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]


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,pancreatitis, Zollinger-Ellison Syndrome,cholelithiasis,gastric outlet syndrome,myocardial infaraction ,pleural empyema and appendicitis

Differentiating Peptic Ulcer from other Diseases

Peptic ulcer disease must be differentiated from other diseases that presents with epigastric pain such as gastritis, gastroesophageal reflux disease,acute pancreatitis,prmary biliary cirrhosis,cholelithiasis,gastric outlet syndrome,myocardial infaraction ,pleural empyema,acute appendicitis [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]

Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Fever Rigors and chills Abdominal Pain Jaundice GI Bleed Hypo-


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 + 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
Cardiovascular disorders Myocardial Infarction Epigastric + in cardiogenic shock N
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 syndromeERCPEndoscopic retrograde cholangiopancreatographyIV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDHLactate dehydrogenaseGI= Gastrointestinal, CXR= Chest X ray, IgAImmunoglobulin AIgGImmunoglobulin GIgM=Immunoglobulin MCTComputed tomographyPMN= Polymorphonuclear cells, ESRErythrocyte sedimentation rateCRPC-reactive protein 

Disease Cause Symptoms Diagnosis Other findings
Pain Nausea



Heartburn Belching or


Weight loss Loss of


Stools Endoscopy findings
Location Aggravating Factors Alleviating Factors
Acute gastritis Food Antacids - Black stools -
Chronic gastritis Food Antacids - H. pylori gastritis

Lymphocytic gastritis

  • Enlarged folds
  • Aphthoid erosions
Atrophic gastritis Epigastric pain - - - - H. pylori


Autoimmune gastritis diagnosis include:

Crohn's disease - - - - -
  • Mucosal nodularity with cobblestoning
  • Multiple aphthous ulcers
  • Linier or serpiginous ulcerations
  • Thickened antral folds
  • Antral narrowing
  • Hypoperistalsis
  • Duodenal strictures
  • Lower esophageal sphincter abnormalities
  • Spicy food
  • Tight fitting clothing

(Suspect delayed gastric emptying)

- - - - Other symptoms:


Peptic ulcer disease

Duodenal ulcer

  • Pain aggravates with empty stomach

Gastric ulcer

  • Pain aggravates with food
  • Pain alleviates with food
- - - 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

Other diagnostic tests
Gastrinoma - -

(suspect gastric outlet obstruction)

- - - Useful in collecting the tissue for biopsy

Diagnostic tests

Gastric Adenocarcinoma - - Esophagogastroduodenoscopy
  • Multiple biopsies are taken to establish the diagnosis
Other symptoms
Primary gastric lymphoma - - - - - - - Useful in collecting the tissue for biopsy Other symptoms


  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.
  2. Dallal HJ, Palmer KR (2001). "ABC of the upper gastrointestinal tract: Upper gastrointestinal haemorrhage". BMJ. 323 (7321): 1115–7. PMC 1121602. PMID 11701581.
  3. 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.
  4. Tsochatzis EA, Bosch J, Burroughs AK (2014). "Liver cirrhosis". Lancet. 383 (9930): 1749–61. doi:10.1016/S0140-6736(14)60121-5. PMID 24480518.
  5. Schuppan D, Afdhal NH (2008). "Liver cirrhosis". Lancet. 371 (9615): 838–51. doi:10.1016/S0140-6736(08)60383-9. PMC 2271178. PMID 18328931.
  6. Kahrilas PJ (2008). "Clinical practice. Gastroesophageal reflux disease". N Engl J Med. 359 (16): 1700–7. doi:10.1056/NEJMcp0804684. PMC 3058591. PMID 18923172.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. Sipponen P, Maaroos HI (2015). "Chronic gastritis". Scand J Gastroenterol. 50 (6): 657–67. doi:10.3109/00365521.2015.1019918. PMC 4673514. PMID 25901896.
  12. 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.
  13. Sipponen P (1989). "Atrophic gastritis as a premalignant condition". Ann Med. 21 (4): 287–90. PMID 2789799.
  14. 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.
  15. Ramakrishnan K, Salinas RC (2007). "Peptic ulcer disease". Am Fam Physician. 76 (7): 1005–12. PMID 17956071.
  16. 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.
  17. 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.
  18. 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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