Asymptomatic peptic ulcer disease.

Peptic ulcer disease is usually diagnosed on the basis of well recognised symptoms confirmed by endoscopy or barium study. Within the community an unknown number of people, however, may have peptic ulcer disease without symptoms, some of whom present only because of haemorrhage or perforation. Roughly a third of the cases of perforated peptic ulcer, for example, occur in people without any previous symptoms, as do a fifth of gastrointestinal haemorrhage.2 3 There are no series reporting asymptomatic people who have been studied with endoscopy, and though necropsy studies indicate that almost a fifth of the population may have some evidence of peptic ulcer disease-active ulcer, scars, or previous surgery-the proportion of those without symptoms has not been recorded; nor is it clear whether the ulcer was a feature of the terminal illness.4 Trials of treatment for duodenal and gastric ulcer have shown that ulcers may persist or recur in patients who have remained symptom free,56 although they are clearly different from the general population in that they have previously had symptoms and will probably also develop further ones within the next year.7 Elderly people, patients with rheumatoid arthritis, and those taking non-steroidal anti-inflammatory drugs are all at greater risk of peptic ulcer disease, which may remain asymptomatic until presentation with haemorrhage or perforation89; moreover, the non-steroidal drugs may also mask the symptoms of peptic ulcer. Io The prognosis for true asymptomatic peptic ulcer disease must be good as it will be discovered only at necropsy or not at all. Even if it is found apparently incidentally at endoscopy, however, it is difficult not to attribute some of the patient's vague gastrointestinal symptoms to the lesion. For patients with a perforated ulcer simple oversewing of the ulcer appears successful in that perforation recurs in only a few. " Although most of these patients remain symptom free, this does not imply that the ulcer has healed. Asymptomatic ulcer presenting with haemorrhage is a cause for concern, as the mortality may be high3 and rebleeding may occur; long term medical treatment or close endoscopic surveillance is required. Peptic ulcer represents a disease process continuing for perhaps 10-15 years,'2 and most patients are treated for their symptoms or given maintenance treatment for only a fraction of this time. For reasons of cost and feasibility-and often desirability-medicine today still responds only to the patient's symptoms and does little to offer surveillance to an asymptomatic person other than to one with a recognised increased risk of cancer. Hence, although a lot of people in the community are likely to have unrecognised peptic ulcer disease, any proposals for endoscopic or radiological screening to discover it, followed by treatment to suppress the process, are hardly likely to find favour with clinicians.