What is the recommended workup for a peptic ulcer?

Recommended Workup for Peptic Ulcer Disease

For patients with suspected peptic ulcer disease, CT scan is the recommended first-line imaging study due to its superior sensitivity in detecting perforation and ability to characterize the site and size of ulcers 1.

Initial Diagnostic Approach

Clinical Assessment

• Evaluate for key symptoms:
  • Sudden onset abdominal pain (most common presentation)
  • Localized or generalized peritonitis (present in approximately two-thirds of patients)
  • Dyspepsia, bloating, abdominal fullness, nausea, or early satiety 2
  • Note: Up to two-thirds of patients with peptic ulcers may be asymptomatic 2

Laboratory Studies

• Complete blood count (to assess for leukocytosis)
• Metabolic panel (to detect metabolic acidosis)
• Serum amylase (often elevated with perforation) 1
• Arterial blood gas analysis (strong recommendation based on very low-quality evidence) 1

Risk Stratification

• Apply appropriate scoring systems to predict outcomes:
  • Boey score (most commonly used)
  • PULP score
  • ASA score 1
  • Note: Hypoalbuminemia is the strongest single predictor of mortality 1

Imaging Studies

First-Line Imaging

• CT scan (strong recommendation based on low-quality evidence) 1
  • Most sensitive for detecting free air
  • Can characterize site and size of perforation
  • Can exclude other possible causes
  • Key findings: pneumoperitoneum, unexplained intraperitoneal fluid, bowel wall thickening, mesenteric fat streaking, extraluminal contrast

Alternative Imaging (if CT unavailable)

• Chest/abdominal X-ray (strong recommendation if CT not promptly available) 1
  • Look for free abdominal air (present in 30-85% of perforations)
  • Erect and left lateral decubitus views have similar diagnostic accuracy
  • Note: Negative X-ray does not rule out perforation

Additional Imaging Techniques

• If free air not seen but suspicion remains high:
  • Water-soluble contrast study (oral or via nasogastric tube) 1
  • Consider triple contrast CT scan (improves sensitivity for detecting perforations) 1
• Point-of-care ultrasound may detect free intraperitoneal air but role still being defined 1

Testing for Helicobacter pylori

H. pylori infection is a principal cause of peptic ulcer disease, affecting approximately 42% of patients 2.

Recommended Testing Methods

• Urea breath tests - most accurate for identifying H. pylori 3
• Stool antigen tests - highly accurate and can confirm cure 3
• Serologic tests - convenient but less accurate and cannot confirm cure 3

Endoscopic Evaluation

• Upper gastrointestinal endoscopy is the diagnostic technique of choice 4
• Essential for:
  • Definitive diagnosis of peptic ulcer disease
  • Ruling out malignancy in patients with alarm symptoms or age >55 years 3
  • Evaluating complications such as bleeding
  • Obtaining biopsies for H. pylori testing

Special Considerations

High-Risk Populations

• Older adults have higher risk of PUD due to:
  • Increased use of high-risk medications (antiplatelet drugs, warfarin, SSRIs, bisphosphonates) 3
  • Higher risk of complications

Complications Requiring Urgent Evaluation

• Bleeding (73% of patients with complications)
• Perforation (9% of patients with complications)
• Pyloric obstruction (3% of patients with complications) 2

Common Pitfalls to Avoid

1. Relying solely on X-rays to rule out perforation (up to 12% of patients with perforations may have normal imaging)
2. Failing to test for H. pylori in patients with NSAID use (combined factors increase risk)
3. Using serologic tests to confirm H. pylori eradication (not accurate for this purpose)
4. Overlooking the possibility of gastric cancer in older patients with new-onset symptoms

By following this systematic diagnostic approach, clinicians can effectively diagnose peptic ulcer disease and its complications, leading to appropriate treatment and improved patient outcomes.