There is great probability of duodenal ulcer when a patient, apparently in good health, has meltena or bxtnatemesis, with pain just under the liver, to the right of the median line, a few hours after eating, with no gastric disturbance and a prompt return of appetite after the haemorrhage. Collins (Revue Inter. de Bibliog., June 10, '94).
A painful spot over the false ribs on the left side as a symptom of ptosis of the colon. The pressure of the corset or of the trouser-button gives rise to this pain, which is relieved on loosening these garments. The pain goes when the pa tient lies down; returns on getting up, especially at the end of the day; and is not removed by the local action of methyl-chloride, which has such a marked effect on neuralgic pain. Direct pressure by the hand is not painful. Reynier (Jour. de Med., Apr., 1900).
Etiology and Pathology.—Ulceration of the duodenum is analogous to the same lesion as it occurs in the stomach, and it has much the same etiology, path ology, morbid anatomy, and treatment. The process is, however, much less com mon in the duodenum than in the stom ach, in a proportion, as given by various authorities, varying from 1-9 to 1-40. Sometimes ulceration is present in both stomach and duodenum in the same case. The condition is due, in the majority of cases, to the action of the gastric juice upon portions of the mucous membrane whose vitality is lowered by any one of a number of conditions, viz.: venous stasis, haemorrhage, ischaemia (thrombosis, em bolism, vascular spasm, arteriosclerosis), hyaline degeneration of the walls of the arteries, traumatism, etc. The affection is observed most commonly between the ages of 20 and 60, the prevalence being fairly equal in several decades. Occa sionally it is encountered in infants. Males suffer in larger number than females, the proportion being given as 3 to 1.
In investigating the records of 17,652 post-mortem examinations at Guy's Hos pital the authors found 70 cases in which there was an ulcer of the duodenum, either open or healed. It is much rarer than gastric ulcer.
The author's cases give a proportion of 52 males to 17 females, or, if burns be excluded, 43 males to 16 females,—a ratio of 3 to 1. The total of the col lected cases gives 109 males to 4S females, or, excluding burns, of 100 males to 30 females. Thus, while duodenal ulcer is
three times as common in males as in females, gastric ulcer is twice as common in females as in males. Perry and Shaw (Guy's Hosp. Reports, vol. 1, p. 171).
The lesion is commonly situated close to the pylorus. Usually there is but a single ulcer; occasionally there are more. The ulcer varies in size and depth.
The simple ulcer of the duodenum is usually round. Sometimes, however, it is oval, angular, or even irregular. In size it is most variable. Generally, the ulcer is more or less perpendicular to the walls of the intestine. When the ulcer is very chronic, the cicatricial con traction occasions considerable deform ity of the adjacent parts. Extension to the neighboring arteries appears to occur in the following order of frequency: the pancreatico-duodenal, the right gastro epiploic, the hepatic, and then the pan creatic artery. Perforation is the com plication most to be dreaded. In 262 cases perforation occurred 181 times. Collin (These de Paris, '94).
In the process of cicatrization it may cause stenosis of the bowel, or, if situated close to the papillae of Vater, it may in the same way cause obstruction of the choledoch and pancreatic ducts. The portal vein may suffer obstruction from a like cause, with the development of thrombosis and the attendant train of symptoms. The ulcer may perforate into the peritoneal cavity and thus cause death from shock or diffuse peritonitis; or by erosion of a blood-vessel it may give rise to copious haemorrhage. Perfora tion may also take place into an adjacent viscus, or through the abdominal wall, giving rise to the development of sub cutaneous emphysema or the formation of a duodenal fistula. Often there is cir cumscribed peritonitis about the site of the ulcer, with adhesions to contiguous organs. Carcinoma develops at times in the seat of previous ulceration of the duodenum.
Burns of the surface are sometimes at tended with ulceration of the gastro intestinal tract, most commonly in the duodenum, but occasionally in other por tions. (See Burt xs, volume i.) Ulceration of the duodenum after burns is due to septic infarction of the vessels of the duodenum, the gastric juice then acting upon the parts cut off from the vascular supply. Marmaduke Sheild (Brit. Med. Jour., Oct. 27, '94).