Duodenal ulcer is 4 or 5 times as common as benign gastric ulcer. Morbiditydue to peptic ulcer is a major public health problem.

About 95% of duodenal ulcers occur in the duodenal bulb or cap, i.e. the first 5cm of the duodenum. The remainders are between this area and the ampulla. Ulcers below the ampulla are rare. The ulceration varies from a few millimeter to 1-2cm in
diameter and extends at least through the muscularis mucosae, often through to the serosa and into the pancreas. The margins are sharp, but the surrounding mucosa is often inflamed and edematous. The base consists of granulation tissue and fibrous tissue, representing healing and continuing digestion.

Gastralgia or pain of the epigastrium in traditional Chinese medicine equal to duodenal ulcer. It is thought to be caused by cold, retention, injuries and indulgency of foods or drinks.

Symptoms may be absent, or vague and atypical. In the typical case, pain is described as gnawing, burning, cramplike, or aching or as "heartburn"; it is usually mild or moderate, located over a small area near the midline in the epigastrium near the xiphoid. The pain may radiate below the costal margins into the back, or rarely to the right shoulder. Nausea may be present and vomiting of small quantities of highly acid gastric juice with little or no retained food may occur. The distress usually occurs 45 to 60 minutes after a meal; is usually absent before breakfast; worsens as the day progresses; and may be most severe between 12 midnight and 2 A.M. It is relieved by food, milk, alkalies and vomiting'generally within 5 to 30 minutes.

Spontaneous remissions and exacerbations are common. Precipitating factors are often unknown but may include trauma, infections, or physical or emotional distress.

Signs include superficial and deep epigastric tenderness, voluntary muscle guarding, and unilateral (rectus) spasm over the duodenal bulb.

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