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Gastritis and Peptic Ulcer Disease: Differential Diagnoses & Workup

Author: Philip Shayne, MD, Associate Professor, Residency Program Director, Vice Chair for Education, Department of Emergency Medicine, Emory University School of Medicine
Coauthor(s): Wendi S Miller, MD, Resident Physician, Department of Emergency Medicine, Emory University School of Medicine
Contributor Information and Disclosures

Updated: Nov 10, 2009

Differential Diagnoses

Acute Coronary Syndrome
Gastroenteritis
Aneurysm, Abdominal
Hepatitis
Cholangitis
Inflammatory Bowel Disease
Cholecystitis and Biliary Colic
Mesenteric Ischemia
Cholelithiasis
Myocardial Infarction
Diverticular Disease
Pancreatitis
Esophageal Perforation, Rupture and Tears
Pulmonary Embolism
Esophagitis
Renal Calculi

Other Problems to Be Considered

Gastric cancer
Esophageal varices
Mallory-Weiss tears
Atrophic gastritis
Nonulcer dyspepsia
Functional gastrointestinal disorder
Atypical appendicitis in the pregnant patient

Workup

Laboratory Studies

  • Emergency department workup will vary based on presentation.
    • Complete blood count is used to evaluate acute or chronic blood loss.
    • Electrolytes, BUN, and creatinine levels are useful tests for critical-appearing patients who require fluid resuscitation.
    • Type and screen or crossmatch for transfusion are indicated in unstable or potentially critical patients.
    • aPTT, PT, and INR are indicated in patients with active bleeding and those on anticoagulants.
    • Amylase, lipase, and liver transaminase levels can be helpful to rule out other common causes of epigastric pain.
  • Patients younger than 55 years with no alarm features should be referred for noninvasive testing for H pylori infection in the outpatient setting.5
    • Antibody tests of serum, blood, or urine are widely available and inexpensive but lack reliable sensitivity and specificity. They also cannot distinguish between active and remote infection, thus limiting their usefulness.
    • Urea breath test identifies active H pylori infection and is also used to detect recurrence, but sensitivity is decreased by PPIs, bismuth preparations, and many antibiotics.
    • Fecal antigen testing also detects ongoing infection and is preferred in populations with low pretest probability of disease. This test is not recommended in the setting of bleeding and also requires suspension of PPIs, antibiotics, and bismuth preparations prior to testing.
  • Gastroenterology consultation for endoscopy and invasive testing for H pylori is recommended in patients aged 55 years and older as well as any patient with suspected peptic ulcer disease (PUD) and signs of bleeding, obstruction, or peritonitis as well as those who have failed prior eradication therapy.
    • Rapid urease testing identifies active infection in biopsy specimens. Active bleeding, PPIs, bismuth, and antibiotics decrease sensitivity.
    • Culture of biopsy specimens allows for identification of infection and determination of sensitivities.
    • PCR is being developed as a highly specific and sensitive test for infection.

Imaging Studies

  • A chest x-ray may be useful to detect free abdominal air when perforation is a possibility.
  • A CT scan is only useful when other conditions are being considered.

Other Tests

  • ECG should be ordered in patients with risk factors for cardiac disease.
  • Relief of symptoms with a GI cocktail is not a diagnostic indicator.
  • Serial abdominal exams are useful in determining that the patient is improving and not developing signs of peritonitis.

Procedures

  • Placement of a nasogastric (NG) tube is rarely helpful or indicated.

More on Gastritis and Peptic Ulcer Disease

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

  1. Malfertheiner P, Chan FK, McColl KE. Peptic ulcer disease. Lancet. Aug 13 2009;[Medline].

  2. Yuan Y, Padol IT, Hunt RH. Peptic ulcer disease today. Nat Clin Pract Gastroenterol Hepatol. Feb 2006;3(2):80-9. [Medline].

  3. Tahara T, Arisawa T, Shibata T, Nakamura M, Okubo M, Yoshioka D. Association of endoscopic appearances with dyspeptic symptoms. J Gastroenterol. 2008;43(3):208-15. [Medline].

  4. Turkkan E, Uslan I, Acarturk G, Topak N, Kahraman A, Dilek FH. Does Helicobacter pylori-induced inflammation of gastric mucosa determine the severity of symptoms in functional dyspepsia?. J Gastroenterol. 2009;44(1):66-70. [Medline].

  5. [Guideline] Chey WD, Wong BC,. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. Aug 2007;102(8):1808-25. [Medline].

  6. Tajima A, Koizumi K, Suzuki K, Higashi N, Takahashi M, Shimada T. Proton pump inhibitors and recurrent bleeding in peptic ulcer disease. J Gastroenterol Hepatol. Dec 2008;23 Suppl 2:S237-41. [Medline].

  7. [Guideline] Talley NJ, Vakil N. Guidelines for the management of dyspepsia. Am J Gastroenterol. Oct 2005;100(10):2324-37. [Medline].

  8. Treatment of peptic ulcers and GERD. Treat Guidel Med Lett. Aug 2008;6(72):55-60. [Medline].

  9. [Guideline] Lanza FL, Chan FK, Quigley EM. Guidelines for prevention of NSAID-related ulcer complications. Am J Gastroenterol. Mar 2009;104(3):728-38. [Medline].

  10. Aro P, Storskrubb T, Ronkainen J, Bolling-Sternevald E, Engstrand L, Vieth M. Peptic ulcer disease in a general adult population: the Kalixanda study: a random population-based study. Am J Epidemiol. Jun 1 2006;163(11):1025-34. [Medline].

  11. Logan RP, Walker MM. ABC of the upper gastrointestinal tract: Epidemiology and diagnosis of Helicobacter pylori infection. BMJ. Oct 20 2001;323(7318):920-2. [Medline].

  12. Lowell M. Esophagus, stomach, and duodenum. In: Marx J, Hockberger R, Walls R, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. Vol 2. 6th ed. Mosby; 2006:1390-1394.

  13. Moss SF, Sood S. Helicobacter pylori. Curr Opin Infect Dis. Oct 2003;16(5):445-51. [Medline].

  14. Pang SH, Leung WK, Graham DY. Ulcers and gastritis. Endoscopy. Feb 2008;40(2):136-9. [Medline].

  15. Suerbaum S, Michetti P. Helicobacter pylori infection. N Engl J Med. Oct 10 2002;347(15):1175-86. [Medline].

  16. Yeomans ND. Management of peptic ulcer disease not related to Helicobacter. J Gastroenterol Hepatol. Apr 2002;17(4):488-94. [Medline].

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Further Reading

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Keywords

gastritis, peptic ulcer disease treatment, peptic ulcer disease symptoms, peptic ulcer, peptic ulcer disease, PUD, esophagitis, gastroesophageal reflux, GERD, abdominal pain, erosive gastritis, reflux gastritis, hemorrhagic gastritis, infectious gastritis, gastric mucosal atrophy, Helicobacter pylori, H pylori, NSAID-induced gastritis, peritonitis, Curling ulcers, gastrinoma, Zollinger-Ellison syndrome

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Contributor Information and Disclosures

Author

Philip Shayne, MD, Associate Professor, Residency Program Director, Vice Chair for Education, Department of Emergency Medicine, Emory University School of Medicine
Philip Shayne, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Wendi S Miller, MD, Resident Physician, Department of Emergency Medicine, Emory University School of Medicine
Wendi S Miller, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, and Southern Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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