Differential Diagnosis of Peptic Ulcer Disease

Instrumental workup: EGD and X-ray

Endoscopic examination (EGD) is recognized as the "gold standard" in the diagnosis of ulcerative lesions. The method provides broad capabilities:

• Visualization: precise determination of the location and size of the mucosal defect.
• Etiological workup: collection of biological material to confirm the presence of Helicobacter pylori.
• Histological verification: performing a biopsy, which is critically necessary to differentiate benign ulcers from malignant neoplasms.

Clinical nuance: Ulcers located on the greater curvature of the stomach may demonstrate a benign picture on X-ray examination, but histological results frequently reveal cancer.

X-ray examination with barium sulfate suspension contrast is used less frequently today. Its main pathognomonic sign is the "niche" sign (accumulation of the contrast agent in the wall defect). However, the method has severe limitations:

• Extremely low specificity when attempting to distinguish a regular ulcer from malignancy.
• Difficult assessment of healing dynamics if scarring deformations are already present on the mucosa.

Diagnostic significance of the character of vomiting

When taking a history, detailing the time of onset of vomiting, its relation to food intake, and the dynamics of the pain syndrome plays a crucial role.

• Morning fasting vomiting: if the vomitus contains a large amount of mucus, it indicates chronic gastritis (especially of alcoholic etiology). If the vomit consists of acidic gastric contents, nocturnal hypersecretion should be suspected.
• Vomiting at the peak of pain: expulsion of acidic masses, after which the patient feels clear relief, is a typical manifestation of classic peptic ulcer disease.
• Vomiting of food eaten the day before: if food consumed 1–2 days ago is found in the masses, this directly indicates content stasis characteristic of pyloric stenosis.

Recognizing complications of the ulcer process

The development of complications cardinally changes the clinical picture and requires a reassessment of the differential diagnosis.

1. Hemorrhage. Most characteristic of duodenal ulcers. It is important to remember that bleeding can occur in a concealed, paucisymptomatic form and be detected only by laboratory fecal occult blood testing.
2. Pyloric stenosis. Localized in the pyloric channel or the initial section of the duodenum. Unlike an uncomplicated ulcer, eating ceases to bring relief and begins to increase pain. Persistent, profuse "projectile" vomiting becomes the leading clinical sign. The loss of gastric juice provokes a decrease in chlorine levels (hypochloremia) and secondary renal failure. Physical examination of the epigastric region reveals a "succussion splash". To rule out gastric cancer and pyloric hypertrophy, EGD with biopsy is mandatory.
3. Penetration. Represents the spread of the infiltrative-destructive process to adjacent organs (pancreas, liver, omentum). Characterized by a clear triad:
4. Persistent nature of the pain syndrome;
5. Appearance of low-grade fever;
6. Laboratory markers of inflammation (high ESR).

Main differential diagnosis

Any acute abdominal pain syndrome requires the immediate exclusion of urgent surgical pathology ("acute abdomen").

After excluding life-threatening conditions, the differential workup for suspected peptic ulcer disease is carried out with the following conditions:

• Functional dyspepsia;
• Chronic gastritis;
• Gastroesophageal reflux disease (GERD);
• Pancreatitis;
• Cholelithiasis.

Class and exam questions

What else to study on this topic

• Pathogenesis of hypochloremia and secondary renal failure development in pyloric stenosis
• Method for detecting the "succussion splash" during physical examination
• Algorithm for differential diagnosis between gastric cancer and benign ulcer
• Clinical criteria and management in concealed gastrointestinal bleeding

Other topics in the "Digestive System" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.