What is the recommended approach for a peptic ulcer workup?

Peptic Ulcer Workup

Initial Diagnostic Approach

For uncomplicated peptic ulcer disease in patients under 55 years without alarm symptoms, use a test-and-treat strategy for H. pylori; all other patients require upper endoscopy to exclude malignancy and confirm diagnosis. 1, 2

Patient Stratification

Low-risk patients (age <55, no alarm symptoms):

• Test for H. pylori using urea breath test or stool antigen test (most accurate methods) 1
• Serologic testing is acceptable but less accurate and cannot confirm eradication 1
• Treat empirically if positive without endoscopy 1, 3

High-risk patients requiring immediate endoscopy:

• Age ≥55 years 1
• Alarm symptoms: weight loss, dysphagia, persistent vomiting, evidence of bleeding (melena, hematemesis), anemia 1, 3
• NSAID users with persistent symptoms 3
• Failed test-and-treat strategy 3

Laboratory Workup

Routine studies include: 4

• Complete blood count (assess for anemia from chronic bleeding) 4
• Blood typing and cross-matching if bleeding suspected 4
• Coagulation studies (INR >1.5 increases mortality risk) 4
• Electrolytes and renal function 4
• Arterial blood gas if perforation suspected 4

Complicated Peptic Ulcer Workup

Suspected Perforation

CT scan is the primary imaging modality with 93-96% sensitivity and 93-100% specificity for detecting perforation. 4, 5

Imaging protocol: 4, 5

• CT scan is first-line (strong recommendation, 1C) 4
• Look for: pneumoperitoneum, unexplained intraperitoneal fluid, bowel wall thickening, mesenteric fat stranding, extraluminal contrast 5
• Note: 12% of perforations have normal CT findings 6
• Chest/abdominal X-ray only if CT unavailable (detects free air in 30-85% of cases) 4, 5
• Water-soluble contrast study (oral or via NG tube) if free air not seen but suspicion remains (weak recommendation, 2D) 4

Clinical assessment: 4, 5

• Sudden onset severe abdominal pain (hallmark presentation) 7
• Peritonitis present in only two-thirds of patients—absence does not exclude perforation 7, 5
• Use SOFA or qSOFA scoring to assess severity 4, 5
• Evaluate for sepsis: altered mental status, tachycardia, tachypnea, hypotension, oliguria, hyperlactatemia 4

Suspected Bleeding

Upper endoscopy is the definitive diagnostic and therapeutic procedure for bleeding peptic ulcer. 4

Risk stratification: 4

• Glasgow-Blatchford score identifies patients needing transfusion or endoscopy 4
• Rockall score predicts adverse outcomes and mortality 4

When endoscopy unavailable or unsuccessful: 6

• CT angiography (CTA) to localize active bleeding via contrast extravasation 6
• CTA has 95% technical success for subsequent catheter angiography/embolization 6

Resuscitation targets during workup: 4

• Hemoglobin ≥7 g/dL (strong recommendation, 1B) 4
• Mean arterial pressure ≥65 mmHg 4
• Urine output ≥0.5 mL/kg/h 4
• Lactate normalization 4

H. pylori Testing Strategy

Preferred diagnostic tests: 1

• Urea breath test (most accurate for active infection) 1
• Stool antigen test (most accurate for active infection) 1
• Both can confirm eradication post-treatment 1

Alternative testing: 1

• Serology (convenient but less accurate, cannot confirm cure) 1
• Endoscopic biopsy with rapid urease test or histology (when endoscopy performed) 1

Etiology Assessment

Primary causes to investigate: 2

• H. pylori infection (42% of cases) 2
• Aspirin/NSAID use (36% of cases) 2
• Both factors together significantly increase perforation and bleeding risk 1

Medication history critical for: 4

• NSAIDs, aspirin, antiplatelet agents 4
• Anticoagulants (warfarin, DOACs) 4
• SSRIs, bisphosphonates (increase risk in elderly) 1
• Corticosteroids 4

Common Pitfalls

Avoid these errors: 5

• Relying on physical examination alone—peritonitis absent in one-third of perforations 5
• Delaying CT scan for plain radiography in unstable patients 6
• Using serology to confirm H. pylori eradication (cannot distinguish active from past infection) 1
• Performing endoscopy in suspected perforation before imaging confirmation 4
• Missing malignancy in gastric ulcers—all require endoscopic biopsy and follow-up endoscopy to confirm healing 6, 2