Distinguishing GERD, Peptic Ulcer Disease, and Gastritis

Core Pathophysiologic Differences

GERD is a condition where reflux of gastric contents into the esophagus causes troublesome symptoms and/or complications, with or without visible esophageal inflammation, resulting from failure of the anti-reflux barrier, often mediated through transient lower esophageal sphincter relaxations 1, 2
Peptic ulcer disease involves focal mucosal breaks that extend through the epithelial lining into the submucosal layer, occurring in either the stomach or duodenum, with an incidence of 0.1% to 0.3% and primarily caused by Helicobacter pylori infection and NSAID use 3, 4
Gastritis refers to inflammation of the gastric mucosa without discrete ulcer formation, characterized by submucosal edema, mucosal hyperenhancement, and inflammatory infiltrate, unlike PUD, gastritis does not create focal outpouching or crater formation through the mucosal layers 3, 4

Regurgitation of gastric contents is a symptom of GERD, which typically worsens after meals and when supine 1, 2
Epigastric pain is the predominant symptom of peptic ulcer disease, often with specific timing patterns, and nocturnal pain is characteristic, particularly for duodenal ulcers 3, 5
Nonspecific epigastric discomfort, nausea, and vomiting are symptoms of gastritis, which overlap extensively with both GERD and PUD, making clinical differentiation difficult 3, 5

The American College of Radiology recommends that clinical history, risk factors, and symptom patterns are important for narrowing the differential diagnosis when symptoms of GERD, PUD, and gastritis overlap 3, 1
Endoscopy is the standard test of choice for diagnosing PUD, which reveals focal ulcer craters with discrete margins, and ulceroproliferative features, focal outpouching of mucosa 3, 4, 6
CT imaging can show distal esophageal wall thickening, presence of air in the esophagus for GERD, and gastric or duodenal wall thickening due to submucosal edema, mucosal hyperenhancement, fat stranding, focal interruption of mucosal enhancement for PUD and gastritis 3, 7

The American College of Radiology advises against assuming benign disease without histologic confirmation when ulceroproliferative features are present, as malignancy can mimic PUD 6
The American College of Radiology recommends not relying solely on symptoms to distinguish these conditions, as overlap is extensive and correlation between reflux symptoms and endoscopy-positive GERD is poor 3
The American College of Radiology advises against delaying imaging or surgical consultation if peritoneal signs develop, as perforated ulcer mortality increases significantly with delayed diagnosis 4, 6