Signs and Laboratory Findings of Peptic Ulcer Disease
The most common presenting sign of peptic ulcer disease is epigastric pain, though approximately two-thirds of patients are asymptomatic, and laboratory tests are generally non-specific with no single diagnostic marker for uncomplicated disease. 1, 2
Clinical Presentation
Uncomplicated Peptic Ulcer Disease
Symptomatic patients typically present with:
- Epigastric pain that is relieved by food intake or antacids 3
- Pain that awakens the patient at night or occurs between meals 3
- Associated dyspepsia, bloating, abdominal fullness, nausea, or early satiety 1
- Loss of appetite and weight loss 3, 4
Complicated Peptic Ulcer Disease (Perforation)
When perforation occurs, the presentation changes dramatically:
- Sudden onset of severe upper abdominal pain with tachycardia and abdominal rigidity 5
- Localized or generalized peritonitis (present in only two-thirds of patients) 6, 5, 7
Critical pitfall: Physical examination findings may be equivocal, and peritonitis may be minimal or absent, particularly in patients with contained or sealed perforations 6, 5, 7
Laboratory Findings
Uncomplicated Disease
Laboratory tests have limited diagnostic value for uncomplicated peptic ulcer disease:
- No specific laboratory markers exist for diagnosis 2
- Testing should focus on identifying H. pylori infection, which affects approximately 42% of patients with peptic ulcer disease 2
Complicated Disease (Perforation/Bleeding)
When complications are suspected, obtain:
- Routine laboratory studies including complete blood count and metabolic panel (Strong recommendation, 1D) 6, 8, 7
- Arterial blood gas analysis (Strong recommendation, 1D) 6, 8, 7
Expected non-specific findings include:
Important caveat: These laboratory abnormalities are commonly associated with perforation but are non-specific and do not confirm the diagnosis 6, 8, 7
Diagnostic Algorithm
For Suspected Uncomplicated Disease
- Younger patients without alarm symptoms: Use test-and-treat strategy based on H. pylori testing 3
- Older patients or those with alarm symptoms (bleeding, weight loss, anemia): Proceed directly to endoscopy 3
For Suspected Complicated Disease (Perforation)
Imaging is essential, not laboratory tests:
- CT scan is the first-line imaging modality (Strong recommendation, 1C) 6, 5, 7
- Chest/abdominal X-ray only if CT is not promptly available (Strong recommendation, 1C) 6, 5, 7
- Water-soluble contrast (oral or via nasogastric tube) when free air is not seen on imaging but suspicion remains high (Weak recommendation, 2D) 6, 7
Helicobacter pylori Testing
All patients with suspected or confirmed peptic ulcer disease should undergo H. pylori testing 8
Preferred non-invasive tests:
- Urea breath test: sensitivity 88-95%, specificity 95-100% 8
- Stool antigen test: sensitivity 94%, specificity 92% 8
Critical pitfall: Stop proton pump inhibitors, antibiotics, and bismuth products for at least 2 weeks before testing to avoid false-negative results 8
Risk Stratification for Complicated Disease
When perforation is confirmed, use scoring systems:
- Boey, PULP, and ASA scores for risk stratification (Weak recommendation, 2C) 7
- SOFA and qSOFA scores to evaluate disease severity (Weak recommendation, 2C) 7
- Hypoalbuminemia is the strongest single predictor of mortality 7
Common Complications and Their Frequencies
Bleeding is the most common complication (73% of complicated cases), followed by perforation (9%) and pyloric obstruction (3%) 2, 9