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A definitive diagnosis of peptic ulcer disease cannot be made on clinical grounds alone. 12 Uncomplicated peptic ulcer disease can be strongly suspected in the presence of a "classic" history including epigastric burning pain; relief of pain with milk, food, or antacids; and night pain accompanied by "benign" physical examination findings, including normal vital signs and with or without mild epigastric tenderness. The differential diagnosis of epigastric pain is extensive and in addition to peptic ulcer disease includes gastritis, gastroesophageal reflux disease (GERD), cholelithiasis, pancreatitis, hepatitis, abdominal aortic aneurysm (AAA), gastroparesis, and "functional" dyspepsia. A careful history may elicit features that point away from peptic ulcer disease: burning pain radiating into the chest, water brash, and belching may suggest GERD; more severe pain radiating to the right upper quadrant and around the right or left side suggests cholelithiasis; radiation through to the back indicates pancreatitis or AAA; chronic pain, anorexia, or weight loss may indicate gastric cancer. Myocardial ischemic pain may also present as epigastric pain and should be strongly considered in the appropriate clinical setting.

Physical examination findings may also suggest other diagnoses: right upper quadrant tenderness points to cholelithiasis or hepatitis, epigastric mass to pancreatitis (pseudocyst), pulsatile mass to aAa, jaundice to hepatitis, and peritoneal findings to an acute abdomen.

In a patient presenting with epigastric pain, a number of ancillary tests may be helpful to exclude peptic ulcer disease complications and to narrow the differential diagnosis. A normal complete blood count will rule out anemia from chronic gastrointestinal bleeding due to peptic ulcer disease, gastritis, or cancer (but does not rule out acute blood loss). Elevated liver function test results may indicate hepatitis, and elevated lipase levels may indicate pancreatitis. An acute abdominal series may show free air associated with perforation. A "limited" emergency department ultrasound examination may show gallstones or an AAA. An electrocardiogram and cardiac enzyme determination are indicated if there is a suspicion of myocardial ischemic pain.

The definitive diagnosis of peptic ulcer disease is made by visualization of the ulcer via upper gastrointestinal barium-contrast radiography or via upper gastrointestinal endoscopy. Endoscopy has a higher yield rate for ulcer and other mucosal pathologic conditions, which may affect clinical care. 1 However, endoscopy also has a higher cost and complication rate.1

Since most peptic ulcers are caused by H. pylori infection and since eradication of H. pylori dramatically decreases ulcer recurrence rate, it is important to note how to diagnose infection. Helicobacter pylori can be diagnosed by endoscopic tests, including the Campylobacter-like organism (CLO) test; histologic study or culture; and noninvasive tests, including serologic tests and breath tests. I.! J.4 The CLO test detects the presence of urease in a biopsy specimen (presumptive evidence of H. pylori infection) with about a 90 percent sensitivity and 100 percent specificity and a cost of about $10. Histologic study using special stains has a sensitivity and specificity above 90 percent and costs about $150. Culture is difficult and has a sensitivity no better than histologic studies (although it has 100 percent specificity if results are positive). The aforementioned costs do not include the cost of endoscopy. Serologic studies detect IgG antibodies to H. pylori with very high sensitivity and specificity at a cost of about $50 to $75. It is not useful as a test of cure, since antibodies remain for several years after eradication. The breath test also relies on the presence of urease produced by H. pylori. Urea, labeled with carbon 13 or 14, is ingested and in the presence of bacterial urease is broken down into labeled carbon dioxide and ammonia. The labeled carbon dioxide is detected in the breath 30 min later. Sensitivity and specificity are greater than 90 percent, and the cost is $200 to $300. This test is ideal for confirming cure of infection.

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