Have a patient complaining of dull epigastric pain? Consider an ulceration in your differential.
In an outpatient setting, a peptic ulcer can be diagnosed clinically. Here is how:
Inquire if the patient is also having abdominal bloating/fullness, acid reflux, belching, and/or burping. Also ask if they have been taking any NSAIDs or
Another key diagnostic question is to ask them if the pain could be described as a “hunger pain” that is resolved with food. An individual with a peptic ulcer will usually state their pain goes away after they eat for 1-2 hours and then it returns. An individual with a duodenal ulcer will state the pain worsens 1-2 hours after they eat.
Virtually all peptic ulcers are caused by h. pylori or NSAID use. I will start my patients on omeprazole or pantoprazole daily for 6 weeks and sucralfate 20 minutes before meals for 5-7 days. The symptoms typically will resolve in 3-5 days.
Make sure you also test for h. pylori via urea breath testing, stool antigen assay or serology. Treatment of h. pylori is straight forward and curative.
If conservative treatment fails after 1-2 weeks, refer the patient to GI for endoscopy.
As always, use your clinical judgement.