Disease of the digestive system: duodenal ulcer. I.

Duodenal ulcer continues to be a common disorder in Britain. It still shows a predominance in males, though there is a suggestion that the difference in incidence between the two sexes may not be as great as it was 20 years ago. Reliable data on the overall incidence of peptic ulceration is understandably difficult to acquire in view of the very variable severity and natural course of the disease. If the incidence of perforation is one factor capable of fairly precise measurement, there is evidence' that at least in one part of the country there has been a real decrease in the number of such complications in the last ten years. Although several interpretations of this finding are possible, it may be that it reflects a recent change in the incidence of duodenal ulcer, just as there is evidence that the pattern of gastric ulcer, at least in Australia, may also be changing.2 The diagnosis of duodenal ulcer is usually strongly suspected from the clinical history alone. The chief and often sole complaint is of epigastric or right hypochondriac pain or discomfort most frequently experienced when the patient is hungry, and by the time he seeks medical advice he has generally noted that eating a meal affords substantial relief for an hour or two. There may also be recurrence of the upper abdominal pain during the night, and if this causes interruption of sleep the patient often has noticed that drinking a glass of milk or taking a small snack will let him return to his sleep. Vomiting is not as common an occurrence in patients with duodenal ulcer as it is with gastric ulcer, but in a minority of duodenal ulcer patients even without pyloric stenosis some vomiting does from time to time occur. Usually this is of partly digested food or clear gastric juice, and the act of vomiting often brings relief of abdominal discomfort. A few patients may deliberately induce vomiting to obtain such relief. Repeated attacks of copious vomiting, particularly of retained gastric contents, do of course suggest the occurrence of pyloric stenosis. By the time the patient seeks medical help he has usually experienced several episodes of his pain or discomfort with remissions of variable length intervening. Since a large variety of antacid and other "indigestion" preparations are widely advertised, and readily available, most patients will have tried one or several of such preparations. Most will have experienced at least partial relief from this self-selected medication, and a good proportion will claim that a dose of bicarbonate of soda is as good as anything to ease the pain. Radiation of the pain through to the back usually occurs only in the most severe relapses of ulcer pain, and this feature is