A thiy year old male presents to the emergency depament with symptoms of epigastric pain radiating to back. He gives a history of epigastric pain that wakes him up at nights and is relieved by consuming food. His past history reveals past 2 episodes of perforated duodenal ulcers which were treated with omental patch surgeries. Pain before and after the surgery has been controlled with proton pump inhibitors and analgesics. The likely diagnosis on this occasion is:
Ans is 'c' i.e. Duodenal ulcer Epigastric pain that awakens the patient at nights, and is relieved by food suggests a diagnosis of duodenal ulcer. Gastric ulcer pain is usually exacerbated by food and does not awaken the patient at nights. "Traditionally pain relieved by food is duodenal and pain exacerbated by food is gastric"- Clinical history taking and examination by Wels 2/e p49. "Two thirds of patients with duodenal ulcers will complain of pain that awakens them from sleep. The pain of gastric ulcer more commonly occurs with eating and is less likely to awaken the patient at night."- Schwaz 9/e p913 The pain of peptic ulcer disease is typically non radiating, burning in quality and located in epigastrium. Radiation to back, as in this patient, is usually a sign of penetration of posterior wall ulcer into the pancreas. This patient gives a history of perforated duodenal ulcers for which he was operated and omental patching done. He is having recurrence as adequate treatment has not been done. He should have been treated for H. pylori infection; either empirically or after confirmation of infection. If despite adequate H. pylori infection or in absence of H. pylori infection if patient is having recurrence, he should be put on lifelong proton pump inhibitors. Schwaz writes - "Patients hospitalized for ulcer complications should receive PPI by continuous IV infusion and, when discharged, should be considered for lifelong PPIs unless the definitive cause is eliminated or a definitive operation performed."
Gastric ulcer
Atrophic gastritis
Duodenal ulcer
Chronic pancreatitis