CT Detection of Gastric or Duodenal Ulcers

Direct Ulcer Findings

The American College of Radiology recommends that CT can identify focal outpouching of the mucosa, representing the ulcer crater itself, with associated citations 1, 2
Focal interruption of mucosal enhancement, where the ulcer crater erodes through the epithelial lining into the submucosal layer or muscularis propria, is a direct sign of peptic ulcer disease 1, 2

Gastric or duodenal wall thickening due to submucosal edema is present in 72% of perforated cases, according to the American College of Radiology 1
Mucosal hyperenhancement from inflammation is a sign of peptic ulcer disease, as stated by the American College of Radiology 1, 2

The American College of Radiology states that IV contrast is essential to assess mucosal hyperenhancement, interrupted mucosal enhancement, and bowel wall changes that indicate ulceration 1, 2, 3
Neutral oral contrast should be used rather than positive contrast, as recommended by the American College of Radiology 1, 2, 3

Extraluminal gas is present in 97% of cases of perforated ulcers, according to the American College of Radiology 2
Wall defect and/or ulcer is present in 84% of cases, with a positive likelihood ratio of 36.83 for perforation, as stated by the American College of Radiology 2
Combined wall defect/ulcer plus wall thickening shows 95% sensitivity and 93% specificity for localizing perforation site, according to the American College of Radiology 2

Endoscopy is the reference standard for diagnosing uncomplicated peptic ulcer disease, gastritis, and esophagitis, as recommended by the American College of Radiology 1, 4
The American College of Radiology states that tissue diagnosis and therapeutic intervention require endoscopy 1

For suspected uncomplicated peptic ulcer disease, the American College of Radiology recommends proceeding directly to endoscopy 1
For nonspecific epigastric pain where diagnosis is unclear, CT abdomen/pelvis with IV contrast and neutral oral contrast can identify ulcers and guide further management, as stated by the American College of Radiology 1 and the American College of Gastroenterology is not mentioned but Praxis Medical Insights: Practical Summaries of Clinical Guidelines is mentioned 5