What are the differences in symptoms between epigastric and duodenal ulcers?

Differences in Symptoms Between Epigastric and Duodenal Ulcers

The main symptomatic difference between gastric (epigastric) and duodenal ulcers is that duodenal ulcer pain typically occurs 1-3 hours after meals and is relieved by food intake, while gastric ulcer pain is often aggravated by food and occurs soon after eating. 1, 2, 3

Key Symptomatic Differences

Gastric (Epigastric) Ulcers

• Pain characteristics:
  • Often worsened by food intake
  • Occurs soon after meals
  • Less likely to be relieved by antacids
  • May cause early satiety and weight loss
• Associated symptoms:
  • More likely to cause nausea and vomiting
  • Weight loss more common
  • Bloating and abdominal fullness
  • Less predictable pain pattern

Duodenal Ulcers

• Pain characteristics:
  • Typically occurs 1-3 hours after meals (when stomach empties)
  • Often occurs at night (1-2 hours after retiring)
  • Relieved by food intake or antacids
  • Pain tends to be more localized to epigastrium
• Associated symptoms:
  • Pain described as "hunger pain" or "empty stomach pain"
  • More predictable pain pattern
  • Less likely to cause significant weight loss
  • May awaken patient from sleep 2, 3

Diagnostic Considerations

Both types of ulcers can present with overlapping and nonspecific symptoms, making clinical differentiation challenging. According to the American College of Radiology guidelines, approximately two-thirds of patients with peptic ulcer disease may be asymptomatic 1, 4.

Important Clinical Distinctions

• Duodenal ulcers are more common than gastric ulcers
• Gastric ulcers have higher risk of malignancy and require biopsy 5
• Both can present with complications including bleeding, perforation, and obstruction
• CT findings may show:
  • Gastric or duodenal wall thickening
  • Focal outpouching of mucosa
  • Focal interruption of mucosal enhancement 1

Complications

Both types of ulcers can lead to similar complications, but with some differences:

• Bleeding: Common in both, but gastric ulcers may have higher risk of significant bleeding
• Perforation: Duodenal ulcers have higher perforation rates, presenting with sudden onset of severe pain 6
• Obstruction: More common with duodenal ulcers due to scarring and inflammation near the pylorus
• Mortality: PUD-related perforation has a mortality rate of up to 30% 1

Diagnostic Approach

Endoscopy remains the gold standard for diagnosis of both types of ulcers 1. CT examination is not typically the first-line test but may be performed when patients present with nonspecific symptoms.

For patients with suspected peptic ulcer disease, a test-and-treat strategy for H. pylori is recommended for younger patients without alarm symptoms, while older patients or those with alarm symptoms should undergo prompt endoscopy 2.

Common Pitfalls

• Misdiagnosing cardiac conditions as peptic ulcer disease (and vice versa)
• Failing to recognize complications requiring urgent intervention
• Not testing for H. pylori infection, which is a major cause of both types of ulcers
• Overlooking NSAID use as a contributing factor
• Failing to obtain biopsy of gastric ulcers to exclude malignancy 1, 5

Understanding these symptomatic differences can help guide initial clinical suspicion, but definitive diagnosis typically requires endoscopic evaluation due to the significant overlap in presentation.