Stomach and duodenal ulcer: diagnosis

Ulcer disease should be suspected if the patient has pain associated with eating, combined with nausea and vomiting, in epigastric, pyloroduodenal areas or right and left hypochondrium.

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

[1], [2]

Indications for consultation of other specialists

• Surgeon: if there are suspicions of complications, bleeding, perforation, penetration of the ulcer, stenosis.
• Oncologist: if there is a suspected malignant character of ulceration.
• Adjacent specialists: if necessary, consultations about concomitant diseases. 

The plan of examination for stomach ulcer and duodenum

Anamnesis and physical examination.

Compulsory laboratory tests

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

[3], [4], [5], [6], [7], [8]

Compulsory instrumental research

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

[9], [10], [11], [12], [13]

Additional laboratory tests

• the determination of Helicobacter pylori infection with an endoscopic urease test, a morphological method, an enzyme immunoassay, or a respiratory test;
• determination of serum gastrin level.

[14], [15]

Additional instrumental studies (according to indications)

• intragastric pH-metry;
• endoscopic ultrasonography;
• X-ray examination of the stomach;
• CT scan. 

[16],

Laboratory examination

Pathognomonic for peptic ulcer laboratory signs are not present.

It should be done to avoid complications, especially ulcer bleeding:

• a general blood test (OAK);
• analysis of feces for occult blood.

Instrumental diagnosis of gastric and duodenal ulcers

• FEGDS allows to reliably diagnose and characterize the ulcerative defect. In addition, PHAGDS makes it possible to control its healing, to perform a cytological and histological evaluation of the morphological structure of the gastric mucosa, to exclude the malignant character of ulceration. In the presence of a stomach ulcer, it is necessary to take 4-6 biopsies from the bottom and edges of the ulcer, followed by a histological study to exclude the presence of a tumor.
• Contrast X-ray examination of the upper gastrointestinal tract also reveals a ulcerative defect, but the sensitivity and specificity of the X-ray method is inferior to the endoscopic method.
• X-ray signs of peptic ulcer of stomach and duodenum
  • The symptom of the "niche" is the shadow of the contrast mass that filled the ulcer crater. Silhouette of the ulcer can be seen in the profile (contour "niche") or in full face in the background of folds of the mucous membrane ("relief-niche"). Small "niches" are indistinguishable in fluoroscopy. The contours of small ulcers are even and clear. In large ulcers the outlines become uneven due to the development of granulation tissues, congestion of mucus, blood clots. The relief "niche" looks like a stable round or oval congestion of contrast mass on the inner surface of the stomach or duodenum. Indirect signs - the presence of fluid in the stomach on an empty stomach, accelerated movement of contrast mass in the area of the ulcer.
  • Symptom of the "pointing finger" - in the stomach and onion, spasm occurs at the level of the ulcer, but on the opposite side of the pathological process.
• Intragastric pH-metry. With peptic ulcer, the most frequently observed increased or preserved acid-forming function of the stomach.
• Ultrasound of the abdominal cavity organs to exclude concomitant pathology.

Identification of Helicobacter pylori

Invasive diagnosis of gastric and duodenal ulcers

Conduct a fence of at least 5 biopsy specimens of the gastric mucosa: two from the antral and base sections and one from the corner of the stomach. To confirm the success of eradication of the microbe, this study is performed no earlier than 4-6 weeks after the completion of therapy. 

Morphological methods for the diagnosis of gastric and duodenal ulcers

"Golden standard" of Helicobacter pylori diagnosis is the coloring of bacteria in the histological sections of the gastric mucosa.

• The cytological method is the staining of bacteria in smears-biopsy specimens of the gastric mucosa by Romanovsky-Giemsa and Gram (currently considered insufficiently informative).
• The histological method - slices stained by Romanovsky-Giemsa, by Wartin-Starry, and others.

Biochemical method (rapid urease test) - determination of urease activity in the biopsy specimen of the gastric mucosa by placing it in a liquid or gel-like medium containing urea and an indicator. In the presence of H. Pylori in his biopsy , his urease turns urea into ammonia, which changes the pH of the medium and, consequently, the color of the indicator.

Bacteriological method is used little in routine clinical practice.

Immunohistochemical method with the use of monoclonal antibodies: has a greater sensitivity, since the antibodies used selectively stain H. Pylori. Little is used in routine clinical practice for the diagnosis of H. Pylori.

Non-invasive diagnosis of gastric and duodenal ulcers

• Serological methods: detection of antibodies to H. Pylori in serum. The method is most informative when conducting epidemiological studies. The clinical use of the test is limited in that it does not allow you to differentiate the fact of infection in an anamnesis from the presence of H. Pylori at the moment. Recently, more sensitive systems have appeared that allow one to diagnose eradication to reduce the titer of anti-Helicobacter antibodies in the blood serum of patients in standard terms 4-6 weeks by the method of enzyme immunoassay.
• Respiratory test - determination in the exhaled patient of air C0 ₂, labeled with ¹⁴ C or ¹³ C isotope , which is formed under the action of H. Pylori urease as a result of cleavage in the stomach of labeled urea. It allows to effectively diagnose the result of eradication therapy.
• PCR diagnostics. You can examine both the biopsy and the feces of the patient.

If all the rules of performing the procedures and proper sterilization of endoscopic equipment are observed, the primary diagnosis of H. Pylori justifies the onset of anti-Helicobacter therapy when the bacterium discovers one of the methods described. 

Diagnosis of the result of H. Pylori eradication therapy

Diagnosis by any method is performed not earlier than 4-6 weeks after the end of the course of anti-Helicobacter therapy.

Reference method to determine the success of eradication therapy H.pylori is a breath test with urea test meal labeled with ¹⁴ C. When using the methods of direct detection of bacteria in biopsy (bacteriological, morphological, urea) necessary to investigate the at least two biopsy samples from gastric body and antrum of one of department.

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

[17], [18], [19], [20], [21]

Differential diagnosis of gastric and duodenal ulcers

Differential diagnosis is conducted between ulcers of different locations, between peptic ulcer and symptomatic ulcers, as well as between benign ulcers and ulcerative form of stomach cancer.

If a peptic ulcer is found in the stomach, a differential diagnosis must be made between benign ulcers and the primary gastric ulcer. This form of cancer can for some time proceed under the "mask" of a benign ulcer. Malignant ulceration is evidenced by its large size (especially in young patients), localization of a peptic ulcer on the large curvature of the stomach, increased ESR. With x-ray and endoscopy, in cases of malignant gastric ulceration, a ulcerative defect of irregular shape with uneven and bumpy edges is detected; The gastric mucosa around the ulcer is infiltrated, the wall of the stomach at the site of ulceration is rigid. The final conclusion about the nature of ulceration is taken after a histological examination of the biopsy specimens. To avoid false negative results, the biopsy should be repeated until the ulcer is completely healed.

[22], [23], [24], [25], [26], [27]