Gastric and duodenal ulcer - Diagnosis

Peptic ulcer disease should be suspected if the patient experiences pain associated with food intake, combined with nausea and vomiting, in the epigastric, pyloroduodenal regions or the right and left hypochondrium.

The clinical picture may depend on the localization of the ulcer defect, its size and depth, the secretory function of the stomach, and the patient's age. The possibility of asymptomatic exacerbation of peptic ulcer disease should always be kept in mind.

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Indications for consultation with other specialists

• Surgeon: if complications are suspected - bleeding, perforation, ulcer penetration, stenosis.
• Oncologist: if there is a suspicion of a malignant nature of the ulcer.
• Related specialists: if consultations are required regarding concomitant diseases.

Examination plan for gastric and duodenal ulcers

History and physical examination.

Mandatory laboratory tests

• general blood test;
• general urine analysis;
• general stool analysis;
• fecal occult blood test;
• the level of total protein, albumin, cholesterol, glucose, serum iron in the blood;
• blood type and Rh factor;
• fractional study of gastric secretion.

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Mandatory instrumental studies

• FEGDS with the taking of 4-6 biopsies from the bottom and edges of the ulcer if it is localized in the stomach and with their histological examination;
• Ultrasound of the liver, pancreas, gallbladder.

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Additional laboratory tests

• determination of Helicobacter pylori infection by endoscopic urease test, morphological method, enzyme immunoassay or breath test;
• determination of serum gastrin levels.

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Additional instrumental studies (as indicated)

• intragastric pH-metry;
• endoscopic ultrasonography;
• X-ray examination of the stomach;
• computed tomography.

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Laboratory examination

There are no pathognomonic laboratory signs for peptic ulcer disease.

Research should be carried out to exclude complications, primarily ulcerative bleeding:

• complete blood count (CBC);
• fecal occult blood test.

Instrumental diagnostics of gastric and duodenal ulcers

• FEGDS allows for reliable diagnosis and characterization of the ulcer defect. Additionally, FEGDS allows for monitoring its healing, performing cytological and histological assessment of the morphological structure of the gastric mucosa, and excluding the malignant nature of ulceration. In the presence of a gastric ulcer, it is necessary to take 4-6 biopsies from the bottom and edges of the ulcer with subsequent histological examination to exclude the presence of a tumor.
• Contrast X-ray examination of the upper gastrointestinal tract also allows for the detection of ulcerative defects, however, in terms of sensitivity and specificity, the X-ray method is inferior to the endoscopic method.
• X-ray signs of gastric ulcer and duodenal ulcer
  • The "niche" symptom is a shadow of a contrast mass filling the ulcer crater. The ulcer silhouette can be seen in profile (contour "niche") or full face against the background of mucosal folds ("relief niche"). Small "niches" are not distinguishable by fluoroscopy. The contours of small ulcers are smooth and clear. In large ulcers, the outlines become uneven due to the development of granulation tissue, accumulation of mucus, and blood clots. A relief "niche" has the appearance of a persistent round or oval accumulation of contrast mass on the inner surface of the stomach or duodenum. Indirect signs are the presence of fluid in the stomach on an empty stomach, accelerated movement of the contrast mass in the ulcer area.
  • The "pointing finger" symptom - in the stomach and bulb, a spasm occurs at the level of the ulcer, but on the opposite side of the pathological process.
• Intragastric pH-metry. In peptic ulcer disease, the most common finding is increased or preserved acid-forming function of the stomach.
• Ultrasound of abdominal organs to exclude concomitant pathology.

Detection of Helicobacter pylori

Invasive diagnostics of gastric and duodenal ulcers

At least 5 biopsies of the gastric mucosa are taken: two from the antral and fundal sections and one from the gastric angle. To confirm the success of microbe eradication, this study is performed no earlier than 4-6 weeks after completion of therapy.

Morphological methods of diagnostics of gastric and duodenal ulcers

The “gold standard” for diagnosing Helicobacter pylori is staining bacteria in histological sections of the gastric mucosa.

• Cytological method - staining of bacteria in smears-prints of biopsy specimens of the gastric mucosa according to Romanovsky-Giemsa and Gram (currently considered insufficiently informative).
• Histological method - sections are stained according to Romanovsky-Giemsa, Warthin-Starry, etc.

Biochemical method (rapid urease test) - determination of urease activity in a biopsy of the gastric mucosa by placing it in a liquid or gel-like medium containing urea and an indicator. If H. pylori is present in the biopsy, its urease converts urea into ammonia, which changes the pH of the medium and, consequently, the color of the indicator.

The bacteriological method is little used in routine clinical practice.

Immunohistochemical method using monoclonal antibodies: has greater sensitivity, since the antibodies used selectively stain H. pylori. Little used in routine clinical practice for the diagnosis of H. pylori.

Non-invasive diagnostics of gastric and duodenal ulcers

• Serological methods: detection of antibodies to H. pylori in the blood serum. The method is most informative when conducting epidemiological studies. Clinical application of the test is limited by the fact that it does not allow differentiating the fact of infection in the anamnesis from the presence of H. pylori at the present moment. Recently, more sensitive systems have appeared that allow diagnosing eradication by reducing the titer of anti-Helicobacter antibodies in the blood serum of patients in the standard time frame of 4-6 weeks using the enzyme immunoassay method.
• _{Breath test - determination of CO2 labeled with}^14C or ^13C isotope in the patient's exhaled air, which is formed under the action of H.pylori urease as a result of the breakdown of labeled urea in the stomach. Allows for effective diagnosis of the result of eradication therapy.
• PCR diagnostics. Both biopsy and feces of the patient can be examined.

If all the rules for performing the methods are followed and the endoscopic equipment is properly sterilized, the primary diagnosis of H.pylori justifies the initiation of anti-Helicobacter therapy when the bacteria is detected by one of the described methods.

Diagnostics of the result of eradication therapy of H. pylori

Diagnostics by any method is carried out no earlier than 4-6 weeks after the end of the course of anti-Helicobacter therapy.

The reference method for determining the success of H.pylori eradication therapy is a breath test with a test breakfast of urea labeled with ¹⁴ C. When using methods for direct detection of bacteria in a biopsy (bacteriological, morphological, urease), it is necessary to examine at least two biopsies from the body of the stomach and one from the antral section.

The cytological method is not applicable for determining the effectiveness of eradication.

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Differential diagnostics of gastric and duodenal ulcers

Differential diagnosis is carried out between ulcers of different localizations, between peptic ulcer disease and symptomatic ulcers, as well as between benign ulcers and the ulcerative form of gastric cancer.

When an ulcerative defect is detected in the stomach, it is necessary to conduct a differential diagnosis between benign ulcers and the primary ulcerative form of stomach cancer. This form of cancer can proceed for some time under the "mask" of a benign ulcer. The following indicate a malignant ulcer: its large size (especially in young patients), localization of the ulcerative defect on the greater curvature of the stomach, increased ESR. In cases of malignant ulcers of the stomach, X-ray and endoscopic examination reveal an ulcerative defect of irregular shape with uneven and bumpy edges; the gastric mucosa around the ulcer is infiltrated, the stomach wall at the site of the ulcer is rigid. The final conclusion on the nature of the ulcer is made after histological examination of the biopsy specimens. To avoid false negative results, the biopsy should be repeated until the ulcer is completely healed.

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