Peptic ulcer differential diagnosis

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2017 ACG Guidelines for Peptic Ulcer Disease
Guidelines for the Indications to Test for, and to Treat, H. pylori Infection
Guidelines for First line Treatment Strategies of Peptic Ulcer Disease for Providers in North America
Guidlines for factors that predict the successful eradication when treating H. pylori infection
Guidelines to document H. pylori antimicrobial resistance in the North America
Guidelines for evaluation and testing of H. pylori antibiotic resistance
Guidelines for when to test for treatment success after H. pylori eradication therapy
Guidelines for penicillin allergy in patients with H. pylori infection
Guidelines for the salvage therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Guillermo Rodriguez Nava, M.D. [2] Manpreet Kaur, MD [3]

Overview

Peptic ulcer disease must be differentiated from other causes of acute upper gastrointestinal bleeding such as esophageal varices, Mallory-Weiss syndrome, gastrointestinal cancer, arteriovenous malformations, esophagitis, and esophageal ulcer. Peptic ulcer disease must also be differentiated from gastroesophageal reflux disease (GERD,pancreatitis, Zollinger-Ellison Syndrome,cholelithiasis,gastric outlet syndrome,myocardial infaraction ,pleural empyema and appendicitis

Differentiating Peptic Ulcer from other Diseases

• Peptic ulcer disease must be differentiated from other diseases that presents with epigastric pain such as gastritis, gastroesophageal reflux disease,acute pancreatitis,prmary biliary cirrhosis,cholelithiasis,gastric outlet syndrome,myocardial infaraction ,pleural empyema,acute appendicitis

Classification of pain in the abdomen based on etiology			Disease	Clinical manifestations									Diagnosis		Comments
				Symptoms					Signs
				Fever	Rigors and chills	Abdominal Pain	Jaundice	GI Bleed	Hypo- tension	Guarding	Rebound Tenderness	Bowel sounds	Lab Findings	Imaging
Abdominal causes	Inflammatory causes	Pancreato-biliary disorders
			Acute pancreatitis	+	−	Epigastric	±	−	±	−	−	N	Increased amylase / lipase	Ultrasound shows evidence of inflammation	Pain radiation to back
			Primary biliary cirrhosis	−	−	RUQ/Epigastric	+	−	−	−	−	N	Increased AMA level, abnormal LFTs
			Cholelithiasis	±	−	RUQ/Epigastric	±	−	−	+	+	N to hyperactive for dislodged stone	Leukocytosis	Ultrasound shows gallstone	Murphy’s sign
		Gastric causes	Peptic ulcer disease	±	−	EpisodicEpigastric	−	Gastric ulcer- melena and hematemesis Duodenal ulcer- melena and hematochezia	+ in perforated	+	+	N	Ascitic fluid LDH > serum LDH Glucose < 50mg/dl Total protein > 1g/dl	Air under diaphragm in upright CXR	Upper GI endoscopy for diagnosis
			Gastritis	±	−	Epigastric		+ in chronic gastritis	−
			Gastroesophageal reflux disease	−	−	Epigastric	−	−	−	−	−
			Gastric outlet obstruction	−	−	Epigastric	−	−	±			Hyperactive
		Intestinal causes	Acute appendicitis	+	+in pyogenic appendicitis	Starts in epigastrium, migrates to RLQ	−	−	+ in perforated appendicitis	+	+	Hypoactive	Leukocytosis	Ultrasound shows evidence of inflammation	Nausea & vomiting, decreased appetite
Extra-abdominal causes	Pulmonary disorders	Pleural empyema		+	±	RUQ/Epigastric	−	−	−	−	−	N
	Cardiovascular disorders	Myocardial Infarction		−	−	Epigastric	−	−	+ in cardiogenic shock	−	−	N
Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM=Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein

{

Disease	Cause	Symptoms									Diagnosis	Other findings
		Pain			Nausea & Vomiting	Heartburn	Belching or Bloating	Weight loss	Loss of Appetite	Stools	Endoscopy findings
		Location	Aggravating Factors	Alleviating Factors
Acute gastritis	H. pylori NSAIDS Corticosteroids Alcohol Spicy food Viral infections Crohn's disease Autoimmune diseases Bile reflux Cocaine use Breathing machine or ventilator Ingestion of corrosives	Epigastric pain	Food	Antacids	✔	✔	✔	-	✔	Black stools	Pangastritis or antral gastritis Erosive (Superficial, deep, hemorrhagic) Nonerosive (H. pylori)	-
Chronic gastritis	H. pylori Alcohol Medications Autoimmune diseases Chronic stress	Epigastric pain	Food	Antacids	✔	✔	✔	✔	✔	-	H. pylori gastritis Atrophy Intestinal metaplasia Lymphocytic gastritis Enlarged folds Aphthoid erosions	-
Atrophic gastritis	H. pylori Autoimmune disease	Epigastric pain	-	-	✔	-		✔	✔	-	H. pylori Mucosal atrophy Autoimmune Mucosal atrophy	Iron deficiency anemia Autoimmune gastritis diagnosis include: Antiparietal and anti-IF antibodies Achlorhydria and hypergastrinemia Low serum cobalamine
Crohn's disease	Autoimmune disease	Abdominal pain	-	-	-	-	-	✔	✔	Chronic diarrhea often bloody with pus or mucus Rectal bleeding	Mucosal nodularity with cobblestoning Multiple aphthous ulcers Linier or serpiginous ulcerations Thickened antral folds Antral narrowing Hypoperistalsis Duodenal strictures	Fever Fatigue Anemia (pernicious anemia)
GERD	Lower esophageal sphincter abnormalities Hiatal hernia Abnormal esophageal contractions Prolonged emptying of stomach Gastrinomas	Epigastric pain	Spicy food Tight fitting clothing	Antacids Head elevation during sleep	✔ (Suspect delayed gastric emptying)	✔	-	-	-	-	Esophagitis Barrette esophagus Strictures	Other symptoms: Dysphagia Regurgitation Nocturnal cough Hoarseness Complications Esophagitis Strictures Barrette esophagus
Peptic ulcer disease	H. pylori Smoking Alcohol Radiation therapy Medications Zollinger-ellison syndrome	Epigastric pain sometimes extending to back Right upper quadrant pain	Duodenal ulcer Pain aggravates with empty stomach Gastric ulcer Pain aggravates with food	Antacids Duodenal ulcer Pain alleviates with food	✔	✔	-	-	-	Black stools	Gastric ulcers Discrete mucosal lesions with a punched-out smooth ulcer base with whitish fibrinoid base Most ulcers are at the junction of fundus and antrum 0.5-2.5cm Duodenal ulcers Well-demarcated break in the mucosa that may extend into the muscularis propria of the duodenum Found in the first part of duodenum <1cm	Other diagnostic tests Serum gastrin levels Secretin stimulation test Biopsy
Gastrinoma	Associated with MEN type 1	Abdominal pain	-	-	✔ (suspect gastric outlet obstruction)	✔	-	-	-	Black stools	Useful in collecting the tissue for biopsy	May present with symptoms of GERD or peptic ulcer disease Associated with MEN type 1 Diagnostic tests Serum gastrin levels Somatostatin receptor scintigraphy CT and MRI
Gastric Adenocarcinoma	H. pylori infection Smoked and salted food	Abdominal pain	-	-	✔	✔	✔	✔	✔	Black stools, or blood in stools	Esophagogastroduodenoscopy Multiple biopsies are taken to establish the diagnosis	Other symptoms Dysphagia Early satiety Frequent burping
Primary gastric lymphoma	H. pylori infection	Abdominal pain Chest pain	-	-	-	-	-	✔	-	-	Useful in collecting the tissue for biopsy	Other symptoms Painless swollen lymph nodes in neck and armpit Night sweats Fatigue Fever Cough or trouble breathing

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