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Peptic ulcer differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Guillermo Rodriguez Nava, M.D. [2] Manpreet Kaur, MD [3]

Overview

Peptic ulcer disease must be differentiated from other causes of acute upper gastrointestinal bleeding such as esophageal varices, Mallory-Weiss syndrome, gastrointestinal cancer, arteriovenous malformations, esophagitis, and esophageal ulcer. Peptic ulcer disease must also be differentiated from gastroesophageal reflux disease (GERD,pancreatitis, Zollinger-Ellison Syndrome,cholelithiasis,gastric outlet syndrome,myocardial infaraction ,pleural empyema and appendicitis

Differentiating Peptic Ulcer from other Diseases

Peptic ulcer disease must be differentiated from other diseases that presents with epigastric pain such as gastritis, gastroesophageal reflux disease,acute pancreatitis,prmary biliary cirrhosis,cholelithiasis,gastric outlet syndrome,myocardial infaraction ,pleural empyema,acute appendicitis [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]

Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Fever Rigors and chills Abdominal Pain Jaundice GI Bleed Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders
Acute pancreatitis + βˆ’ Epigastric Β± βˆ’ Β± βˆ’ βˆ’ N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back
Primary biliary cirrhosis βˆ’ βˆ’ RUQ/Epigastric + βˆ’ βˆ’ βˆ’ βˆ’ N Increased AMA level, abnormal LFTs
Cholelithiasis Β± βˆ’ RUQ/Epigastric Β± βˆ’ βˆ’ + + N to hyperactive for dislodged stone Leukocytosis Ultrasound shows gallstone Murphy’s sign
Gastric causes Peptic ulcer disease Β± βˆ’ EpisodicEpigastric βˆ’ + in perforated + + N
  • Ascitic fluid
    • LDH > serum LDH
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
 Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis
Gastritis Β± βˆ’ Epigastric + in chronic gastritis βˆ’
Gastroesophageal reflux disease βˆ’ βˆ’ Epigastric βˆ’ βˆ’ βˆ’ βˆ’ βˆ’
Gastric outlet obstruction βˆ’ βˆ’ Epigastric βˆ’ βˆ’ Β± Hyperactive
Intestinal causes Acute appendicitis + +in pyogenic appendicitis Starts in epigastrium, migrates to RLQ βˆ’ βˆ’ + in perforated appendicitis + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite
Extra-abdominal causes Pulmonary disorders Pleural empyema + Β± RUQ/Epigastric βˆ’ βˆ’ βˆ’ βˆ’ βˆ’ N
Cardiovascular disorders Myocardial Infarction βˆ’ βˆ’ Epigastric βˆ’ βˆ’ + in cardiogenic shock βˆ’ βˆ’ N
Abbreviations:Β RUQ= Right upper quadrant of the abdomen,Β LUQ= Left upper quadrant,Β LLQ= Left lower quadrant,Β RLQ= Right lower quadrant,Β LFT= Liver function test, SIRS=Β Systemic inflammatory response syndrome,Β ERCP=Β Endoscopic retrograde cholangiopancreatography,Β IV= Intravenous,Β N= Normal,Β AMA= Anti mitochondrial antibodies,Β LDH=Β Lactate dehydrogenase,Β GI= Gastrointestinal,Β CXR= Chest X ray,Β IgA=Β Immunoglobulin A,Β IgG=Β Immunoglobulin G,Β IgM=Immunoglobulin M,Β CT=Β Computed tomography,Β PMN= Polymorphonuclear cells,Β ESR=Β Erythrocyte sedimentation rate,Β CRP=Β C-reactive proteinΒ 



Disease Cause Symptoms Diagnosis Other findings
Pain Nausea

&

Vomiting

Heartburn Belching or

Bloating

Weight loss Loss of

Appetite

Stools Endoscopy findings
Location Aggravating Factors Alleviating Factors
Acute gastritis Food Antacids βœ” βœ” βœ” – βœ” Black stools –
Chronic gastritis Food Antacids βœ” βœ” βœ” βœ” βœ” – H. pylori gastritis

Lymphocytic gastritis

  • Enlarged folds
  • Aphthoid erosions
 –
Atrophic gastritis Epigastric pain – – βœ” – βœ” βœ” – H. pylori

Autoimmune

Autoimmune gastritis diagnosis include:

Crohn’s disease – – – – – βœ” βœ”
  • Mucosal nodularity with cobblestoning
  • Multiple aphthous ulcers
  • Linier or serpiginous ulcerations
  • Thickened antral folds
  • Antral narrowing
  • Hypoperistalsis
  • Duodenal strictures
GERD
  • Lower esophageal sphincter abnormalities
  • Spicy food
  • Tight fitting clothing
 βœ”

(Suspect delayed gastric emptying)

βœ” – – – – Other symptoms:

Complications

Peptic ulcer disease

Duodenal ulcer

  • Pain aggravates with empty stomach

Gastric ulcer

  • Pain aggravates with food
  • Pain alleviates with food
 βœ” βœ” – – – Gastric ulcers
  • Discrete mucosal lesions with a punched-out smooth ulcer base with whitish fibrinoid base
  • Most ulcers are at the junction of fundus and antrum
  • 0.5-2.5cm

Duodenal ulcers

Other diagnostic tests
Gastrinoma – – βœ”

(suspect gastric outlet obstruction)

βœ” – – – Useful in collecting the tissue for biopsy

Diagnostic tests

Gastric Adenocarcinoma – – βœ” βœ” βœ” βœ” βœ” Esophagogastroduodenoscopy
  • Multiple biopsies are taken to establish the diagnosis
 Other symptoms
Primary gastric lymphoma – – – – – βœ” – – Useful in collecting the tissue for biopsy Other symptoms

References

  1. ↑ Gralnek IM, Barkun AN, Bardou M (2008). “Management of acute bleeding from a peptic ulcer”. N Engl J Med. 359 (9): 928–37. doi:10.1056/NEJMra0706113. PMIDΒ 18753649.
  2. ↑ Dallal HJ, Palmer KR (2001). “ABC of the upper gastrointestinal tract: Upper gastrointestinal haemorrhage”. BMJ. 323 (7321): 1115–7. PMCΒ 1121602. PMIDΒ 11701581.
  3. ↑ Nelson DR, Teckman J, Di Bisceglie AM, Brenner DA (2012). “Diagnosis and management of patients with Ξ±1-antitrypsin (A1AT) deficiency”. Clin Gastroenterol Hepatol. 10 (6): 575–80. doi:10.1016/j.cgh.2011.12.028. PMCΒ 3360829. PMIDΒ 22200689.
  4. ↑ Tsochatzis EA, Bosch J, Burroughs AK (2014). “Liver cirrhosis”. Lancet. 383 (9930): 1749–61. doi:10.1016/S0140-6736(14)60121-5. PMIDΒ 24480518.
  5. ↑ Schuppan D, Afdhal NH (2008). “Liver cirrhosis”. Lancet. 371 (9615): 838–51. doi:10.1016/S0140-6736(08)60383-9. PMCΒ 2271178. PMIDΒ 18328931.
  6. ↑ Kahrilas PJ (2008). “Clinical practice. Gastroesophageal reflux disease”. N Engl J Med. 359 (16): 1700–7. doi:10.1056/NEJMcp0804684. PMCΒ 3058591. PMIDΒ 18923172.
  7. ↑ Kahrilas PJ, Shaheen NJ, Vaezi MF, Hiltz SW, Black E, Modlin IM; et al. (2008). “American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease”. Gastroenterology. 135 (4): 1383–1391, 1391.e1–5. doi:10.1053/j.gastro.2008.08.045. PMIDΒ 18789939.
  8. ↑ Bredenoord AJ, Pandolfino JE, Smout AJ (2013). “Gastro-oesophageal reflux disease”. Lancet. 381 (9881): 1933–42. doi:10.1016/S0140-6736(12)62171-0. PMIDΒ 23477993.
  9. ↑ Fox M, Forgacs I (2006). “Gastro-oesophageal reflux disease”. BMJ. 332 (7533): 88–93. doi:10.1136/bmj.332.7533.88. PMCΒ 1326932. PMIDΒ 16410582.
  10. ↑ Sugimachi K, Inokuchi K, Kuwano H, Ooiwa T (1984). “Acute gastritis clinically classified in accordance with data from both upper GI series and endoscopy”. Scand J Gastroenterol. 19 (1): 31–7. PMIDΒ 6710074.
  11. ↑ Sipponen P, Maaroos HI (2015). “Chronic gastritis”. Scand J Gastroenterol. 50 (6): 657–67. doi:10.3109/00365521.2015.1019918. PMCΒ 4673514. PMIDΒ 25901896.
  12. ↑ Sartor RB (2006). “Mechanisms of disease: pathogenesis of Crohn’s disease and ulcerative colitis”. Nat Clin Pract Gastroenterol Hepatol. 3 (7): 390–407. doi:10.1038/ncpgasthep0528. PMIDΒ 16819502.
  13. ↑ Sipponen P (1989). “Atrophic gastritis as a premalignant condition”. Ann Med. 21 (4): 287–90. PMIDΒ 2789799.
  14. ↑ Badillo R, Francis D (2014). “Diagnosis and treatment of gastroesophageal reflux disease”. World J Gastrointest Pharmacol Ther. 5 (3): 105–12. doi:10.4292/wjgpt.v5.i3.105. PMCΒ 4133436. PMIDΒ 25133039.
  15. ↑ Ramakrishnan K, Salinas RC (2007). “Peptic ulcer disease”. Am Fam Physician. 76 (7): 1005–12. PMIDΒ 17956071.
  16. ↑ Banasch M, Schmitz F (2007). “Diagnosis and treatment of gastrinoma in the era of proton pump inhibitors”. Wien Klin Wochenschr. 119 (19–20): 573–8. doi:10.1007/s00508-007-0884-2. PMIDΒ 17985090.
  17. ↑ Dicken BJ, Bigam DL, Cass C, Mackey JR, Joy AA, Hamilton SM (2005). “Gastric adenocarcinoma: review and considerations for future directions”. Ann Surg. 241 (1): 27–39. PMCΒ 1356843. PMIDΒ 15621988.
  18. ↑ Ghimire P, Wu GY, Zhu L (2011). “Primary gastrointestinal lymphoma”. World J Gastroenterol. 17 (6): 697–707. doi:10.3748/wjg.v17.i6.697. PMCΒ 3042647. PMIDΒ 21390139.

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