Diagnosis:

Peptic ulcers are always suspected in patients with persistent dyspepsia (bloating, belching, and abdominal pain). Symptoms of dyspepsia occur in 20 - 25% of people who live in industrialized nations, but only about 15 - 25% of those with dyspepsia actually have ulcers. A number of steps are needed to accurately diagnose ulcers.

Medical and Family History

The doctor will ask for a thorough report of a patient's dyspepsia and other important symptoms, such as weight loss or fatigue, present and past medication use (especially chronic NSAID use), family members with ulcers, and drinking and smoking habits.

Ruling out Other Disorders

In addition to peptic ulcers, a number of conditions, notably gastroesophageal reflux disease (GERD) and irritable bowel syndrome, cause dyspepsia. Often, however, no cause can be determined. In such cases, the symptoms are referred to collectively as functional dyspepsia.

Peptic ulcer symptoms, particularly abdominal pain and chest pain, may resemble those of other conditions, such as gallstones or a heart attack. Certain features may help to distinguish these different conditions. However, symptoms often overlap, and it is impossible to make a diagnosis based on symptoms alone. A number of tests are needed.

The following disorders may be confused with peptic ulcers:

• GERD. About half of patients with GERD also have dyspepsia. With GERD or other problems in the esophagus, the main symptom is usually heartburn, a burning pain that radiates up to the throat. It typically develops after meals and is relieved by antacids. The patient may have difficulty swallowing and may experience regurgitation or acid reflux. Elderly patients with GERD are less likely to have these symptoms, but instead may experience appetite loss, weight loss, anemia, vomiting, or dysphagia (difficult or painful swallowing). [For more information, see In-Depth Report #85: Gastroesophageal reflux disease.]
• Heart Events. Cardiac pain, such as angina or a heart attack, is more likely to occur with exercise and may radiate to the neck, jaw, or arms. In addition, patients typically have distinct risk factors for heart disease, such as a family history, smoking, high blood pressure, obesity, or high cholesterol. [For more information, see In-Depth Report #12: Heart attack.]
• Gallstones. The primary symptom in gallstones is typically a steady gripping or gnawing pain on the right side under the rib cage, which can be quite severe and can radiate to the upper back. Some patients experience pain behind the breast bone. The pain often occurs after a fatty or heavy meal, but gallstones almost never cause dyspepsia. [For more information, see In-Depth Report #10: Gallstones and gallbladder disease.]
• Irritable Bowel Syndrome. Irritable bowel syndrome can cause dyspepsia, nausea and vomiting, bloating, and abdominal pain. It occurs more often in women than in men.

Dyspepsia may also occur with gastritis, stomach cancer, or as a side effect of certain drugs, including NSAIDs, antibiotics, iron, corticosteroids, theophylline, and calcium blockers.

Noninvasive Tests for Gastrointestinal (GI) Bleeding

When ulcers are suspected, the doctor will order tests to detect bleeding. These may include a rectal exam, complete blood count, and fecal occult blood test (FOBT). The FOBT tests for hidden (occult) blood in stools. Typically, the patient is asked to supply up to six stool specimens in a specially prepared package. A small quantity of feces is smeared on treated paper, which reacts to hydrogen peroxide. If blood is present, the paper turns blue.

Traditional radiology tests have not yet proven valuable for diagnosing ulcers.

Tests to Detect H. pylori

Simple blood, breath, and stool tests can now detect H. pylori with a fairly high degree of accuracy. It is not entirely clear, however, which individuals should be screened for H. pylori.

Candidates for Screening. Some doctors currently test for H. pylori only in individuals with dyspepsia who also have high-risk conditions, such as:

• Symptoms of ulcers, such as weight loss, anemia, or indications of bleeding
• History of active ulcers
• Risk factors for stomach cancer or other complications from ulcers

Smokers and those who experience regular and persistent pain on an empty stomach may also be good candidates for screening tests. Some doctors argue that testing for H. pylori may be beneficial for patients with dyspepsia who are regular NSAID users. In fact, given the possible risk for stomach cancer in H. pylori- infected people with dyspepsia, some experts now recommend that any patient with dyspepsia lasting longer than 4 weeks should have a blood test for H. pylori. This is a subject of considerable debate, however.

Tests for Diagnosing H. pylori. The following tests are used to diagnose H. pylori infection. Testing may also be done after treatment to ensure that the bacteria have been completely eliminated.

• Breath Test. A simple test called the carbon isotope-urea breath test (UBT) can identify up to 99% of people who have H. pylori. Up to 2 weeks before the test, the patient must stop taking any antibiotics, bismuth-containing medications such as Pepto-Bismol, and proton pump inhibitors (PPIs). As part of the test, the patient swallows a special substance containing urea (a waste product the body produces as it breaks down protein) that has been treated with carbon atoms. If H. pylori are present, the bacteria convert the urea into carbon dioxide, which is detected and recorded in the patient's exhaled breath after 10 minutes. This test can also be used to confirm that H. pylori have been fully treated.
• Blood Tests. Blood tests are used to measure antibodies to H. pylori, and the results are available in minutes. Diagnostic accuracy is reported to be 80 - 90%. One such important test is called enzyme-linked immunosorbent assay (ELISA). An ELISA test of the urine is also showing promise for diagnosing H. pylori in children.
• Stool Test. A test to detect the genetic fingerprints of H. pylori in the feces appears to be as accurate as the breath test for initially detecting the bacteria, and for detecting recurrences after antibiotic therapy. This test can also be used to confirm that the H. pylori infection has been fully treated.
• The most accurate way to identify the presence of H. pylori is by taking a tissue biopsy from the lining of the stomach. The only way to do this is with endoscopy. It is an invasive procedure, but it is the most accurate test. However, many patients are treated for H. pylori based on the three noninvasive tests listed above.

Endoscopy

Endoscopy is a procedure used to evaluate the esophagus, stomach, and duodenum using an endoscope -- a long, thin tube equipped with a tiny video camera. When combined with a biopsy, endoscopy is the most accurate procedure for detecting the presence of peptic ulcers, bleeding, and stomach cancer, or for confirming the presence of H. pylori.

Appropriate Candidates for Endoscopy. Because endoscopy is invasive and expensive, it is unsuitable for screening everyone with dyspepsia. Most individuals with these symptoms are managed effectively without endoscopy. Endoscopy is usually reserved for patients with dyspepsia who also have risk factors for ulcers, stomach cancer, or both. Risk factors include the following:

• "Alarm" symptoms (unexplained weight loss, gastrointestinal bleeding, vomiting, difficulty swallowing, or anemia). Patients with these symptoms generally have an endoscopy before treatment.
• Over age 55 (when the risk for stomach cancer increases)
• Failure to respond to medical treatment of H. pylori, if present

Experts disagree about whether endoscopy should be performed on all patients who do not respond to initial medication, unless there is evidence or suspicion of bleeding or serious complications, because it does not appear to add any useful information about treatment choices. There is also some debate about whether patients under age 45 who have persistent dyspepsia but no alarm symptoms should have an endoscopy.

The Procedure. Endoscopy may be performed in a hospital, doctor's office, or outpatient surgery center, and typically involves the following:

• The doctor administers a local anesthetic using an oral spray and an intravenous sedative to suppress the gag reflex and relax the patient.
• The doctor then places the thin, flexible plastic tube into the patient's mouth and maneuvers it down the esophagus into the stomach.
• A tiny camera in the endoscope allows the doctor to see the surface of the esophagus, stomach, and duodenum, and to search for abnormalities.
• The doctor will remove about 10 small tissue samples (biopsies), which will be tested for H. pylori.

In endoscopy, the doctor places a long, thin, flexible tube (called an endoscope) down the patient's throat and into the stomach and duodenum. A camera and light on the tip of the endoscope enables the doctor to check for abnormalities. Tiny samples may be taken to check for H. pylori bacteria, a cause of many peptic ulcers. If a bleeding ulcer is found, it may be sealed with a burning tool (cauterized) during the procedure.

Upper GI Series

An upper GI series was the standard method for diagnosing peptic ulcers until endoscopy and tests for detecting H. pylori were introduced. In an upper GI series, the patient drinks a solution containing barium. X-rays are then taken, which may reveal inflammation, active ulcer craters, or deformities and scarring due to previous ulcers. Endoscopy is more accurate, although it is also more invasive and expensive.

Other Laboratory Tests

Stool tests may show traces of blood that are not visible to the naked eye, and blood tests may reveal anemia in those who have bleeding ulcers. If Zollinger-Ellison syndrome is suspected, blood levels of gastrin should be measured.