How can I differentiate between gastritis and peptic ulcer disease in a patient presenting with epigastric pain?

Differentiating gastritis from peptic ulcer disease (PUD) in a patient presenting with epigastric pain relies primarily on clinical features, risk factors, and diagnostic testing.

Both conditions can present with epigastric pain, but PUD often causes a more localized, burning or gnawing pain that may improve or worsen with food intake depending on ulcer location (gastric vs duodenal), whereas gastritis pain tends to be more diffuse and associated with nausea or bloating ¹.

Alarm symptoms such as weight loss, anaemia, vomiting, or gastrointestinal bleeding suggest complications more typical of PUD or malignancy and warrant urgent investigation ¹,³.

Risk factors for PUD include Helicobacter pylori infection, NSAID or aspirin use, and smoking, which should be assessed in history taking ¹. Gastritis may also be related to H. pylori but can be caused by other irritants such as alcohol or stress ¹.

Non-invasive testing for H. pylori using a carbon-13 urea breath test or stool antigen test is recommended after a 2-week washout from PPIs to help identify infection associated with PUD or gastritis ¹,².

Endoscopy is the definitive diagnostic tool to differentiate PUD from gastritis, as it allows direct visualization of ulcers, erosions, or mucosal inflammation and biopsy if needed ¹,⁴. It is particularly indicated if alarm features are present or symptoms are refractory to initial management ¹,³.

Empirical treatment with proton pump inhibitors (PPIs) may be initiated for symptom relief, but lack of response or recurrent symptoms should prompt endoscopy ¹,⁴.

In summary, clinical differentiation is challenging; history focusing on pain characteristics, risk factors, and alarm symptoms guides initial management, while H. pylori testing and endoscopy provide definitive diagnosis [1, (Robinson and Perkins JC Jr, 2016)].