What is the advised workflow to diagnose acid peptic disease in adults?

Diagnostic Workflow for Acid Peptic Disease in Adults

Upper endoscopy (esophagogastroduodenoscopy) is the gold standard for diagnosing acid peptic disease in adults, with specific biopsies for H. pylori testing being essential components of the diagnostic process. 1, 2

Initial Assessment

History Taking - Focus on:

• Epigastric pain/burning - Most common presenting symptom
• Meal-related symptoms - Pain that improves or worsens with eating
• Dyspeptic symptoms - Bloating, early satiety, postprandial fullness
• Alarm symptoms requiring immediate investigation:
  • Weight loss
  • Dysphagia
  • Persistent vomiting
  • Gastrointestinal bleeding (melena, hematemesis)
  • Anemia
  • Family history of gastroesophageal malignancy
  • Age >40 years from high-risk gastric cancer areas 3

Risk Factor Assessment:

• H. pylori infection (accounts for ~42% of PUD cases)
• NSAID or aspirin use (accounts for ~36% of PUD cases)
• Smoking
• Alcohol consumption
• Previous history of PUD 1

Diagnostic Algorithm

Step 1: Initial Testing

• For patients <60 years without alarm features:
  • Test for H. pylori using non-invasive methods:
    • Urea breath test (preferred)
    • Stool antigen test
    • Serology (less preferred due to lower accuracy) 3

Step 2: Endoscopic Evaluation

• Immediate endoscopy indicated for:

  • Patients with alarm symptoms
  • Patients ≥60 years with new-onset dyspepsia
  • Patients >40 years from high-risk areas for gastric cancer
  • Patients with treatment-resistant symptoms 3

• During endoscopy:

  • Visual inspection of esophagus, stomach, and duodenum
  • Biopsy protocol for H. pylori detection:
    • Follow the 5-biopsy Sydney System:
      • Two samples from antrum (lesser and greater curve)
      • One from incisura angularis
      • Two from corpus (lesser and greater curve)
    • All specimens can be placed in the same jar 3

Step 3: Additional Testing Based on Clinical Suspicion

• For suspected GERD contribution:

  • Consider ambulatory pH monitoring or pH impedance testing if symptoms persist despite therapy 3

• For suspected bile acid-related symptoms:

  • Consider SeHCAT testing or serum 7α-hydroxy-4-cholesten-3-one (C4) measurement 3

• For suspected functional dyspepsia:

  • Diagnosis of exclusion after negative endoscopy and H. pylori testing
  • Consider specialized testing for gastric emptying if symptoms suggest gastroparesis 3, 4

Interpretation and Next Steps

Endoscopic Findings:

• Peptic ulcers: Visible breaks in mucosa >5mm with depth
• Erosions: Superficial mucosal breaks <5mm
• Gastritis/Duodenitis: Mucosal inflammation without ulceration
• Normal findings: Consider functional dyspepsia if symptoms persist 2

H. pylori Testing Results:

• Positive H. pylori: Treat with eradication therapy
• Negative H. pylori: Consider acid suppression therapy and NSAID cessation if applicable 1

Common Pitfalls to Avoid

1. Empiric PPI trial without testing: While commonly practiced, this may mask underlying conditions and delay diagnosis 3

2. Inadequate biopsy sampling: Following the Sydney System protocol increases H. pylori detection accuracy 3

3. Overlooking functional dyspepsia: Most common diagnosis when no structural abnormality is found (affects ~7% of population) 4

4. Missing extraesophageal reflux manifestations: Consider GERD even in atypical presentations 3

5. Neglecting to test for H. pylori: Testing should be performed in all patients with suspected PUD, as eradication reduces recurrence rates from 50-60% to 0-2% 1, 5

By following this systematic approach to diagnosing acid peptic disease, clinicians can ensure appropriate identification and management of these common conditions, ultimately improving patient outcomes related to morbidity, mortality, and quality of life.