What are the guidelines for diagnosing peptic ulcer disease?

Guidelines for Diagnosing Peptic Ulcer Disease

CT scan is the recommended first-line imaging modality for suspected peptic ulcer disease, particularly in cases of suspected perforation, due to its superior sensitivity in detecting free air and ability to characterize the site and size of perforation. 1

Clinical Presentation

• The typical presentation of peptic ulcer disease includes sudden onset of abdominal pain, with localized or generalized peritonitis in cases of perforation 1
• Physical examination findings may be equivocal, and peritonitis may be present in only two-thirds of patients with perforated peptic ulcer 1
• Common symptoms include postprandial abdominal pain, nausea, vomiting, and weight loss, though approximately two-thirds of patients with peptic ulcer disease are asymptomatic 2, 3

Diagnostic Algorithm

Laboratory Studies

• Routine laboratory studies and arterial blood gas analysis are strongly recommended in patients with suspected gastroduodenal perforation 1
• Laboratory tests are generally non-specific, though leukocytosis, metabolic acidosis, and elevated serum amylase are usually associated with perforation 1

Imaging Studies

1. First-line imaging:

   • CT scan is strongly recommended as the first radiological examination in patients with suspected perforated peptic ulcer (Strong recommendation, 1C) 1
   • CT findings suggestive of perforation include unexplained intraperitoneal fluid, pneumoperitoneum, bowel wall thickening, mesenteric fat streaking, and extraluminal water-soluble contrast 1

2. When CT is not immediately available:

   • Chest/abdominal X-ray should be performed as the initial diagnostic assessment (Strong recommendation, 1C) 1
   • Erect and left lateral decubitus X-rays have similar diagnostic accuracy, with the latter being better tolerated by patients with peritonitis 1
   • Free air on X-ray ranges between 30-85% of perforations, making it less reliable than CT 1

3. When free air is not seen on initial imaging:

   • Water-soluble contrast administered orally or via nasogastric tube is suggested to detect gastro-duodenal perforation (Weak recommendation, 2D) 1
   • Triple contrast CT scan may improve diagnostic sensitivity and specificity when initial CT is normal 1

Endoscopic Diagnosis

• Endoscopy is the gold standard for diagnosis of peptic ulcer disease, especially in:
  • Older patients 2
  • Patients with alarm symptoms (weight loss, bleeding, anemia) 2, 4
  • Cases where malignancy needs to be ruled out 3

Test-and-Treat Strategy

• For younger patients (under 55 years) without alarm symptoms, a test-and-treat strategy for H. pylori can be used instead of immediate endoscopy 2, 4
• H. pylori testing options include:
  • Urea breath tests and stool antigen tests (most accurate and can confirm cure) 4
  • Serologic tests (convenient but less accurate and cannot confirm cure) 4

Risk Stratification

• Scoring systems including Boey, PULP, and ASA scores are suggested for risk stratification of patients with perforated peptic ulcer (Weak recommendation, 2C) 1
• SOFA and qSOFA scores can be used to evaluate disease severity in patients with perforated peptic ulcer (Weak recommendation, 2C) 1
• Hypoalbuminemia remains the strongest single predictor of mortality in perforated peptic ulcer 1

Special Considerations and Pitfalls

• Up to 12% of patients with perforations may have a normal CT scan, requiring additional diagnostic measures 1
• "Point-of-care" ultrasound performed by trained operators can detect free intraperitoneal air, though its role in diagnostic work-up still needs further definition 1
• The most common causes of peptic ulcer disease are H. pylori infection and NSAID use, which should be specifically addressed in the diagnostic workup 3, 4, 5
• Chronic use of NSAIDs in patients with H. pylori infection significantly increases the risk of peptic ulcer disease 4