What is the diagnosis for abdominal pain, gastric reflux, and mild hematuria?

Differential Diagnosis: Peptic Ulcer Disease vs. Urolithiasis

The combination of abdominal pain, gastric reflux, and mild hematuria most likely represents peptic ulcer disease (PUD) with concurrent urolithiasis, or PUD alone with hematuria as a complication of NSAID use or bleeding diathesis. 1, 2, 3

Primary Diagnostic Consideration: Peptic Ulcer Disease

The triad you describe strongly suggests peptic ulcer disease as the unifying diagnosis:

• Epigastric pain with gastric reflux is the hallmark presentation of PUD, with 63-66% of patients experiencing both epigastric pain and heartburn simultaneously 3
• Gastric ulcers cause pain immediately after eating, while duodenal ulcers cause pain several hours after meals or at night 4
• Hematuria in this context may represent occult bleeding complications from PUD, which can manifest systemically 3

Critical Red Flags Requiring Immediate Action

You must exclude cardiac causes first - obtain ECG and troponins immediately, as myocardial infarction can present with epigastric pain as the primary manifestation 3. This is non-negotiable before pursuing gastrointestinal workup.

Warning signs of complicated PUD include 3:

• Occult blood in stool
• Vomiting
• Fever and tachycardia
• Sudden severe pain with abdominal rigidity (suggests perforation with 30% mortality if delayed) 3

Diagnostic Algorithm

Step 1: Initial Imaging Decision

For suspected uncomplicated PUD with typical symptoms:

• Proceed directly to upper endoscopy (EGD), which is the reference standard for diagnosis and allows tissue sampling 1, 2
• Endoscopy is mandatory because all gastric ulcers require biopsy to exclude malignancy 3

For nonspecific presentation or concern for complications:

• Obtain CT abdomen/pelvis with IV contrast using neutral oral contrast (not positive contrast) 1, 2
• CT can identify ulcer complications with high accuracy: extraluminal gas (97% of perforations), wall defect/ulcer (84% of perforations with positive likelihood ratio of 36.83) 1, 2
• Combined wall defect plus wall thickening shows 95% sensitivity and 93% specificity for perforation localization 2

Step 2: Addressing the Hematuria

The hematuria requires parallel evaluation because it may represent:

1. Urolithiasis (most common cause of painful hematuria) 1
2. Medication-related bleeding (NSAIDs used for pain can cause both PUD and hematuria) 5
3. Systemic bleeding from PUD complications

For mild hematuria workup:

• Start with renal and bladder ultrasound as first-line imaging 1
• If ultrasound is negative but clinical suspicion remains high for stones, proceed to non-contrast CT (sensitivity and specificity >90% for urolithiasis) 1
• Urinalysis to quantify hematuria and assess for infection or crystals 1

Step 3: Gastroesophageal Reflux Component

The reflux symptoms may represent:

• GERD coexisting with PUD (extremely common overlap) 1, 4, 6
• Reflux as a symptom of gastric outlet obstruction from chronic PUD 1

Do not use empiric PPI trial for diagnosis in this setting - the sensitivity is only 71-78% and specificity 41-54% even for classic reflux symptoms, and would be substantially lower for extraesophageal manifestations 1. However, initiate PPI therapy immediately while pursuing diagnostic workup, as acid suppression is critical for ulcer healing 7.

Common Pitfalls to Avoid

Never diagnose isolated GERD or functional dyspepsia when hematuria is present - this mandates investigation for organic disease 1, 6

Do not assume benign disease without tissue diagnosis - gastric ulcers can represent adenocarcinoma with ulceroproliferative features 3

Do not miss medication reconciliation - check for warfarin, NSAIDs, antiplatelet agents, or corticosteroids that can cause both PUD and hematuria 5

Avoid fluoroscopy/barium studies as initial tests - they cannot provide tissue diagnosis and may delay definitive management 1

Practical Management Sequence

1. Immediate: ECG, troponins, CBC, comprehensive metabolic panel, coagulation studies 3
2. Urgent (same day): Upper endoscopy if typical PUD symptoms predominate 1, 2
3. Concurrent: Renal ultrasound for hematuria evaluation 1
4. Therapeutic: Start high-dose PPI (omeprazole 40mg daily or equivalent) 7
5. If complications suspected: CT abdomen/pelvis with IV contrast before endoscopy 1, 2

The key is recognizing that these symptoms likely represent a single unifying diagnosis (PUD) rather than multiple separate conditions, though urolithiasis must be excluded given the hematuria 1, 3, 4.