Situation Of The Ulcer

Ordinarily the ulcer is found in the ascending or the upper horizontal part of the duodenum, much more rarely in the descending part, and only exceptionally in the lower horizontal section. As a rule it is situated immediately behind the pyloric fold, rarely at some distant point. If the ulcer is situated in the descending part of the duodenum, especially in the immediate neighborhood of the diverticulum Vateri, it may cause through cicatricial strictures important complications involving the pancreatic and biliary outlets.

As a rule there is one duodenal ulcer, exceptionally there are two or four. In the latter instance the ulcers may be found in different stages of development: in the initial stage, in that of commencing cicatrization, or fully cicatrized. The cicatricial process may lead to manifold complications. A stenosis of the duodenum just behind the pylorus or at some distance may result, and create exactly the same disturbances of the stomach as are found in cicatricial stenosis of the pylorus itself. I had the opportunity of observing two cases of this kind. In both the diagnosis of a benign stricture of the pylorus had been made and the patients subjected to operation. At the laparotomy the stricture was found in the duodenum, in one case immediately behind the pylorus and in the other at some distance therefrom.

Sometimes the ulcer progresses quickly and leads to perforation into the peritoneal cavity. Death from shock or from diffuse peritonitis then occurs. If there is a slow extension of the ulcer, it often gives rise to circumscribed peritonitis, usually with adhesions to neighboring organs. If the ulcer perforates after adhesions have been formed, it usually leads to an encapsuled purulent peritonitis. The ulcerative process may occasionally extend to contiguous parts with the formation of ulcers in the liver, gall bladder, or other neighboring organs. The development of a cancer at the base of a duodenal ulcer has also been observed by Eichhorst 1 and Ewald.2

Symptomatology

Occasionally there may be no symptoms whatever during life and the duodenal ulcer may not be discovered until at the autopsy. Sometimes there are no symptoms at first, then suddenly the disease manifests itself by a severe and dangerous hemorrhage or by a fatal perforation. In the majority of cases, however, there are pronounced manifestations during the existence of a duodenal ulcer. Most frequently pains are present, usually to the right of the linea alba, extending up to the right parasternal line in the region below the liver. These pains usually appear from half an hour to two or three hours after meals; as a rule they do not radiate to the back but rather somewhat downward in the abdominal cavity. While the pyloric region is often found slightly painful on pressure, there is no circumscribed area in the epigastrium intensely painful on deep palpation as in ulcer of the stomach. In rare instances the pains are felt by the patient in the epigastric region, which may also show tenderness on pressure. Dyspeptic symptoms, as for instance loss of appetite, nausea, fulness in the epigastric region, are as a rule absent.

Vomiting is likewise a rare occurrence in simple duodenal ulcer, which has not gone on to a partial stenosis of the intestinal lumen.

1 Eichhorst. Zeitschr. f. klin. Medicin, Bd. 14, p. 522.

2 C. A. Ewald: Berl. klin. Wochenschr., 1886.

Hemorrhages as the consequence of an erosion of a more or less large blood-vessel, through the progressing necrotic process, occur in about thirty per cent of duodenal ulcers. The blood is frequently voided with the stools (melaena) which appear dark red or tarry. Occasionally, however, there may be vomiting of blood (haematemesis), in connection with the melaema or without it. If the hemorrhage is very great the patient may bleed to death. This, however, is rare; as a rule the patients recuperate from the loss of blood in about the same time as they do from a gastric hemorrhage.

Constipation is often present. The general condition of the patient is usually good and there may be no loss in flesh.

Perforation is quite a frequent event in duodenal ulcer. The symptoms will differ according to whether perforation has taken place before or after adhesions have been formed. In the former instance perforation leads to a general peritonitis, ending fatally in eighteen to thirty hours. Rarely the course is more protracted when the inflammatory process of the peritoneum has not assumed large dimensions and has become quickly localized through the formation of adhesions in the neighborhood. The perforation manifests itself by a sudden appearance of intense pains in the abdominal cavity, by the usual signs of a general collapse (cold extremities, very quick pulse), and by a swelling of the abdomen. The patient presents an expression of extreme anguish and maintains a rigid attitude often with the legs flexed, being afraid even to stir. The abdomen is painful to the slightest touch. Nausea and constant singultus soon appear. Sometimes the patient is greatly tormented with vomiting. A few hours later, in addition to these symptoms, the area of liver dulness may be found absent in consequence of the escaped gas which has accumulated above its surface and has pressed it down.

Dyspnoea and coma ultimately set in and the patient succumbs.

If perforation has taken place after adhesions have been formed, the same complications occur as in ulcer of the stomach under similar conditions. The duodenal ulcer often heals and there is a complete disappearance of all the morbid symptoms. Sometimes the cicatrix leads to a stricture of the duodenal lumen and then gives rise to ischo-chymia.

Course

The duodenal ulcer has, as a rule, a very protracted course. In some instances a perfect cure may be established without any ill consequences. In the majority, however, complications are common. Hemorrhages, obstruction of the duodenal lumen in consequence of the stenosis and perforation are often observed.

Diagnosis

The diagnosis of a duodenal ulcer can be made with certainty only in a very few instances. Most often only a probable diagnosis will be possible. A duodenal ulcer can be diagnosed with certainty if the symptoms of ulceration follow within a short period after extensive scalding of the skin has taken place. The sudden development of icterus in a case presenting symptoms of gastric ulcer speaks with a certain amount of probability for a duodenal ulcer if gall stones can be excluded. The points which indicate a probable location of the ulcer within the duodenum are the following: 1. The pains usually appear from half an hour to three hours after the ingestion of food and are situated most often to the right of the linea alba in the pyloric region. They never radiate to the back. 2. Repeated attacks of melaena, either not associated with haermatemesis or in which the latter was only slight compared with the mela3na. 3. Most of the patients are men presenting a healthy appearance. 4. Perforation is a frequent occurrence in duodenal ulcer, while it is very rare in the course of gastric ulcer.

If all these points are found associated, then a probable diagnosis of duodenal ulcer may be made, otherwise it is uncertain.

With regard to the differential diagnosis between ulcer of the stomach and that of the duodenum, Leube 1 stated that in the latter the gastric contents show a normal degree of acidity, while in gastric ulcer, as a rule, hyperchlorhy-dria prevails. This point, however, is not of much value, for on the one hand cases of gastric ulcer are found with a lessened degree of secretion, and on the other hand duodenal ulcer may be attended with hyperchlorhydria. In the two cases of duodenal ulcers mentioned above which had been operated upon, the condition of the gastric juice in one was normal, while the other showed intense hyperchlorhydria. The differential diagnosis between ulcer and cancer of the duodenum is the same as that between ulcer and cancer of the stomach or pylorus.

Prognosis

The prognosis of duodenal ulcer is almost always quite serious, as complete recovery is very rare. Relapses after apparent perfect recovery often occur. The sequelae to which the cicatrizing process may give rise, namely, obstruction of the duodenal lumen, must also be taken into consideration, and the possibility of death from perforation should never be forgotten. Another danger lies in the formation of a cancerous growth on the base of the ulcer.

Treatment

On the whole the treatment must be conducted on the same line as that of ulcer of the stomach.

1 Leube: von Ziemssen's "Handbuch der speciellen Pathologie und Therapie," Bd. vii., Abth. 2. "Die Krankheiten des Magens und Darms," Leipzig, 1876.

In some cases the advisability of operative intervention must be considered. Cases in which a duodenal ulcer can be diagnosed with great probability and in which hemorrhages have recurred several times may perhaps be subjected to a gastro-enterostomy during the period of comparative euphoria. For by this procedure the duodenum is relieved of a great deal of irritation caused by the passage of the chyme, and the ulcer is thus given a better chance to heal. Cases in which the cicatrix has led to a partial stenosis of the duodenal lumen should certainly be operated upon, pyloroplasty or gastro-enterostomy being selected.