Tests
1st tests to order
Helicobacter pylori urea breath test or stool antigen test
Test
Ordered in patients aged <60 years, even in the presence of alarm symptoms.
Proton-pump inhibitors (PPIs), bismuth, and antibiotics can interfere with the performance of diagnostic tests for Helicobacter pylori.
Note that no test for H pylori is 100% sensitive. The use of a second test may be considered if an ulcer is found in a patient without H pylori.
Result
positive result if H pylori present
upper gastrointestinal endoscopy
Test
The most specific and sensitive test. Initially ordered if the patient presenting with dyspeptic symptoms is aged ≥60 years. May also be considered subsequent to treatment if the patient fails to respond.
If an ulcer is present, Helicobacter pylori testing should always be performed. Histology and biopsy urease testing (rapid urease test) are performed on stomach biopsies obtained during endoscopy. Both tests can detect H pylori; however, histology can determine if the ulcer is neoplastic (very rarely) and/or if there is evidence of a nonsteroidal anti-inflammatory drug (NSAID) being the likely cause.
Endoscopy should be repeated after 6 to 8 weeks in patients with gastric ulcer to ensure ulcer healing and to rule out malignancy (unless excluded at initial endoscopy).
If the patient presents with upper GI bleeding, endoscopy is usually carried out first-line; however, if endoscopy is not possible, CT 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]
Result
peptic ulcer; may also detect cause (e.g., H pylori)
CBC
Test
Ordered only if the patient seems clinically anemic or has evidence of gastrointestinal bleeding.
Aids in evaluating the urgency with which the patient requires further workup, but does not definitively diagnose peptic ulcer disease.
Result
microcytic anemia
Investigations to avoid
Serology
Recommendations
Do not order serologic antibody tests when testing for active H pylori infection.[51]
Tests to consider
fasting serum gastrin level
Test
Ordered if there are multiple duodenal ulcers (especially postbulbar) or in patient with ulcers and diarrhea.
Patient must be fasting and proton-pump inhibitor therapy stopped.
Elevated levels in pernicious anemia and other hypochlorhydric states results in low specificity.
Result
hypergastrinemia in Zollinger-Ellison syndrome
CTA abdomen and pelvis without and with contrast
Test
If the patient presents with upper GI bleeding, endoscopy is usually carried out first-line; however, if endoscopy is not possible, 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]
Result
may localize bleeding site
arteriography visceral
Test
If the patient presents with upper GI bleeding, endoscopy is usually carried out first-line; however, if endoscopy is not possible 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] A limitation of this test is that venous bleeding can be missed because the contrast resolution of the venous phase of an angiogram is relatively poor.[55]
Result
detects bleeding if the rate of bleeding is ≥0.5 mL/min
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