• Mild epigastric pain that may be described as burning, gnawing, or aching in character.

• Abdominal pain may be described as burning or a feeling of discomfort.

• Some patients report nocturnal pain.

• The severity of pain often fluctuates.

• The intensity of pain can vary widely (e.g., from dull to sharp).

• DU pain occurs 1 to 3 hours after meals and may be relieved by food ingestion.

• GU pain occurs immediately after meals and is often aggravated by food.

• Patients may also complain of heartburn, belching, bloating, nausea, or vomiting. Signs

• Weight loss may be associated with nausea and vomiting.

• Complications such as bleeding, perforation, or obstruction may occur.

• Alarm signs and symptoms include: bleeding, anemia, tarry stools or "coffee-grounds" emesis, and weight loss.

Nonendoscopic testing methods include the urea breath test, serological testing, and the stool antigen assay. Compared to endoscopic procedures, these tests are more comfortable, less expensive, and do not require a special procedure. The urea breath test is usually the first-line test to detect active H. pylori infection because it has a sensitivity and specificity greater than 95% and a short turnaround time. The BreathTek urea breath test used with a desktop infrared spectrometer can provide results within a few minutes. Concomitant acid-suppressive or antibiotic therapy may give false-negative results with this test.

Office-based serological testing provides a quick assessment (within 15 minutes) of an exposure to H. pylori, but patients can remain seropositive for up to 1 year after eradication, making the clinical utility of this test limited. Stool antigen assays can be useful for the initial diagnosis or to confirm H. pylori eradication, and unlike the urea breath test, are less affected by concomitant medication use.9 However, the stool antigen assay should not be used to test for eradication until 6 to 8 weeks after completion of therapy.

Radiological and/or endoscopic procedures are usually required to document the presence of ulcers objectively. Barium studies have a high sensitivity and are con sidered first-line tests to document an ulcer radiographically. However, the cost and complexity of all of these tests has led to the promotion of an early empiric treatment strategy for patients at low risk for PUD-related sequelae (e.g., malignancy). An empiric treatment strategy is appropriate for patients less than 50 years of age who have mild or intermittent epigastric symptoms and no evidence of PUD-related systemic symptoms or complications.

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