What is the recommended initial work‑up for a patient presenting to the emergency department with epigastric pain, nausea, vomiting and possible melena or hematemesis suggestive of duodenitis?

Emergency Department Workup for Suspected Duodenitis

For patients presenting to the ED with epigastric pain, nausea, vomiting, and possible melena or hematemesis suggestive of duodenitis, the initial workup should prioritize hemodynamic assessment, followed by upper endoscopy as the definitive diagnostic test, with CT abdomen/pelvis with IV contrast reserved for patients with nonspecific presentations or when complications like perforation are suspected. 1

Immediate Clinical Assessment

Hemodynamic Stabilization First

• Assess hemodynamic stability immediately upon presentation, as this determines the urgency and sequence of diagnostic interventions 1
• Patients with hemodynamic instability and suspected upper GI bleeding require immediate resuscitation and urgent endoscopy 1
• Signs of peritonitis, shock, or clinical deterioration mandate emergency surgical consultation before extensive diagnostic workup 1

Key Clinical Features to Identify

• Presence and character of bleeding: melena versus hematemesis indicates location and severity 1
• Signs of perforation: sudden onset severe pain, peritoneal signs, or clinical deterioration suggest duodenal ulcer perforation—a surgical emergency with up to 30% mortality 1
• Risk factors: NSAID/aspirin use, alcohol consumption, H. pylori infection history, smoking 2, 3

Diagnostic Approach

Upper Endoscopy: The Gold Standard

• Upper endoscopy is the standard test of choice for diagnosing duodenitis, peptic ulcer disease, and duodenal ulcers 1
• Endoscopy allows direct visualization of duodenal mucosa, identification of erosions, ulcerations, and active bleeding sources 1
• Obtain endoscopic biopsies to confirm histological diagnosis and exclude other pathology, as endoscopic appearance alone may not be specific 4, 2
• Endoscopy should be performed urgently in hemodynamically stable patients with suspected upper GI bleeding 1

CT Abdomen/Pelvis with IV Contrast: When to Use

CT is not the first-line test for suspected duodenitis but has specific indications: 1

• Use CT when presentation is nonspecific and differential diagnosis is broad, as symptoms of duodenitis overlap with other acute abdominal conditions 1
• CT with IV contrast is essential when complications are suspected, particularly perforation or bleeding 1
• Perform CT with neutral oral contrast (water or dilute barium) rather than positive contrast to assess mucosal enhancement and detect intraluminal bleeding 1

CT findings suggestive of duodenitis/peptic ulcer disease include: 1

• Duodenal wall thickening due to submucosal edema
• Mucosal hyperenhancement from inflammation
• Focal outpouching indicating ulcer crater
• Focal interruption of mucosal enhancement
• Extraluminal gas (97% sensitive for perforation) 1
• Focal wall defect and/or ulcer (positive likelihood ratio 36.83 for perforation) 1
• Fat stranding, ascites, or free fluid 1

Laboratory Studies

• Complete blood count: assess for anemia from chronic or acute bleeding 4
• Basic metabolic panel: evaluate for dehydration from vomiting 4
• Coagulation studies: if bleeding is present 1
• Type and screen/crossmatch: if hemodynamically unstable or significant bleeding 1

Critical Pitfalls to Avoid

Do Not Delay Endoscopy for CT

• Endoscopy provides both diagnosis and potential therapeutic intervention (hemostasis), whereas CT only provides anatomic information 1
• In stable patients with classic upper GI bleeding symptoms, proceed directly to endoscopy rather than obtaining CT first 1

Recognize Duodenitis as Part of Ulcer Spectrum

• Duodenitis may represent the production or healing phase of duodenal ulceration rather than a separate disease 5
• Up to 43% of patients initially diagnosed with duodenitis may develop frank duodenal ulcers on follow-up 5
• This underscores the importance of definitive endoscopic diagnosis and appropriate follow-up 5

Hemorrhagic Erosive Duodenitis Requires Urgent Attention

• The erosive form with friability can cause marked GI bleeding and should be considered a potentially serious complication, especially in patients taking aspirin/NSAIDs or alcohol 3
• These patients may require urgent endoscopic hemostasis 3

When Emergency Surgery Is Indicated

Immediate surgical consultation is mandatory for: 1

• Free perforation with generalized peritonitis
• Hemodynamic instability despite resuscitation with ongoing massive hemorrhage
• Clinical deterioration with signs of shock
• CT evidence of perforation (extraluminal gas, focal wall defect, extraluminal contrast) 1