Peptic Ulcer

What Is It?

A peptic ulcer is a type of sore or hole that forms in the lining of the stomach or intestine. The word "peptic" refers to the digestive process. An ulcer in the lining of the stomach is called a gastric ulcer. An ulcer in the upper part of the small intestine, or duodenum, is called a duodenal ulcer.

The lining of the stomach is a layer of special cells, chemicals and mucous that prevent the stomach from being damaged by its own acids and digestive enzymes. If there is a break or ulcer in the lining, the tissue under the lining can be damaged by the enzymes and corrosive acid. If the ulcer is small, there may be few symptoms, and the wound can heal on its own. If the ulcer is deep, it can cause serious pain or bleeding, and may eat completely through the stomach or duodenum wall.

Peptic ulcers are relatively common, affecting approximately 500,000 people in the United States each year. It has been estimated that about 10% of Americans will develop an ulcer at some time in their lives. Ulcers can develop in anyone at any age, but they become more common as people age. Duodenal ulcers tend to occur at an earlier age than gastric ulcers. While ulcers used to be more common in men, recent studies show that ulcers now occur at the same rate in men and women.

It's still unclear what causes ulcers, current research suggests that the bacterium Helicobacter pylori plays a major role. In fact, this bacterium is believed to cause between 70% and 90% of all peptic ulcers. But infection is not the whole story, because only about 20% of people infected with H. pylori develop ulcers. In some people, H. pylori infection somehow upsets the delicate balance between the damaging effects of gastric acids and the body's natural protection. When the lining is no longer able to protect the stomach or intestine, an ulcer develops.

The second most common cause of ulcers is the use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen (Advil, Motrin and others) and naproxen (Aleve, Naprosyn). These drugs interfere with the body's methods of protecting the stomach lining from the harmful effects of acid. Ulcers caused by NSAIDs are particularly common in the elderly. Ulcers also can be caused by other drugs, such as those used to treat osteoporosis.

Several other factors can increase your risk of developing a peptic ulcer. Both gastric and duodenal ulcers seem to run in families. Cigarettes appear to interfere with the body's natural protection against ulcers, particularly in people who are infected with H. pylori. Alcohol may increase the production of acid and damage the lining of the stomach. However, contrary to popular belief, stress and spicy foods do not seem to increase the risk of ulcers.

Symptoms

Most people with ulcers complain of a burning or gnawing pain in the upper abdomen. This typically occurs when the stomach is empty, and may be worse at night or upon waking. However, some people's pain may worsen when they eat. Other symptoms include nausea, vomiting, loss of appetite, bloating, burping and weight loss. Some of these symptoms may be relieved by taking over-the-counter antacids or avoiding spicy or acidic foods. In general, symptoms worsen as an ulcer grows, or if more than one ulcer develops. Some people with mild disease don't have any symptoms.

In more severe cases, ulcers may bleed or extend deep into the wall of the stomach or intestine. Bleeding from large ulcers can be life threatening. Blood may appear in the vomit, which would appear either red or black, or resemble coffee grounds. Blood also may appear in the stools, which would look tarry-black or maroon. Peritonitis, a very serious abdominal infection, may develop if the ulcer eats completely through the wall of the stomach or intestine.

Diagnosis

If your health care professional suspects that you have a peptic ulcer, he or she may recommend one of the following tests:

• A blood antibody test for evidence of H. pylori infection This test is widely available and simple to do, and if the test is positive, treatment may be given without more invasive tests. However, the H. pylori blood test is not always accurate. For example, the test results may remain positive for years after an H. pylori infection has been treated. Another problem is that the test cannot tell whether an H. pylori infection has caused an ulcer. Newer tests that use breath or stool samples may be more accurate, but are not yet widely available.
• An esophagogastroduodenoscopy, better known as an EGD or endoscopy In this procedure a flexible, lighted tube with a tiny camera on the end is passed through your throat into your stomach and intestines. This allows your doctor to examine the walls of the stomach and duodenum. He or she also may snip off a small piece of the lining of the stomach for a biopsy, which is a close examination of the tissue in a laboratory.
• An upper-gastrointestinal (GI) series This test involves X-rays taken after you drink a chalky liquid that coats the esophagus, stomach and upper part of the intestine. An ulcer will show up on the X-rays as a crater. An upper GI series is sometimes less accurate than endoscopy for diagnosing peptic ulcers, but can be a useful and less invasive test under some circumstances.

Sometimes, more than one test is needed to diagnose your condition. If you have had a peptic ulcer in the past, your health care professional may recommend treatment without doing any diagnostic tests.

Expected Duration

Ulcers caused by a medication should begin healing as soon as you stop taking the drug. Antacids or medications that limit the amount of acid your stomach produces may be used for two to six weeks to help healing and relieve pain.

Ulcers caused by H. pylori won't heal completely or may heal and then return if the bacteria are not killed. Typically, you will take antibiotics and other medication for two weeks, then may take acid-suppressing medication for another four to eight weeks. Gastric ulcers tend to heal more slowly than duodenal ulcers. Uncomplicated gastric ulcers take up to two or three months to heal completely, while duodenal ulcers take about six weeks. The H. pylori infection can return and cause another ulcer, particularly if the first infection is not eliminated completely.

Prevention

Because no one knows exactly how people become infected with H. pylori or why it causes ulcers, there is no way to prevent most cases of peptic ulcers. The only precaution is to wash your hands thoroughly before eating and after using the bathroom. You may help to prevent peptic ulcers not related to H. pylori by eliminating or limiting the use of NSAIDs and tobacco.

Treatment

For ulcers caused by H. pylori, treatment requires a combination of medications. The goals are to kill H. pylori bacteria in the body, reduce the amount of acid in the stomach, and protect the lining of the stomach and intestines. Most patients are treated with "triple therapy," which requires taking two antibiotics and one acid-suppressing medication for one to two weeks. A variety of antibiotics and acid-suppressing medications may be used. Typically, the acid-suppressing medication will be either an H2 blocker, such as ranitidine (Zantac) or cimetidine (Tagamet) or a proton pump inhibitor, such as omeprazole (Prilosec) or lansoprazole (Prevacid). Your doctor will prescribe a specific regimen based on convenience, cost and any allergies you have. Triple therapy requires taking as many as 8 to 12 pills every day, and it can cause side effects such as nausea, vomiting, diarrhea, headache and yeast infection in women. However, the treatment is 80% to 90% effective.

If your symptoms don't go away completely, your doctor may suggest re-testing for H. pylori after your treatment is completed.

People whose ulcers are caused by NSAIDs or other drugs should stop using these drugs. Healing will begin almost immediately. Doctors also may recommend medications to reduce acid damage during healing. These may include antacids to neutralize gastric acids or medications that decrease the amount of acid produced by the stomach, such as an H2 blocker or proton pump inhibitor.

Emergency treatment may be needed if an ulcer causes serious bleeding. Usually, this treatment is done through an endoscope using special clips or probes. Acid-blocking medications may be given intravenously (injected into a vein), and blood transfusions may be necessary if the bleeding is severe. In extremely rare circumstances, surgery may be needed to treat a perforated or bleeding peptic ulcer. The surgery, which usually requires an abdominal incision, involves sewing normal tissue over the ulcer to seal it. However, it is rarely done now because treatments for H. pylori infections are so successful.

When To Call A Professional

Call for medical advice if you have continuing abdominal pain or indigestion, or need to take antacids frequently to prevent these symptoms. Seek emergency care if you experience a sudden sharp pain in your upper abdomen, bloody or black vomit, or maroon or black stools.

Prognosis

Before H. pylori was identified, many people had peptic ulcers for years. Now, with proper treatment, the outlook for peptic ulcers is excellent. However, people who have had a peptic ulcer should avoid aspirin, NSAIDs and smoking to prevent ulcers from returning.

Additional Info

National Institute of Diabetes & Digestive & Kidney Disorders

Office of Communications and Public Liaison

Building 31, Room 9A04

31 Center Drive, MSC 2560

Bethesda, MD 20892-2560

Phone: (301) 496-4000

E-Mail: niddk_inquiries@nih.gov

http://www.niddk.nih.gov/

American College of Gastroenterology (ACG)

P.O. Box 3099

Arlington, VA 22302

http://www.acg.gi.org/

American Gastroenterological Association

4930 Del Ray Ave.

Bethesda, MD 20814

Phone: (301) 654-2055

Fax: (301) 654-5920

http://www.gastro.org/