Detection of ulcer disease Endoscopy is the most accurate diagnostic test for peptic

ulcer disease (PUD). Sensitivity of endoscopy depends in part upon the location of the
ulcer, the experience of the endoscopist, and the "gold" standard used. Experienced
endoscopists detect about 90 percent of gastroduodenal lesions found by a second
endoscopist, by radiography, or at surgery
Peptic ulcers are mucosal breaks of 3 mm or greater and are common, occurring in about
10% of adults in Western countries.
[1]
Gastric ulcers account for about one third of peptic
ulcers, and duodenal ulcers account for the remainder. Because a small percentage (< 5%)
of gastric ulcers are caused by ulceratedgastric carcinomas, all gastric ulcers must be
carefully assessed to differentiate benign lesions from malignant lesions. Radiologic
characteristics of gastric ulcers are seen in the images below.

Image from an upper gastrointestinal series. A 5-cm ulcer crater in the lesser curve of the stomach is
depicted en face. The filling defects in the ulcer crater are caused by a blood clot from recent bleeding.

This lateral view (same patient as in the previous image) shows poor mucosal coating caused by recent
bleeding.
Hemorrhage
Hemorrhage occurs in 20-30% of ulcers.
[1]
Endoscopy is the modality of choice for the
investigation of hemorrhages, having a sensitivity of more than 90% in the detection of the
bleeding site.
Double-contrast barium studies are limited by poor mucosal coating in the presence of
bleeding. Nevertheless, the bleeding site may be detected in as many as 75% of cases. A
filling defect caused by a blood clot may be seen at the base of the barium-filled ulcer (as
seen in the images below).
Image from an upper gastrointestinal series. A 5-cm ulcer crater in the
lesser curve of the stomach is depicted en face. The filling defects in the ulcer crater are caused by a
blood clot from recent bleeding. This lateral view (same patient as in the
previous image) shows poor mucosal coating caused by recent bleeding.
Perforation
Perforation occurs in as many as 10% of patients with peptic ulcer disease but is less
common in gastric ulcers.
[1]

Most perforations arise from ulcers in the anterior aspect of the duodenal cap and, less
commonly, from the anterior aspect of the lesser curve of the stomach.
In 75% of cases, free gas is present in the peritoneum; this is best shown on an erect chest
radiograph (as demonstrated in the first image below) rather than on an erect or supine
abdominal radiograph.
This supine abdominal radiograph shows a pneumoperitoneum.
An upper GI series performed with water-soluble contrast agent may demonstrate the
presence and site of the perforation and whether it has sealed.
Subphrenic collections are common sequelae of a perforated peptic ulcer. They may be
depicted on plain radiographs (see the first image below), but they are best assessed with
ultrasonography
[5, 6]
or computed tomography (CT) scanning (see the second image below).

This radiograph depicts a subphrenic collection resulting from a perforated gastric ulcer.
Computed tomography scan. Subphrenic collection with gaseous and liquid
components. Note the interface between the edge of the liver and the collection.