Symptoms and diagnosis of peptic ulcer disease
The most common presentation of peptic ulcer disease is epigastric pain or discomfort (sometimes relieved by antacids), which may be accompanied by nausea, vomiting and heartburn. Symptoms overlap considerably with those of other upper gastrointestinal disorders, particularly functional heartburn and functional dyspepsia and gastro-oesophageal reflux. A patient can have both peptic ulcer disease and gastro-oesophageal reflux.
Relief or exacerbation of symptoms by food, and the timing of symptoms after a meal, are not reliable indicators of the presence of an ulcer or whether an ulcer is gastric or duodenal. Peptic ulcers can be asymptomatic; a minority of patients first present with a complication, most commonly bleeding.
Peptic ulcer disease is more likely if there is:
- a remitting and relapsing course and nocturnal wakening with epigastric pain (differentiated from nocturnal reflux or regurgitation)
- documented history of an ulcer or a family history of ulcer disease
- use of aspirin or another nonsteroidal anti-inflammatory drug (NSAID).
Peptic ulcers are readily diagnosed at endoscopy. Biopsies (most commonly for histology and a rapid urease test) can identify the presence of Helicobacter pylori and exclude malignancy. The accuracy of tests on biopsies is reduced by antibiotic therapy within the past 4 weeks, or proton pump inhibitor (PPI) therapy within the past 2 weeks; H2-receptor antagonists do not have this effect. If histology suggests H. pylori infection (active chronic gastritis) but H. pylori is not identified, additional testing such as a urea breath test (or serology if the patient cannot stop PPI therapy) may clarify H. pylori status.