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Laboratory Tests and Ancillaries
Diagnostic
Procedures
Esophagogastroduodenoscopy
(EGD)
The main role of
esophagogastroduodenoscopy in uncomplicated PUD is to confirm the diagnosis and
to rule out cancer. This identifies gastric and duodenal ulcers and malignant
lesions with 90% sensitivity and specificity. NSAID-associated ulcers typically
present as a shallow, flat, antral ulcer with associated lesions. This is recommended
in patients with evidence of bleeding, anemia, >10% weight loss, chronic
PUD, persistent vomiting, or any alarm features that may suggest significant
structural disease or malignancy (eg dysphagia, odynophagia, early satiety,
abdominal mass, lymphadenopathy, or history of prior malignancy); in patients
whose symptoms do not respond to pharmacological therapy, and in
>50-year-old patients with new-onset dyspepsia.
Esophagogastroduodenoscopy
may be used for surveillance of ulcers. This should be considered in patients with
duodenal ulcers who have persistent symptoms despite appropriate therapy. This
may rule out refractory peptic ulcers and ulcers with non-peptic origin. This has
low yield if patients’ symptoms resolved after a course of acid suppression with
eradication treatment for H pylori and discontinuation of NSAIDs. EGD may
identify gastric cancer early in patients with gastric ulcer, hence improving
survival. This should be performed depending on patients’ risk for gastric
ulcer. This should be considered in patients with gastric ulcer without clear
etiology and in those who did not undergo biopsy during index EGD. This should
be performed in patients with refractory PUD until the ulcer has healed or the
etiology has been identified.
Esophagogastroduodenoscopy
allows biopsy of the lesion. This is indicated for gastric ulcer with malignant
features (eg associated mass lesion, elevated irregular ulcer borders and
abnormal adjacent mucosal folds). Surveillance EGD with biopsy is recommended
for gastric ulcers even those without malignant features because of the higher
risk for malignancy. There is a 3- to 6-fold increased risk for gastric cancer
to develop from H pylori-associated ulcer. Initially, some malignant
ulcers may appear endoscopically benign. 2-5% of malignant ulcers may have
false-negative biopsy results. Ulcers that are not healed after 8-12 weeks of
medical therapy should have a repeat biopsy. Routine cytologic brushings may
add to sensitivity but are not advised as an alternative or adjunct to
endoscopic biopsy.
Peptic Ulcer Disease_Diagnostics 1Esophagogastroduodenoscopy may also be used in diagnosing, prognosticating, and managing complications of PUD. In bleeding PUD, EGD done within 24 hours of admission has been shown to reduce the need for blood transfusion, shorten intensive care unit (ICU) and hospital stays, decrease the need for surgery, and lower the mortality rate. Patients with features of high risk of rebleeding on endoscopy (eg presence of adherent clots, visible vessels, active arterial bleeding) should undergo endoscopic therapy (ie clips, bipolar electrocoagulation, heater probe, sclerosant) to attain hemostasis and to lower the risk of rebleeding. Endoscopic hemostasis using Epinephrine should be followed by another modality (eg fibrin glue, thrombin, alcohol). Repeat endoscopic therapy is advised prior to considering surgical or radiological intervention in patients who rebleed after initial endoscopic therapy. EGD allows identification of ulcer penetration to adjacent organs like the liver and spleen through biopsy obtained via endoscopy. It is important in confirming the presence and distinguishing benign from malignant obstruction. Endoscopic balloon dilation has been used to manage benign gastric outlet obstruction, causing good to excellent short-term relief of symptoms in 67-83% of patients.
Acquisition of tissue samples for histological exam and culture or rapid urease testing for H pylori may also be done endoscopically. This is contraindicated in patients with acute perforated peptic ulcer. In some studies, role has been limited in identifying perforation site and in guiding subsequent laparoscopic intercorporeal suture repair with omental patch.
Laboratory Tests
Laboratory tests have a minimal role in evaluating patients with uncomplicated PUD. A fasting serum gastrin level may be measured in patients with duodenal ulcers in whom the presence of other diagnoses (eg Zollinger-Ellison syndrome) is suspected.
H pylori testing is recommended for all patients with peptic ulcer disease for diagnosing and managing concomitant infection and may include rapid urease test, serologic ELISA (IgG antibody), urea breath test or stool antigen test. The test and treat strategy is recommended in areas where the H pylori infection rate is >10% and in patients with past or active PUD, low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma, or a history of endoscopic resection of early gastric cancer. A routine screening for H pylori in asymptomatic individuals is not recommended.
Imaging
Radiologic Upper Gastrointestinal Series
An upper gastrointestinal series may be an option when EGD is
not available. This can be used for initial assessment in patients with
suspected perforation. This is not effective in identifying ulcers <0.5 cm
in size and does not allow biopsy.
Abdominal Computed Tomography (CT) Scan
An abdominal CT scan is recommended for diagnosing PUD complications (eg
perforation and obstruction). A perforated ulcer will present with free air
below the diaphragm on CT scan. This is not sensitive for diagnosing
uncomplicated PUD and may miss superficial ulcers.
Peptic Ulcer Disease_Diagnostics 2