How Frequent is Back Pain with Duodenal Ulcers?

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How common is back pain with duodenal ulcers?

Back pain is common with a duodenal ulcer. Approximately one-third of painful duodenal ulcers will radiate to the back. In addition, back pain is often associated with epigastric pain. Isolated back pain without epigastric pain is rare.

According to Yamada’s Textbook of Gastroenterology, Back pain is seen in:

  • Up to 31% of patients with duodenal ulcers.
  • Up to 34% of patients with stomach (gastric) ulcers.

Back pain can occur in both gastric and duodenal ulcers. So, it is not a helpful differentiator between the two types of ulcers.

The most common duodenal ulcer pain is in the epigastric area (upper central abdomen below the breast bone). Other less common locations include the left and right upper abdominal areas.


Duodenal ulcer pain locationFrequency (%)
EpigastricUp to 86%
Right upper abdomenUp to 17%
Left upper abdomenUp to 5%
Radiation to the backUp to 31%
Associated heartburn (in the chest)27-59%

Can back pain be the only symptom of a duodenal ulcer?

Although back pain is associated with duodenal ulcers, it often occurs as radiation from epigastric pain.

Isolated back pain without other symptoms is not typical for duodenal ulcers.

However, some studies reported back pain as a primary symptom of duodenal ulcers. For example, This study found that one patient out of 35 with a duodenal ulcer had back pain as a primary symptom.

Another case report found a patient with back pain due to a duodenal ulcer as the primary cause of pain. The pain improved after he received the treatment for the ulcer.

Interestingly, the location of back pain, in this case, was extended to the lower back. Therefore, the researchers in this scientific paper recommended listing duodenal ulcers as a cause of low back pain.

But case reports are considered weak evidence. We need more research to prove or disprove this association between isolated back pain and duodenal ulcers.

Differences between the stomach and duodenal ulcers (in locations and symptoms):

The following key facts may help the differentiation between stomach and duodenal ulcers. However, pain locations and symptoms are not reliable for differentiation.

  • Duodenal ulcers, gastric ulcer pain locations, and radiation to the back are the same. Pain locations are not a reliable differentiator between the two types.
  • Eating often improves duodenal ulcer pain. But on the other hand, eating worsens and triggers gastric ulcer pain.
  • As a result, patients with duodenal ulcers have a normal or increased appetite, while patients with stomach ulcers may suffer from weight loss.
  • Stomach ulcer pain starts shortly after eating (30 minutes to 2 hours), while duodenal ulcer pain often starts several hours after eating (2 to 5 hours).
  • Duodenal ulcer pain is often more frequent at night and attacks (episodes). In contrast, stomach ulcer pain persists for more extended periods.

The complete comparison between the two types of ulcers are in the table below:


Duodenal UlcerGastric Ulcer
The primary pain is in the epigastric area, may spread to the left or right hypochondrium and the back.The same pain locations and radiations.
Often improved by eating.Often aggravated by eating.
Good appetite, with normal or overweight.Loss of appetite is often associated with weight loss.
Pain starts later after eating (two to four hours after meals).Pain starts shortly after eating (within one to two hours)
The pain is often episodic (comes in attacks that are short-lived).The pain is often persistent for long hours or days.
More likely to occur at night (up to 88% of the time).Less common for the pain to occur at night (up to 48%).
Nausea and vomiting are slightly less commonNausea and vomiting are slightly more common
Less likely to turn malignantmore likely to turn malignant (gastric cancer), especially in the elderly.
Associated with H. Pylori infection100% of the time.Associated with H. Pylori infection in 70% of the time
When it bleeds, it is more likely to cause hematemesis (vomiting of blood).When it bleeds, it is more likely to cause melena (black stool).

Mimics of duodenal ulcer back pain.

Back pain can be due to local causes (spines, back muscles, or pinched nerves) or radiation from internal abdominal organs.

If you have isolated back pain, it is better to think of local causes. However, if the back pain is associated with digestive symptoms, you should consider causes in the digestive system, such as:

  • Stomach ulcers
  • Duodenal ulcers
  • Acute and chronic pancreatitis or pancreatic tumors.
  • Gallbladder conditions as gallstones.

The following are the most common mimics of duodenal ulcer back pain.

1] Functional dyspepsia.

Functional dyspepsia (or non-ulcer dyspepsia) is a term used to describe gastroduodenal symptoms that are not explained by ulcers.

Functional dyspepsia refers to epigastric pain or discomfort in patients who don’t have evidence of stomach or duodenal diseases (as ulcers).

Many people who have symptoms identical to duodenal and gastric ulcers will have no ulcers by endoscopy. Those patients are far more common than peptic ulcer patients.

The pain from functional dyspepsia is also referred to the back as peptic ulcers.

Symptoms include:

  • Pain or discomfort in the middle of the stomach (the pain may be referred to in the back as peptic ulcers)
  • Early satiety soon after you start eating.
  • A sense of fullness in the upper-middle part of your abdomen after eating.
  • Epigastric (upper-middle abdomen) burning.
  • Bloating after eating.
  • Excessive bleching.
  • Nausea can also be present.

2] Pancreatic conditions

The pancreas lies behind other abdominal organs (just in front of the vertebral column).

Pancreatic pain is mainly epigastric area but is commonly referred to as the back.

Many conditions can lead to pancreatic pain, such as acute pancreatitis, chronic pancreatitis, and pancreatic cancers.

The most common cause is acute pancreatitis, which presents with a more extreme epigastric and back pain and is often associated with vomiting.

Symptoms of acute pancreatitis:

  • Acute onset, severe, persistent pain in the upper central stomach (a few inches above the belly button). The pain can radiate to the mid-back.
  • Nausea and vomiting are present in about 90% of the causes (reference).
  • The pain radiates to the back (upper mid-back area) in 50% of the cases (reference).
  • Shortness of breath.
  • Fever.

Symptoms of chronic pancreatitis:

  • Pain above the belly button in the middle of the stomach (less severe than acute pancreatitis pain).
  • The pain often radiates to the back.
  • Recurrent diarrhea, particularly after eating fatty foods. The stool is yellowish or grey, with an oily consistency.
  • Weight loss.
  • Occasional nausea or vomiting.
  • Some patients are asymptomatic.

3] Gallbladder conditions.

Gallbladder conditions such as gallstones can cause epigastric and right upper quadrant abdominal pain that radiates to the back.

The typical gallbladder attack (uncomplicated biliary colic is described in the table below)

Biliary colic.


1. Site

Usually, the upper-middle or the upper-right quadrant of your abdomen

2. Spread

– The pain may spread to the back of the right shoulder or between shoulder blades.

3. Character

Constant builds up then disappears gradually.

4. Duration

At least 30 minutes. It may last up to 6 hours.

5. Relation to food

– Triggered by foods (especially fatty food and large meals.
– However, it can start spontaneously.

6. NOT related to:

Movement, bowel movements, or the passage of flatus.

7. Nausea

Often Present, severe.

8- Commonly associated symptoms

  • Vomiting, sweating during the attack.
  • Jaundice, dark urine, and itching if there is an obstruction.
  • Fever if there is an infection

4] musculoskeletal conditions.

Muscles, spines of the vertebral column, and nerves can be the source of back pain.

The musculoskeletal causes are the first to be considered if you experience back pain without any other symptoms suggestive of duodenal ulcers.

Features of musculoskeletal back pain include:

  • Character: aching, shooting, or stabbing sensation in the mid-back.
  • Related to movement: bending, standing up, or any move triggers the right mid-back pain. movement
  • Worse in certain positions: the pain is more when you hold specific postures (such as standing upright or lying on the right side).
  • In most cases, the pain heals after 1 or 2 weeks.
  • Sometimes, tender: touching or pressing the affected muscle or ligament exaggerates the pain.