesion more likely — the alarm features.
Alarm features
Alarm features are findings that raise the possibility of a cancer or a complication rather than a simple ulcer. They include unintentional weight loss, anaemia, visible or occult gastrointestinal bleeding (haematemesis, vomiting blood, or melaena, black tarry stool), difficulty or pain on swallowing, persistent vomiting, an epigastric mass, and new dyspepsia in an older patient. Their presence is an indication for prompt upper gastrointestinal endoscopy rather than a trial of empirical acid suppression, and the same applies when dyspepsia begins for the first time after about the age of 50.
When the first sign is a complication
A silent ulcer can announce itself through a complication before any pain is noticed. Bleeding with haematemesis or melaena, the sudden severe abdominal pain of perforation, or persistent vomiting from gastric outlet obstruction can each be the first event, and each carries its own urgency and management.