Peptic ulcer differential diagnosis

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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), irritable bowel syndrome, pancreatitis, and Zollinger-Ellison Syndrome.

Differentiating Peptic Ulcer from other Diseases

Acute upper gastrointestinal bleeding: PUD accounts for the majority of acute episodes of gastrointestinal bleeding^[1] (up to 40%)^[2], but there are other causes:^[3]
- Esophageal varices: history of cirrhosis (and portal hypertension)
- Mallory-Weiss syndrome: history of repeated vomiting
- Gastrointestinal cancer: history of anorexia or weight loss, tobacco smoking and alcohol drinking.
- Arteriovenous malformations: Painless bleeding in >70 years old patients, history of iron deficiency anemia.
- Esophagitis or esophageal ulcer: heartburn, indigestion, or dysphagia
- Dieulafoy ulcer: painless bleeding
Alpha-1 Antitrypsin Deficiency AATD: besides lung disease, liver disease (hepatitis, cirrhosis, and hepatoma) represents another clinical manifestation of AATD,^[4]^[5] therefore those patients can present upper gastrointestinal bleeding and abdominal pain, in the context of altered liver function.^[6]
Cirrhosis:^[7]^[8] chronic liver disease is often asymptomatic until complications occur, such as variceal bleeding, ascites, primary peritonitis, sepsis or hepatic encephalopathy.
Gastroesophageal reflux disease (GERD):^[9]^[10]^[11]^[12] current definition is "a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.” Heartburn and regurgitation are the cardinal symptoms of GERD, but patients can often present dysphagia and chest pain. Less common symptoms include odynophagia, sialorrhea, subxiphoid pain or nausea. Also, patients can present extraesophageal GERD-related syndromes, such as chronic cough, laryngitis, asthma or erosion of dental enamel.
Irritable bowel syndrome
Pancreatitis
Zollinger-Ellison Syndrome

Differential Diagnosis

Peptic ulcer disease must be differentiated from:^[13]^[14]^[15]^[16]^[17]^[18]^[19]^[20]^[21] 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 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

Classification of pain in the abdomen based on etiology			Disease	Clinical manifestations									Diagnosis		Comments
				Symptoms					Signs				Diagnosis
				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
Extra-abdominal causes	Cardiovascular disorders	Myocardial Infarction		−	−	Epigastric	−	−	+ in cardiogenic shock	−	−	N

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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	Nausea & Vomiting	Heartburn	Belching or Bloating	Weight loss	Loss of Appetite	Stools	Endoscopy findings
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

References

↑ Gralnek IM, Barkun AN, Bardou M (2008). "Management of acute bleeding from a peptic ulcer". N Engl J Med. 359 (9): 928–37. doi:10.1056/NEJMra0706113. PMID 18753649.
↑ Dallal HJ, Palmer KR (2001). "ABC of the upper gastrointestinal tract: Upper gastrointestinal haemorrhage". BMJ. 323 (7321): 1115–7. PMC 1121602. PMID 11701581.CS1 maint: PMC format (link)
↑ Wilkins T, Khan N, Nabh A, Schade RR (2012). "Diagnosis and management of upper gastrointestinal bleeding". Am Fam Physician. 85 (5): 469–76. PMID 22534226.
↑ Stoller JK, Aboussouan LS (2012). "A review of α1-antitrypsin deficiency". Am J Respir Crit Care Med. 185 (3): 246–59. doi:10.1164/rccm.201108-1428CI. PMID [ 21960536 [ Check |pmid= value (help).
↑ Silverman EK, Sandhaus RA (2009). "Clinical practice. Alpha1-antitrypsin deficiency". N Engl J Med. 360 (26): 2749–57. doi:10.1056/NEJMcp0900449. PMID 19553648.
↑ Nelson DR, Teckman J, Di Bisceglie AM, Brenner DA (2012). "Diagnosis and management of patients with α1-antitrypsin (A1AT) deficiency". Clin Gastroenterol Hepatol. 10 (6): 575–80. doi:10.1016/j.cgh.2011.12.028. PMC 3360829. PMID 22200689.
↑ Tsochatzis EA, Bosch J, Burroughs AK (2014). "Liver cirrhosis". Lancet. 383 (9930): 1749–61. doi:10.1016/S0140-6736(14)60121-5. PMID 24480518.
↑ Schuppan D, Afdhal NH (2008). "Liver cirrhosis". Lancet. 371 (9615): 838–51. doi:10.1016/S0140-6736(08)60383-9. PMC 2271178. PMID 18328931.CS1 maint: PMC format (link)
↑ Kahrilas PJ (2008). "Clinical practice. Gastroesophageal reflux disease". N Engl J Med. 359 (16): 1700–7. doi:10.1056/NEJMcp0804684. PMC 3058591. PMID 18923172.CS1 maint: PMC format (link)
↑ Kahrilas PJ, Shaheen NJ, Vaezi MF, Hiltz SW, Black E, Modlin IM; et al. (2008). "American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease". Gastroenterology. 135 (4): 1383–1391, 1391.e1–5. doi:10.1053/j.gastro.2008.08.045. PMID 18789939.
↑ Bredenoord AJ, Pandolfino JE, Smout AJ (2013). "Gastro-oesophageal reflux disease". Lancet. 381 (9881): 1933–42. doi:10.1016/S0140-6736(12)62171-0. PMID 23477993.
↑ Fox M, Forgacs I (2006). "Gastro-oesophageal reflux disease". BMJ. 332 (7533): 88–93. doi:10.1136/bmj.332.7533.88. PMC 1326932. PMID 16410582.CS1 maint: PMC format (link)
↑ Sugimachi K, Inokuchi K, Kuwano H, Ooiwa T (1984). "Acute gastritis clinically classified in accordance with data from both upper GI series and endoscopy". Scand J Gastroenterol. 19 (1): 31–7. PMID 6710074.
↑ Sipponen P, Maaroos HI (2015). "Chronic gastritis". Scand J Gastroenterol. 50 (6): 657–67. doi:10.3109/00365521.2015.1019918. PMC 4673514. PMID 25901896.
↑ Sartor RB (2006). "Mechanisms of disease: pathogenesis of Crohn's disease and ulcerative colitis". Nat Clin Pract Gastroenterol Hepatol. 3 (7): 390–407. doi:10.1038/ncpgasthep0528. PMID 16819502.
↑ Sipponen P (1989). "Atrophic gastritis as a premalignant condition". Ann Med. 21 (4): 287–90. PMID 2789799.
↑ Badillo R, Francis D (2014). "Diagnosis and treatment of gastroesophageal reflux disease". World J Gastrointest Pharmacol Ther. 5 (3): 105–12. doi:10.4292/wjgpt.v5.i3.105. PMC 4133436. PMID 25133039.
↑ Ramakrishnan K, Salinas RC (2007). "Peptic ulcer disease". Am Fam Physician. 76 (7): 1005–12. PMID 17956071.
↑ Banasch M, Schmitz F (2007). "Diagnosis and treatment of gastrinoma in the era of proton pump inhibitors". Wien Klin Wochenschr. 119 (19–20): 573–8. doi:10.1007/s00508-007-0884-2. PMID 17985090.
↑ Dicken BJ, Bigam DL, Cass C, Mackey JR, Joy AA, Hamilton SM (2005). "Gastric adenocarcinoma: review and considerations for future directions". Ann Surg. 241 (1): 27–39. PMC 1356843. PMID 15621988.
↑ Ghimire P, Wu GY, Zhu L (2011). "Primary gastrointestinal lymphoma". World J Gastroenterol. 17 (6): 697–707. doi:10.3748/wjg.v17.i6.697. PMC 3042647. PMID 21390139.

Template:WikiDoc Sources

[pmid18753649-1] Gralnek IM, Barkun AN, Bardou M (2008). "Management of acute bleeding from a peptic ulcer". N Engl J Med. 359 (9): 928–37. doi:10.1056/NEJMra0706113. PMID 18753649.

[pmid11701581-2] Dallal HJ, Palmer KR (2001). "ABC of the upper gastrointestinal tract: Upper gastrointestinal haemorrhage". BMJ. 323 (7321): 1115–7. PMC 1121602. PMID 11701581.CS1 maint: PMC format (link)

[pmid22534226-3] Wilkins T, Khan N, Nabh A, Schade RR (2012). "Diagnosis and management of upper gastrointestinal bleeding". Am Fam Physician. 85 (5): 469–76. PMID 22534226.

[pmid21960536_[-4] Stoller JK, Aboussouan LS (2012). "A review of α1-antitrypsin deficiency". Am J Respir Crit Care Med. 185 (3): 246–59. doi:10.1164/rccm.201108-1428CI. PMID [ 21960536 [ Check |pmid= value (help).

[pmid19553648-5] Silverman EK, Sandhaus RA (2009). "Clinical practice. Alpha1-antitrypsin deficiency". N Engl J Med. 360 (26): 2749–57. doi:10.1056/NEJMcp0900449. PMID 19553648.

[pmid22200689-6] Nelson DR, Teckman J, Di Bisceglie AM, Brenner DA (2012). "Diagnosis and management of patients with α1-antitrypsin (A1AT) deficiency". Clin Gastroenterol Hepatol. 10 (6): 575–80. doi:10.1016/j.cgh.2011.12.028. PMC 3360829. PMID 22200689.

[pmid24480518-7] Tsochatzis EA, Bosch J, Burroughs AK (2014). "Liver cirrhosis". Lancet. 383 (9930): 1749–61. doi:10.1016/S0140-6736(14)60121-5. PMID 24480518.

[pmid18328931-8] Schuppan D, Afdhal NH (2008). "Liver cirrhosis". Lancet. 371 (9615): 838–51. doi:10.1016/S0140-6736(08)60383-9. PMC 2271178. PMID 18328931.CS1 maint: PMC format (link)

[pmid18923172-9] Kahrilas PJ (2008). "Clinical practice. Gastroesophageal reflux disease". N Engl J Med. 359 (16): 1700–7. doi:10.1056/NEJMcp0804684. PMC 3058591. PMID 18923172.CS1 maint: PMC format (link)

[pmid18789939-10] Kahrilas PJ, Shaheen NJ, Vaezi MF, Hiltz SW, Black E, Modlin IM; et al. (2008). "American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease". Gastroenterology. 135 (4): 1383–1391, 1391.e1–5. doi:10.1053/j.gastro.2008.08.045. PMID 18789939.

[pmid23477993-11] Bredenoord AJ, Pandolfino JE, Smout AJ (2013). "Gastro-oesophageal reflux disease". Lancet. 381 (9881): 1933–42. doi:10.1016/S0140-6736(12)62171-0. PMID 23477993.

[pmid16410582-12] Fox M, Forgacs I (2006). "Gastro-oesophageal reflux disease". BMJ. 332 (7533): 88–93. doi:10.1136/bmj.332.7533.88. PMC 1326932. PMID 16410582.CS1 maint: PMC format (link)

[pmid6710074-13] Sugimachi K, Inokuchi K, Kuwano H, Ooiwa T (1984). "Acute gastritis clinically classified in accordance with data from both upper GI series and endoscopy". Scand J Gastroenterol. 19 (1): 31–7. PMID 6710074.

[pmid25901896-14] Sipponen P, Maaroos HI (2015). "Chronic gastritis". Scand J Gastroenterol. 50 (6): 657–67. doi:10.3109/00365521.2015.1019918. PMC 4673514. PMID 25901896.

[pmid16819502-15] Sartor RB (2006). "Mechanisms of disease: pathogenesis of Crohn's disease and ulcerative colitis". Nat Clin Pract Gastroenterol Hepatol. 3 (7): 390–407. doi:10.1038/ncpgasthep0528. PMID 16819502.

[pmid2789799-16] Sipponen P (1989). "Atrophic gastritis as a premalignant condition". Ann Med. 21 (4): 287–90. PMID 2789799.

[pmid25133039-17] Badillo R, Francis D (2014). "Diagnosis and treatment of gastroesophageal reflux disease". World J Gastrointest Pharmacol Ther. 5 (3): 105–12. doi:10.4292/wjgpt.v5.i3.105. PMC 4133436. PMID 25133039.

[pmid17956071-18] Ramakrishnan K, Salinas RC (2007). "Peptic ulcer disease". Am Fam Physician. 76 (7): 1005–12. PMID 17956071.

[pmid17985090-19] Banasch M, Schmitz F (2007). "Diagnosis and treatment of gastrinoma in the era of proton pump inhibitors". Wien Klin Wochenschr. 119 (19–20): 573–8. doi:10.1007/s00508-007-0884-2. PMID 17985090.

[pmid15621988-20] Dicken BJ, Bigam DL, Cass C, Mackey JR, Joy AA, Hamilton SM (2005). "Gastric adenocarcinoma: review and considerations for future directions". Ann Surg. 241 (1): 27–39. PMC 1356843. PMID 15621988.

[pmid21390139-21] Ghimire P, Wu GY, Zhu L (2011). "Primary gastrointestinal lymphoma". World J Gastroenterol. 17 (6): 697–707. doi:10.3748/wjg.v17.i6.697. PMC 3042647. PMID 21390139.

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Peptic ulcer differential diagnosis

Overview

Differentiating Peptic Ulcer from other Diseases

Differential Diagnosis

References

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