From the Guidelines
A CT abdomen with oral contrast is not the preferred method for diagnosing peptic ulcers, as it lacks the sensitivity to reliably identify uncomplicated peptic ulcers, and the use of oral contrast can impede assessment of mucosal enhancement and preclude assessment of intraluminal bleeding. According to the American College of Radiology, when gastric disease is suspected, the CT examination should be performed with intravenous (IV) contrast and a neutral oral contrast such as water or dilute barium suspension 1. The addition of IV contrast significantly improves conspicuity of findings such as interrupted mucosal enhancement and bowel wall hyperenhancement, making the CT examination more sensitive in diagnosis. However, even with IV contrast, CT imaging is not the gold standard for diagnosing peptic ulcers.
Upper endoscopy (esophagogastroduodenoscopy or EGD) is the preferred method for diagnosing peptic ulcers as it allows direct visualization of the ulcer, assessment of its severity, and the ability to take biopsies to test for Helicobacter pylori infection or malignancy. While CT with oral contrast can sometimes detect complications of peptic ulcers such as perforation or significant inflammation, it is not a reliable method for diagnosing uncomplicated peptic ulcers. The mucosal detail needed to diagnose early or smaller ulcers is not adequately captured by CT imaging.
Some key findings that can be detected by CT include:
- Gastric or duodenal wall thickening due to submucosal edema
- Mucosal hyperenhancement or fat stranding due to inflammation
- Fluid along the gastroduodenal region
- Focal outpouching of the mucosa resulting from ulcerations
- Focal interruption of mucosal enhancement resulting from an ulcer crater eroding through the epithelial lining of the mucosal layer into the submucosal layer or muscularis propria
- Focal perforation of a gastric ulcer with associated free air
- Gastric outlet obstruction due to edema or chronic inflammatory changes near the antrum and pylorus 1.
However, these findings are not specific to peptic ulcers and can be seen in other conditions, highlighting the importance of using upper endoscopy as the primary diagnostic tool. In summary, a CT abdomen with oral contrast is not the preferred method for diagnosing peptic ulcers, and upper endoscopy should be used as the primary diagnostic tool.
From the Research
CT Abdomen with Oral Contrast for Diagnosing Peptic Ulcers
- The use of a CT abdomen with oral contrast for diagnosing peptic ulcers is a topic of discussion among radiologists, with some studies suggesting that oral contrast may not be necessary in certain cases 2, 3.
- A study published in 2025 found that CT is crucial in diagnosing complications of gastric or duodenal ulcers, such as uncontrolled acute hemorrhage, perforation, organ penetration, or gastric obstruction 4.
- Another study from 2015 highlighted the importance of recognizing the CT findings of peptic ulcer disease (PUD), including both uncomplicated and complicated PUD, to direct patient management and prevent complications 5.
- However, the use of oral contrast material for abdominal CT is a matter of debate, with some arguing that it can increase diagnostic confidence and make a major impact on diagnosis, while others believe that it may not be necessary in many cases 6, 3.
- A study from 2017 found that oral contrast was noncontributory to radiological diagnosis in most patients presenting with acute nontraumatic abdominal pain, and that these patients can undergo abdominal CT scanning without oral contrast with no effect on radiological diagnostic performance 3.