Approach

Diagnosis relies on testing for the presence of Helicobacter pylori and taking a history with specific reference to nonsteroidal anti-inflammatory drug (NSAID) use and the presence of upper abdominal pain.

In patients aged ≥60 years presenting with dyspepsia, an endoscopy should be ordered. Endoscopy is diagnostic and may show an ulcer in the stomach or proximal duodenum. Patients aged under 60 years with dyspeptic symptoms should haveH pylori testing.[46][Evidence A]

History

NSAID use, H pylori infection, smoking, increasing age, personal or family history of peptic ulcer disease, and an intensive care stay are key risk factors.

A common clinical feature is dyspepsia, a chronic or recurrent abdominal pain or discomfort centered in the upper abdomen.[46] This symptom is commonly related to eating and is often nocturnal. However, the absence of epigastric pain does not rule out the diagnosis. In patients with duodenal ulcers, the abdominal pain may be severe and radiate through to the back as a result of penetration of the ulcer posteriorly into the pancreas.

Nausea and vomiting are uncommon; the former may be relieved by eating. Vomiting, if present, generally occurs after eating. Weight loss and anorexia may also be present.

A history of NSAID use and the relief of symptoms after the use of antacids may support the diagnosis. However, these are neither sensitive nor specific indicators. It should be noted that most people with dyspepsia do not have peptic ulcer disease.[46]

If diarrhea is also present, this may indicate Zollinger-Ellison syndrome. Rarely, nausea, vomiting, and early satiety indicate pyloric stenosis (a complication of peptic ulcer disease).

Importantly, peptic ulcers may cause no symptoms, especially in the elderly and those taking NSAIDs.

Physical exam

There may be some epigastric tenderness on palpation of the abdomen, but often there are no other signs on exam. The patient can generally show the site of pain with one finger ("pointing sign").

Atypical presentations of peptic ulcer disease also occur. Gastric and duodenal ulcers may cause occult blood loss and iron deficiency anemia. However, presentation may be sudden, with the signs of bleeding (hematemesis and/or melena and shock), or perforation with peritonitis.

Rarely, a succussion splash may be heard in patients with pyloric stenosis (caused by gastric outlet obstruction).

Endoscopy

Clinical guidelines that aid the evaluation of patients with dyspepsia should be applied when peptic ulcer disease is suspected.[46][47]​​[48]​​ If the patient is aged ≥60 years with dyspeptic symptoms, prompt endoscopy is indicated.[46] It is the definitive diagnostic test for peptic ulcer disease and upper gastrointestinal (GI) tract neoplasms. Debate continues as to whether patients aged under 60 years with alarm symptoms for dyspepsia (e.g., weight loss, anemia, vomiting, early satiety, or dysphagia) need endoscopy to exclude upper GI tract neoplasm; the need for endoscopy should be evaluated on a case-by-case basis.[46]

Endoscopy is widely available and is more sensitive and specific for peptic ulcer disease than barium radiography. Additionally, it enables biopsy (for diagnosing malignancy and for H pylori detection).

Barium radiography should be reserved for patients who are unable or unwilling to undergo endoscopy, and it is not routinely recommended.

H pylori testing

US guidance recommends noninvasive testing for H pylori(i.e., urea breath or stool antigen tests) in patients with dyspepsia who are aged under 60 years.[46][49][50]​​​​[Evidence A]​ ​Do not request serologic (antibody) testing when detecting an active H pylori infection.[51]​ Serology (antibody) testing gives less accurate results, and is unable to distinguish between active and historical infection.[49]​​[52]​​​​​​[53][54]​​​​

Histology and biopsy urease testing (rapid urease test) are invasive, and are reserved for patients in whom endoscopy is indicated. Both tests can detect H pylori; however, histology can determine if the ulcer is neoplastic (very rarely) and/or if there is evidence of an NSAID being the likely cause.

Proton-pump inhibitors, bismuth, or other medications can interfere with the performance of diagnostic tests for H pylori. Switching to an H2 antagonist for 2 weeks prior to endoscopy may be an alternative, especially in patients without alarm features.

Other investigations

A CBC should be ordered if the patient seems clinically anemic or has evidence of GI bleeding.

If the patient presents with upper GI bleeding, endoscopy is usually carried out first-line; however, if endoscopy is not possible, computed tomography angiography (CTA) abdomen and pelvis or visceral angiography are alternatives that may be considered depending on the stability of the patient to undergo these procedures.[55][56]

Zollinger-Ellison syndrome should be considered in patients with multiple or refractory ulcers, diarrhea, ulcers distal to the duodenum, or a family history of multiple endocrine neoplasia type 1. In these patients, a fasting serum gastrin level should be ordered to look for evidence of gastrin hypersecretion. The patient should stop taking proton-pump inhibitor (PPI) therapy prior to the test.

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