Duodenal Ulcer in the Presence of a Gall-Bladder Symptomatology

Abstract

IN its typical form, peptic ulcer gives a symptom complex which runs more true to form than is the case in almost any other condition. The characteristics for peptic ulcer in general may be roughly divided into four as follows: First, meal relation; second, food ease; third, intermittance, and fourth, chronicity. There is a variation in the symptomatology, particularly as regards food ease, between ulcers in the prepyloric region and those in the postpyloric region. Moynihan (1) has aptly illustrated this in the sequence of pain in relationship to food, in the following manner: “In cases of gastric ulcer, the pain which, after an interval, follows the taking of a meal, gradually disappears before the next meal. In cases of duodenal ulcer, the pain continues until the next meal, or until food is taken to give ease to a wearisome pain. The rhythm of gastric ulcer is ‘food, comfort, pain, comfort’: of duodenal ulcer it is ‘food, comfort, pain’: a quadruple rhythm in the former disease, a triple rhythm in the latter.” Following the ingestion of food, pain is liable to occur at an earlier time in gastric ulcer than in duodenal ulcer. A characteristic which is frequently noted is the occurrence of night pain, which may come on at the same hour every night. The type of food ingested may cause greater or less pain, the aromatic vegetables and heavy meats producing the most severe type of pain. In duodenal ulcer, particularly, although these same foods may give relief more rapidly, pain tends to return in a more severe form. In both gastric and duodenal ulceration, a certain number of individuals will give a history which is in no way typical of either condition. In going over a group of cases operated upon at St. Luke's Hospital, New York City, for gall-bladder disease, I was interested in the number in which either mild or moderately severe cholecystitis was noted, with adhesions to the duodenum and the presence of single or multiple ulcers in the adherent area. The interesting question that arises is, which came first, the cholecystitis or the duodenal pathology? Among many theories as to the cause of peptic ulcer (Nelson, 2), there is mentioned an anatomic relationship between the gall bladder, appendix, and the stomach and duodenum through the related vascular supply of the omentum. The causes of peptic ulcer are generally considered to be thermal, chemical, bacterial, or nervous. Whatever the etiologic factors may be, it is generally accepted that the final stages are (a) lowering the resistance of the intestinal mucosa, possibly by altering the production of their protective secretions, and (b) allowing digestion of the mucosa by the acid pepsin formed in its own glands.