A 45 yr old male was a known case of duodenal ulcer for which he was on drug therapy. He was also operated twice in past for perforated duodenal ulcer, when omental patch was done, once 2 yrs back and another 6 months prior. Now he presents with complains of epigastric pain since 2-3 days with pain radiating to back and especially severe is pain in the nighttime. Patient says that the pain is relieved by food intake. What is the most likely diagnosis?
(Ref: Sabiston 18th /chapter no 47)
a. The most common symptom associated with duodenal ulcer disease is midepigastric abdominal pain that is usually well localized. The pain is usually tolerable and frequently relieved by food.
b. Moreover, the pain may be episodic, may be seasonal in the spring and fall, or may relapse during periods of emotional stress.
c. For these reasons and because it is relieved, many patients do not seek medical attention until they have had the disease for many years. When the pain becomes constant, this suggests that there is deeper penetration of the ulcer, and referral of pain to the back is usually a sign of penetration into the pancreas. Diffuse peritoneal irritation is usually a sign of free perforation.
d. Epigastric pain described as a burning or gnawing discomfort can be present in both DU and GU. The discomfort is also described as an ill-defined, aching sensation or as hunger pain.
e. The typical pain pattern in DU occurs 90 min to 3 h after a meal and is frequently relieved by antacids or food. Pain that awakes the patient from sleep (between midnight and 3 A.M.) is the most discriminating symptom, with two-thirds of DU patients describing this complaint. Unfortunately, this symptom is also present in one-third of patients with NUD.
f. The pain pattern in GU patients may be different from that in DU patients, where discomfort may actually be precipitated by food. Nausea and weight loss occur more commonly in GU patients.
g. Endoscopy detects ulcers in <30% of patients who have dyspepsia. Variation in the intensity or distribution of the abdominal pain, as well as the onset of associated symptoms such as nausea and/or vomiting, may be indicative of an ulcer complication. Dyspepsia that becomes constant, is no longer relieved by food or antacids, or radiates to the back may indicate a penetrating ulcer (pancreas).
h. Sudden onset of severe, generalized abdominal pain may indicate perforation. Pain worsening with meals, nausea, and vomiting of undigested food suggest gastric outlet obstruction. Tarry stools or coffee-ground emesis indicate bleeding.