When a patient has epigastric pain that worsens 1 to 3 hours after meals, the possibility of peptic ulcer disease should be considered. Completely typical clinical presentations in patients younger than age 50 justify empirical therapy when no physical or laboratory findings suggest a mimicking disorder. Esophagogastroduodenoscopy should be undertaken when response to therapy is incomplete, symptoms recur quickly, or dyspeptic symptoms present for the first time in a patient older than age 50. When gastric ulcers are diagnosed radiographically, endoscopy and biopsy at multiple sites should be done to exclude malignant disease. Intractable duodenal ulcers may necessitate endoscopic biopsy of antral and duodenal mucosa to rule out an associated Helicobacter pylori infection, which may modify therapeutic approaches. Zollinger-Ellison syndrome is rare but should be suspected when ulcer disease presents atypically or aggressively or in families. Diagnosis is not difficult to confirm.
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