Differential diagnosis

The differential diagnosis of suspected peptic ulcer disease includes intra-abdominal and extra-abdominal disorders. The most common diagnosis among patients presenting with chronic epigastric pain is functional dyspepsia. Esophageal diseases such as esophagitis or esophageal dysmotility present with epigastric pain that radiates substernally and to the back, jaw, left shoulder, and arm. Small intestinal disease including inflammatory bowel disease most commonly produces periumbilical pain. Liver capsular distension produces right upper quadrant pain. Gallbladder and bile duct pain is experienced in the epigastrium and right upper quadrant. Pancreatic pain typically is felt in the epigastrium with radiation to the back. Left upper quadrant pain suggests pancreatic disease but may also result from splenic lesions, perinephric disease, and colonic splenic flexure lesions. Cholecystitis may begin in the epigastrium and migrate to the right upper quadrant. Mesenteric ischemia can present with epigastric pain, as can malignancy of the stomach or small intestine. Appendicitis generally causes right lower quadrant abdominal pain but should be considered in any differential diagnosis of abdominal pain.

Nongastrointestinal disease can present with upper abdominal pain. Renal pain from acute pyelonephritis or obstruction of the ureteropelvic junction usually is sensed in the costovertebral angle or flank but upper abdominal pain is not unusual. Pneumonia, especially basilar in location, can present with abdominal pain that is sufficiently severe to prompt exploratory laparotomy.

Diagnostic investigation

Endoscopy

Esophagogastroduodenoscopy (EGD) has emerged as the preferred test because biopsy specimens can be obtained to document the presence of H. pylori infection and to exclude malignancy in gastric ulcers. All suggestive gastric ulcers should be examined by repeat upper gastrointestinal endoscopy 8–12 weeks after initiating appropriate therapy. Although gastric ulcers that clearly develop in association with NSAID use do not always need biopsy, they should be observed until healed.

Helicobacter pylori testing

A variety of invasive and noninvasive methods may be used to document H. pylori infection. Some tests can document active infection whereas others cannot distinguish current from prior infection.

Invasive tests

Biopsy specimens obtained by endoscopy are examined using Giemsa, Warthin–Starry silver, or hematoxylin-eosin stains, which are the standard for diagnosing H. pylori. Biopsy specimens may also be placed in gels containing urea and an indicator (e.g. CLO test, Hpfast, PyloriTek, Pronto Dry) to detect the presence of H. pylori-associated urease activity. Urease tests have 90% sensitivity with specificity of 95–100%. Biopsy tests may give false-negative results in patients who are bleeding acutely or who have been given short courses of antibiotics.

Noninvasive tests

Enzyme-linked immunosorbent assays are available for detecting serum ­immunoglobulin G (IgG) antibodies to H. pylori, with sensitivities of 80–95% and specificities of 75–95%. Titers frequently remain elevated after successful eradication; therefore, serological testing is a poor means of assessing active H. pylori infection and is not recommended for documenting eradication after therapy. Breath tests may be performed using either ¹³C-urea (nonradioactive isotope) or ¹⁴C-urea (radioactive isotope) labels, which are orally administered. Breath tests have 90–100% sensitivities and specificities for active H. pylori

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