eMedicine Specialties > Gastroenterology > Stomach

Peptic Ulcer Disease: Differential Diagnoses & Workup

Author: Tri H Le, MD, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Penn State Milton S Hershey Medical Center
Coauthor(s): George T Fantry, MD, Director of Clinical Gastroenterology, Department of Internal Medicine, Division of Gastroenterology, Associate Professor, University of Maryland School of Medicine
Contributor Information and Disclosures

Updated: Jul 17, 2008

Differential Diagnoses

Biliary Colic
Myocardial Ischemia
Cholecystitis
Pancreatic Cancer
Cholelithiasis
Pancreatitis, Acute
Gastritis, Acute
Pancreatitis, Chronic
Gastritis, Chronic
Gastroesophageal Reflux Disease
Mesenteric Artery Ischemia

Other Problems to Be Considered

Crohn disease with gastric or duodenal involvement
Drug-induced dyspepsia
Duodenitis
Functional (nonulcerous) dyspepsia
Gastric infections
Infiltrative diseases of the stomach

Workup

Laboratory Studies

  • In most patients with uncomplicated PUD, routine laboratory tests usually are not helpful. Documentation of PUD depends on radiographic and endoscopic confirmation.
  • If the diagnosis of PUD is unclear or complicated and PUD is suspected, obtaining CBC, liver function tests (LFTs), amylase, and lipase might be useful.

Imaging Studies

  • Upper gastrointestinal series

    • Double-contrast radiography performed by an experienced radiologist might approach the diagnostic accuracy of upper GI endoscopy. However, it has been replaced largely by diagnostic endoscopy, when available.
    • It is not as sensitive as endoscopy for establishing a diagnosis of small ulcers (<0.5 cm).
    • It also does not allow for obtaining a biopsy to rule out malignancy in the setting of a gastric ulcer or to assess for H pylori infection in the setting of a gastroduodenal ulcer.

Other Tests

  • Detection of H pylori infection is essential in all patients with peptic ulcers.
  • Endoscopic or invasive tests include a rapid urease test, histopathology, and culture.

    • Rapid urease tests are considered the endoscopic diagnostic test of choice. The presence of H pylori in gastric mucosal biopsy specimens is detected by testing for the bacterial product urease. Three kits (ie, CLOtest, Hp-fast, Pyloritek) are commercially available, each containing a combination of a urea substrate and a pH sensitive indicator. One or more gastric biopsy specimens are placed in the rapid urease test kit. If H pylori is present, bacterial urease converts urea to ammonia, which changes pH and produces a color change.
    • Obtain histopathology, often considered the criterion standard to establish a diagnosis of H pylori infection , if the rapid urease test result is negative and a high suspicion for H pylori persists (presence of a duodenal ulcer).
    • Culture primarily is used in research studies and is not available routinely for clinical use.
  • Nonendoscopic or noninvasive tests include serum H pylori antibody detection, fecal antigen tests, and urea breath tests.

    • Antibodies (immunoglobulin G [IgG]) to H pylori can be measured in serum, plasma, or whole blood. Results with whole blood tests obtained from finger sticks are less reliable.
    • Urea breath tests detect active H pylori infection by testing for the enzymatic activity of bacterial urease. In the presence of urease produced by H pylori, labeled carbon dioxide (heavy isotope, carbon-13, or radioactive isotope, carbon-14) is produced in the stomach, absorbed into the bloodstream, diffused into the lungs, and exhaled.
    • Fecal antigen testing identifies active H pylori infection by detecting the presence of H pylori antigens in stools. This test is more accurate than antibody testing and is less expensive than urea breath tests.
  • Special studies

    • A fasting serum gastrin level should be obtained in certain cases to screen for Zollinger-Ellison syndrome. Such cases include the following: patients with multiple ulcers; ulcers occurring distal to the duodenal bulb; strong family history of PUD; peptic ulcer associated with diarrhea, steatorrhea, or weight loss; peptic ulcer not associated with H pylori infection or NSAID use; peptic ulcer associated with hypercalcemia or renal stones; ulcer refractory to medical therapy; and ulcer recurs after surgery.
    • A secretin stimulation test may be used if the diagnosis of Zollinger-Ellison syndrome cannot be made with the gastrin level alone. This test can distinguish Zollinger-Ellison syndrome from other conditions with a high serum gastrin level, such as antisecretory therapy with a proton pump inhibitor, renal failure, or gastric outlet obstruction.
    • Measurement of acid secretion is not useful in the routine evaluation of PUD.

Procedures

  • Upper GI endoscopy

    • Preferred diagnostic test in the evaluation of patients with suspected PUD
    • Highly sensitive for the diagnosis of gastric and duodenal ulcers
    • Allows for biopsies and cytologic brushings in the setting of a gastric ulcer to differentiate a benign ulcer from a malignant lesion
    • Allows for detection of H pylori infection with antral biopsies for a rapid urease test and/or histopathology in patients with PUD

More on Peptic Ulcer Disease

Overview: Peptic Ulcer Disease
Differential Diagnoses & Workup: Peptic Ulcer Disease
Treatment & Medication: Peptic Ulcer Disease
Follow-up: Peptic Ulcer Disease
References
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References

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  5. Hawkey CJ, Karrasch JA, Szczepanski L, et al. Omeprazole compared with misoprostol for ulcers associated with nonsteroidal anti-inflammatory drugs. Omeprazole versus Misoprostol for NSAID-induced Ulcer Management (OMNIUM) Study Group. N Engl J Med. 338(11):727-34. [Medline].

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  8. Quan C, Talley NJ. Management of peptic ulcer disease not related to Helicobacter pylori or NSAIDs. Am J Gastroenterol. Dec 2002;97(12):2950-61. [Medline].

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  11. Silverstein FE, Graham DY, Senior JR, et al. Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 123(4):241-9. [Medline].

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  13. Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. N Engl J Med. Jun 17 1999;340(24):1888-99. [Medline].

  14. Yeomans ND, Tulassay Z, Juhasz L, et al. A comparison of omeprazole with ranitidine for ulcers associated with nonsteroidal anti-inflammatory drugs. Acid Suppression Trial: Ranitidine versus Omeprazole for NSAID-associated Ulcer Treatment (ASTRONAUT) Study Group. N Engl J Med. 338(11):719-26. [Medline].

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Further Reading

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Keywords

PUD, Helicobacter pylori infection, H pylori infection, nonsteroidal anti-inflammatory drugs, NSAIDs, mucosal break, dyspepsia, heartburn, smoking, stress, epigastric pain, belching, bloating, distention, fatty food intolerance, hematemesis, melena, gastrointestinal bleeding, Guaiac-positive stool, occult blood loss, succussion splash, gastric outlet obstruction, duodenal ulcers, perforation, gastrinoma, Zollinger-Ellison syndrome, multiple endocrine neoplasia syndrome, MEN-I, antral G cell hyperplasia, systemic mastocytosis, basophilic leukemias, cirrhosis, chronic pulmonary disease, renal failure, renal transplantation, radiation-induced ulcers, chemotherapy-induced ulcers, vascular insufficiency, crack cocaine, duodenal obstruction

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Contributor Information and Disclosures

Author

Tri H Le, MD, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Penn State Milton S Hershey Medical Center
Tri H Le, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and Crohns and Colitis Foundation of America
Disclosure: Nothing to disclose.

Coauthor(s)

George T Fantry, MD, Director of Clinical Gastroenterology, Department of Internal Medicine, Division of Gastroenterology, Associate Professor, University of Maryland School of Medicine
George T Fantry, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Medical Editor

Terence David Lewis, MBBS, FRACP, FRCPC, FACP, Program Director, Internal Medicine Residency, & Assistant Chairman, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, Loma Linda University Medical Center
Terence David Lewis, MBBS, FRACP, FRCPC, FACP is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, California Medical Association, Royal College of Physicians and Surgeons of Canada, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Noel Williams, MD, Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
Noel Williams, MD is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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