Digestive disorders

IV/4.5: Diagnostics beyond imaging

The presentation of pain, its association with meals, and the accompanying symptoms raise the suspicion of peptic ulcer.

There are direct and indirect signs of gastric ulcer during X-ray examination. In the diagnostics of peptic ulcer the radiologic examination has been put in the shade by the complete endoscopic examination of the upper gastrointestinal tract (panendoscopy). An X-ray examination of the stomach is indicated if there is a presumed disorder of emptying of the stomach. Native abdominal X-ray examination has a role in the detection of free abdominal air  and in the exclusion of other causes of an acute abdomen (ileus).

Upper panendoscopy is an essential technique (gold standard) of the diagnostics of peptic ulcer. Recognition of the ulcer depends on its localization and on the skill of the person who performs the examination. 90% of cases are recognized during the examination. During endoscopy of the stomach, the ulcer appears as a circumscribed lack of the mucosa. Macroscopic examination of the ulcer’s border is helpful in the differentiation from gastric cancer, though an exact diagnosis is provided by the histopathological examination of the samples taken by biopsy during the endoscopy; this also helps determining the H. pylori status.

Usually the development of a single ulcer is typical; multiple ulcer presentations raise the possibility of the etiologic role of a medicine. Usually the transition between the mucosa and the ulcer is even, the folds running to the border of ulcer are star-shaped, and regular. A malignant process is suggested by the appearance of nodes with roughly granulated surface, the interruption  and thickening  of the folds running to the ulcer’s border or when the crater is surrounded by a sunken-in ring . Multiple histological sample taking is necessary, even if the lesions seem to be benign macroscopically.

In patients with gastric ulcer endoscopic follow up is necessary at 4 to 6 weeks and at the end of the 3rd month. Surgery is indicated if malignancy or severe dysplasia is demonstrated by the histopathological examination or the gastric ulcer does not heal until the end of the 3rd month of therapy. An assessment of the successfulness of H. pylori eradication is performed by a rapid urease test or histological examination associated with the follow up endoscopy.

IV/4.6: Differential diagnosis

The differential diagnosis of gastric ulcer should primarily exclude the malignant processes (ulcerated gastric carcinoma, lymphoma). The disease should be differentiated from the ulcerous subtype of functional dyspepsia, duodenal ulcer and erosive duodenopathy.