The symptoms of duodenal ulcer differ but little from those which arc met with when the disease occurs in the stomach. Pain is much oftener absent in the duo denal disease.
When present, it is often extremely severe, making the patient writhe while it lasts; it may occur at regular in tervals, without reference to food; or, if due to food. it is said to begin from two to four hours after the meal, but may, doubtless occur as early as half an hour. The occurrence of such pain in the right hypochondrium, in absence of other symptoms, is considered suffi cient by some to establish a diagnosis of duodenal ulcer.
As to the significance of haemorrhage, in the absence of causes, in the lower bowel, sudden profuse discharge indicates strongly the duodenum as the seat of bleeding, as do also repeated small bleed ings; in the latter case the blood is all tarry. In gastric haemorrhage, if small, the blood passed by the bowel will prob ably be found more altered by the action of the gastric fluid, and, if large, the vomiting will be more prominent than the alvine evacuations; while the con verse probably holds true when the bleeding is duodenal. Wilson Fox ("Reynolds's system of Med.,'"91).
The pain is at times spontaneous, and it can usually be induced or intensified by pressure. At times it recurs in severe paroxysms, radiating to the epigastrium and the sacrum. At other times there is only a sense of vague discomfort or of pressure or of tension. Occasionally there is a feeling of hunger, of gnawing, of corrosion, or of the presence of a foreign body. Barely a tumor can be felt. The appetite may be unaffected and the bowels regular. Dyspeptic symptoms, if present at all, are not pro nounced. Exceptionally there is diar rhoea, but more commonly there is con stipation. Vomiting is not usual, but when it does occur, it takes place usually after a paroxysm of pain or in conse quence of a complicating gastric disorder or perhaps of cicatricial stricture of the duodenum close to the pylorus. Unless the vomitus contain blood it is not dis tinctive. Iaquorrhage is one of the more common symptoms, and it may be slight or copious. The blood may be vomited, or it may be passed by the bowel, or it may be expelled in both these ways. The loss of blood may lie sufficient to cause death without the es cape of blood externally. Jaundice oc
curs rarely and may then be attributed to cicatricial constriction of the chole doch-duct. The disorder may be of long duration and recurrence is not rare after recovery has taken place. Death may re sult suddenly from perforation or }Hemorrhage.
Collin's investigations have shown that, in 262 cases collected, the distance be tween the ulcer and the pylorus was less than 2 inches in 242 eases: i.e., in the upper third of the duodenum. In S5.6 per cent. there was a single ulcer; in 26 cases two ulcers; in 3 cases three ulcers; in 4 eases five ulcers. The usual site is on the anterior duodenal wall. Duodenal ulcers are far more likely to perforate than ulcers of the stomach. Sixty-nine per cent. perforate. In the majority of cases perforation took place directly into the peritoneal cavity.
Intense pain is a constant symptom, and is located in half the cases below the right costal arch or in the epigastrium; rarely on the left side. Prostration is rapid. Temperature is rarely above 100° F., but the pulse is markedly accelerated. Vomiting may not appear for forty-eight hours. There is rapidly increasing rigid ity of the abdominal muscles. Percussion gives tympany in place of normal liver dullness. Schwartz (Brooklyn Med. Jour., July, '99).
Diagnosis.—The diagnosis may be at tended with much difficulty; in fact, the condition may escape detection. The pain and tenderness of duodenal ulcera tion are situated rather more to the right than that of gastric ulceration, while the pain induced by the taking of food oc curs, as a rule, later with the former than with the latter; and when }Hemorrhage occurs the blood is more likely to be passed by the bowel than to be vomited. From malignant disease ulceration of the duodenum is to be differentiated usually by the absence of a tumor and of cachexia and by the greater likelihood of limmor rhage, by the acidity of the gastric juice, with the presence of free hydrochloric acid. riche paroxysms of pain may simu late biliary colic, but with the latter jaundice is more common, the symptoms of digestive derangement are less • pro nounced, the symptoms in general, or their aggravation, are less related to the taking of food, and there is an absence of emesis and of hemorrhage from the bowel.