Editing Peptic ulcer disease (section)

==Diagnosis==
[[Image:Gastric ulcer 3.jpg|right|thumb|upright=1.2|Endoscopic image of gastric ulcer, biopsy proven to be [[gastric cancer]].]]
[[File:Adenocarcinoma of the stomach.jpg|thumb|A [[biopsy]] sample of a stomach ulcer that was diagnosed as [[stomach cancer]]]]
The diagnosis is mainly established based on the characteristic symptoms. Stomach pain is the most common sign of a peptic ulcer.<ref name=":0" />

More specifically, peptic ulcers erode the [[muscularis mucosae]], at minimum reaching to the level of the submucosa (contrast with erosions, which do not involve the muscularis mucosae).<ref>{{cite web |url=http://www.merckmanuals.com/professional/gastrointestinal-disorders/gastritis-and-peptic-ulcer-disease/peptic-ulcer-disease |title=Peptic Ulcer Disease |access-date=2016-01-17 |url-status=live |archive-url=https://web.archive.org/web/20160113063138/http://www.merckmanuals.com/professional/gastrointestinal-disorders/gastritis-and-peptic-ulcer-disease/peptic-ulcer-disease |archive-date=13 January 2016 |df=dmy-all }}</ref>

Confirmation of the diagnosis is made with the help of tests such as endoscopies or barium contrast [[x-ray]]s. The tests are typically ordered if the symptoms do not resolve after a few weeks of treatment, or when they first appear in a person who is over age 45 or who has other symptoms such as [[weight loss]], because [[stomach cancer]] can cause similar symptoms. Also, when severe ulcers resist treatment, particularly if a person has several ulcers or the ulcers are in unusual places, a doctor may suspect an underlying condition that causes the stomach to overproduce [[acid]].<ref name="Peptic Ulcer"/>

An [[esophagogastroduodenoscopy]] (EGD), a form of [[endoscopy]], also known as a [[gastroscopy]], is carried out on people in whom a peptic ulcer is suspected. It is also the gold standard of diagnosis for peptic ulcer disease.<ref name="Angel 2017"/> By direct visual identification, the location and severity of an ulcer can be described. Moreover, if no ulcer is present, EGD can often provide an alternative diagnosis.

One of the reasons that [[blood test]]s are not reliable for accurate peptic ulcer diagnosis on their own is their inability to differentiate between past exposure to the bacteria and current infection. Additionally, a false negative result is possible with a blood test if the person has recently been taking certain drugs, such as [[antibiotics]] or [[proton-pump inhibitor]]s.<ref>{{cite web|url=http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION=tests-and-diagnosis|title=Peptic ulcer|access-date=18 June 2010|url-status=live|archive-url=https://web.archive.org/web/20100209072021/http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION%3Dtests-and-diagnosis|archive-date=9 February 2010|df=dmy-all}}</ref>

The diagnosis of ''[[Helicobacter pylori]]'' can be made by:
* [[Urea breath test]] (noninvasive and does not require EGD);
* Direct culture from an EGD biopsy specimen; this is difficult and can be expensive. Most labs are not set up to perform ''H. pylori'' cultures;
* Direct detection of [[urease]] activity in a biopsy specimen by [[rapid urease test]];<ref name="Angel 2017"/>
* Measurement of [[antibody]] levels in the blood (does not require EGD). It is still somewhat controversial whether a positive antibody without EGD is enough to warrant eradication therapy;
* Stool [[antigen]] test;<ref name="Stenstrom2008">{{cite journal | vauthors = Stenström B, Mendis A, Marshall B | title = Helicobacter pylori--the latest in diagnosis and treatment | journal = Australian Family Physician | volume = 37 | issue = 8 | pages = 608–12 | date = August 2008 | pmid = 18704207 }}</ref>
* Histological examination and staining of an EGD biopsy.

The breath test uses radioactive [[carbon]] to detect H. pylori.<ref>{{cite web|url=http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION=tests-and-diagnosis|title=Tests and diagnosis|access-date=18 June 2010|url-status=live|archive-url=https://web.archive.org/web/20100209072021/http://www.mayoclinic.com/health/peptic-ulcer/DS00242/DSECTION%3Dtests-and-diagnosis|archive-date=9 February 2010|df=dmy-all}}</ref> To perform this exam, the person is asked to drink a tasteless liquid that contains the carbon as part of the substance that the bacteria breaks down. After an hour, the person is asked to blow into a sealed bag. If the person is infected with ''H. pylori'', the breath sample will contain radioactive [[carbon dioxide]]. This test provides the advantage of being able to monitor the response to treatment used to kill the bacteria.

The possibility of other causes of ulcers, notably [[malignancy]] ([[gastric cancer]]), needs to be kept in mind. This is especially true in ulcers of the [[greater curvature of the stomach]]; most are also a consequence of chronic ''H. pylori'' infection.

If a peptic ulcer perforates, air will leak from inside the gastrointestinal tract (which always contains some air) to the peritoneal cavity (which normally never contains air). This leads to "free gas" within the peritoneal cavity. If the person stands, as when having a chest X-ray, the gas will float to a position underneath the diaphragm. Therefore, gas in the peritoneal cavity, shown on an erect chest X-ray or supine lateral abdominal X-ray, is an omen of perforated peptic ulcer disease.

===Classification===
[[File:Peptic ulcer.svg|thumb|upright=1.2|{{olist
    |Esophagus
    |Stomach
    |Ulcers
    |Duodenum
    |Mucosa
    |Submucosa
    |Muscle
}}]]

Peptic ulcers are a form of [[acid peptic diseases|acid–peptic disorder]]. Peptic ulcers can be classified according to their location and other factors.

====By location====
* [[Duodenum]] (called duodenal ulcer)
* [[Esophagus]] (called esophageal ulcer)
* [[Stomach]] (called gastric ulcer)
* [[Meckel's diverticulum]] (called Meckel's diverticulum ulcer; is very tender with palpation)

====Modified Johnson====
* Type '''I''': Ulcer along the body of the stomach, most often along the lesser curve at incisura angularis along the locus minoris resistantiae. Not associated with acid hypersecretion.
* Type '''II''': Ulcer in the body in combination with duodenal ulcers. Associated with acid oversecretion.
* Type '''III''': In the pyloric channel within 3&nbsp;cm of pylorus. Associated with acid oversecretion.
* Type '''IV''': Proximal gastroesophageal ulcer.
* Type '''V''': Can occur throughout the stomach. Associated with the chronic use of NSAIDs (such as [[ibuprofen]]).

===Macroscopic appearance===
[[Image:Benign gastric ulcer 1.jpg|thumb|upright=1.2|A benign gastric ulcer (from the antrum) of a [[gastrectomy]] specimen.]]

Gastric ulcers are most often localized on the lesser curvature of the stomach. The ulcer is a round to oval parietal defect ("hole"), 2–4&nbsp;cm diameter, with a smooth base and perpendicular borders. These borders are not elevated or irregular in the acute form of peptic ulcer, and regular but with elevated borders and inflammatory surrounding in the chronic form. In the ulcerative form of gastric cancer, the borders are irregular. Surrounding mucosa may present radial folds, as a consequence of the parietal scarring.{{cn|date=July 2022}}

===Microscopic appearance===
[[File:Erosive gastric ulcer.jpg|thumb|upright=1.2|Micrograph showing erosive gastric ulcer. (H&E stain)]]
A gastric peptic ulcer is a mucosal perforation that penetrates the [[muscularis mucosae]] and lamina propria, usually produced by acid-pepsin aggression. Ulcer margins are perpendicular and present chronic gastritis. During the active phase, the base of the ulcer shows four zones: fibrinoid necrosis, inflammatory exudate, granulation tissue and fibrous tissue. The fibrous base of the ulcer may contain vessels with thickened wall or with thrombosis.<ref name="pathologyatlas">{{cite web|url=http://www.pathologyatlas.ro/chronic-peptic-ulcer.php| title= ATLAS OF PATHOLOGY| access-date= 26 August 2007| url-status= live| archive-url=https://web.archive.org/web/20090209051200/http://www.pathologyatlas.ro/chronic-peptic-ulcer.php| archive-date= 9 February 2009| df= dmy-all}}</ref>

===Differential diagnosis===
[[File:Gastric MALT lymphoma 2.jpg|thumb|Endoscopic image of gastric MALT lymphoma taken in body of [[stomach]] in patient who presented with [[upper gastrointestinal bleed|upper GI hemorrhage]].  Appearance is similar to [[gastric ulcer]] with adherent clot.]]
Conditions that may appear similar include:
{{div col|colwidth=30em}}
* [[Gastritis]]
* [[Stomach cancer]]
* [[Gastroesophageal reflux disease]]
* [[Pancreatitis]]
* [[Congestive hepatopathy|Hepatic congestion]]
* [[Cholecystitis]]
* [[Biliary colic]]
* [[Myocardial infarction|Inferior myocardial infarction]]
* [[Referred pain]] ([[pleurisy]], [[pericarditis]])
* [[Superior mesenteric artery syndrome]]
* [[Gastric lymphoma]]
{{div col end}}