Peptic ulcer

• ANATOMY OR SYSTEM AFFECTED: Abdomen, digestive system, gastrointestinal system, intestines, stomach
• ALSO KNOWN AS: Duodenal ulcer, gastric ulcer, ulcer

Definition

Peptic ulcers are eroded areas in the stomach (gastric ulcer) or the first part of the intestine (duodenal ulcer). Ulcers occur in areas where the lining of the stomach or intestine is worn away and irritated, causing pain or bleeding.

Causes

Normally, a mucous coating protects the lining of the stomach and the intestine. This coating can be disrupted by a bacterial infection from Helicobacter pylori (H. pylori) or by stomach-irritating medicines (such as nonsteroidal anti-inflammatory drugs or NSAIDs). When this mucous coat is disrupted, strong digestive juices can erode the lining underneath it and cause an ulcer.

Lifestyle factors (such as diet and stress) were once thought to be wholly responsible for causing ulcers. They are now known to worsen ulcer conditions but not to actually cause erosion. Most ulcers are caused by H. Pylori infection or NSAID use, including ibuprofen (Advil, Motrin IB) and naproxen (Aleve). These are the easiest ulcers to treat, but in the first two decades of the twenty-first century, the incidence of non-H. pylori and non-NSAID ulcers increased.

In addition to creating discomfort, ulcers are serious because they can cause perforation, obstruction, and gastric cancer. An ulcer that eats through the entire wall of the stomach or intestine is called a perforated ulcer. This is a serious and potentially life-threatening condition because the hole allows the contents of the stomach and intestine to leak into the abdominal cavity.

Scarring from ulcers can block flow through the stomach, duodenum, or both. This obstruction can cause repeated vomiting, weight loss, and intense pain. People who have had peptic ulcers have a much higher rate of stomach cancer than others. H. pylori is almost certainly a cause of stomach cancer and may account for the excess risk associated with peptic ulcer disease.

Many more people are infected with H. pylori than ever develop an ulcer. Researchers do not understand why some people infected with this kind of bacteria develop ulcers and others do not. Researchers also do not know how people become infected with H. pylori. The bacterium may be passed in food or water. It also seems to live in the saliva of infected people, allowing the bacteria to be passed through kissing, for example.

Risk Factors

It is possible to develop a peptic ulcer with or without the risk factors listed here. Risk factors for peptic ulcers fall into two categories: factors that actually cause peptic ulcers and factors that irritate the stomach or increase acid production, making a person more susceptible to H. pylori infection.

Lifestyle factors. Some studies suggest that cigarette smoking can increase the risk of H. pylori and can slow the healing of peptic ulcers. Drinking acidic beverages such as fruit juices and consuming caffeinated foods and beverages can cause stomach irritation and increase the production of stomach acid. This can make a person more susceptible to H. pylori infection. Alcohol in large quantities can irritate the stomach, leading to an increased susceptibility to H. pylori. Alcohol taken while using NSAIDs can further irritate the stomach, increasing the chance of developing a peptic ulcer.

Even in the absence of alcohol misuse, certain NSAIDs (including aspirin and most other drugs commonly available over the counter or by prescription as “nonsteroidal”) can increase the risk of peptic ulcer. These drugs are responsible for at least one-half of all peptic ulcers in older adults.

H. pylori infection. Infection with H. pylori is the best-defined risk factor for the development of peptic ulcers. A person increases their risk of being infected with H. pylori by living in crowded or unsanitary conditions; by using certain medications, including NSAIDs, COX-2 inhibitors, and corticosteroid drugs (although this connection is less clear than the others); and by having a history of peptic ulcer disease, Zollinger-Ellison syndrome, recent major surgery or severe injury or burns, head trauma, radiation therapy, congenital malformations of the stomach or duodenum (or both), and specific malignant diseases such as mastocytosis and basophilic leukemia.

Age. Duodenal ulcers are more common in persons between thirty and fifty, while gastric ulcers are more common in people over sixty.

Gender. Duodenal ulcers are twice as likely in men, and gastric ulcers are more common in women.

Genetic factors. A person is more likely to develop a peptic ulcer if they have other family members who have had ulcers.

Ethnic background. A person has twice the risk of developing a peptic ulcer if they are of African American or Hispanic background.

Other risk factors. Stress is no longer believed to cause ulcers. However, many researchers still believe that stress can play a role in exacerbating symptoms and in the slow healing of preexisting peptic ulcers. Also, a person might have an increased risk of peptic ulcers if they have type O blood.

Symptoms

Abdominal pain may be described as burning, gnawing, feeling worse several hours after eating, improved with eating (duodenal ulcers), stabbing through to the back, coming and going over months, worse in the middle of the night, relieved by taking antacid medicines, bloating of the abdomen, cramping, uncomfortable sensation of fullness, belching, nausea, vomiting (may contain blood or may look like coffee grounds), decreased appetite, weight loss, bloody or tarry black stools, and tired and weak feeling (if anemia is present).

Screening and Diagnosis

The purpose of screening is early diagnosis and treatment. Screening tests are usually administered to people without current symptoms but who may be at high risk for certain diseases or conditions. For peptic ulcers, however, there are no screening tests or screening guidelines. Because of the relationship between peptic ulcers and the bacterium H. pylori, screening for the latter might prove possible. Some data supports screening for bacterial infection, but not specifically for a peptic ulcer.

Peptic ulcers can be diagnosed using both X-ray and endoscopic examinations. Specialized blood, breath, and stool tests are used to identify the presence of H. pylori. Rectal examination and stool guaiac test can reveal if a person has a bleeding ulcer. The following exams and tests can be administered:

Barium swallow/upper gastrointestinal (GI) X-ray examination. The person drinks a chalky solution containing barium that coats the digestive tract and helps ensure that X-ray images of the gastrointestinal tract are well-detailed. Multiple X-rays are taken before, during, and after barium consumption.

Endoscopy. An examination of the lining of the gastrointestinal tract. After sedation or numbing of the throat, a small tube with a light and camera on the end will be passed into the patient’s mouth, into the throat, and into the esophagus, stomach, and duodenum. Other instruments can be passed down through the endoscope to inspect the area, take biopsy samples, and treat any bleeding that is present.

Blood tests. If a peptic ulcer is suspected, a doctor probably will order a complete blood count to check for anemia. Anemia is common for an untreated bleeding ulcer. Rapid tests in the doctor’s office may also be used to identify the presence of H. pylori. Blood may also be sent to a laboratory so that more sophisticated tests can be run to confirm or deny the presence of H. pylori.

Stool tests. A tiny stool sample might be obtained through a rectal examination and then tested for the presence of H. pylori. This is a rapid, on-the-spot test and can also be used to check for response to antibiotic treatment against H. pylori. A stool guaiac uses a small sample obtained through a rectal examination or after a bowel movement. The sample is then smeared onto a little card, and several drops of a chemical are dropped onto the stool sample. This can reveal whether blood is present in the stool, which can be a sign of a bleeding ulcer.

Breath tests. The patient is first given a special drink, a capsule, or a pudding containing urea with carbon, and a special radioactive label. To collect the patient’s breath, the healthcare provider will have the patient inflate a balloon or breathe into a bottle of water. If the breath sample contains the radioactively labeled carbon dioxide, this indicates that the patient has an H. pylori infection.

Treatment and Therapy

The treatment and management of peptic ulcers involves lifestyle changes, medications, alternative and complementary therapies, and surgery. The goals of treatment include eliminating the H. pylori infection, treating excess bleeding, promoting healing of the ulcer, relieving pain and discomfort, avoiding the development of complications (such as perforation, obstruction, and gastric cancer), and preventing ulcer recurrence.

Medications for ulcers include antacids (for heartburn relief; they do not heal ulcers); antibiotics (such as amoxicillin, tetracycline, and clarithromycin); a bismuth-containing drug (Pepto-Bismol); proton pump inhibitors (such as omeprazole and lansoprazole); histamine II blockers, to decrease stomach acid production (such as famotidine, ranitidine, cimetidine, and nizatidine); medications to coat the ulcer (such as sucralfate); and medications to protect the stomach against NSAID damage (such as misoprostol).

Surgery and endoscopy may be necessary if the patient has bleeding, a perforation, or an obstruction. Surgical options include highly selective vagotomy, vagotomy with antrectomy, endoscopy, and vagotomy and drainage. A highly elective vagotomy is a technique in which only part of the vagus nerve is cut, and there is no required extra drainage. A vagotomy with antrectomy involves cutting the vagus nerve and removing the lower part of the stomach, or antrum. The antrum makes a chemical that promotes acid production; without that chemical, acid production drops.

An endoscopy involves a thin, lighted tube that is inserted into the throat and stomach or intestine. Heat, electricity, epinephrine, or a substance called fibrin glue can then be applied to the area. This should stop the blood flow. In a vagotomy and drainage, the vagotomy cuts parts of the vagus nerve. This procedure can greatly reduce acid production. Cutting the entire nerve can also create further problems with the stomach. In this case, drainage must be created through one of the following procedures: pyloroplasty (widening the opening between the stomach and the duodenum, allowing stomach contents to flow more easily into the intestine); gastroduodenostomy (creating a new opening to connect the stomach and the duodenum); and gastrojejunostomy (creating a new opening to connect the stomach and the jejunum, the second part of the small intestine).

Prevention and Outcomes

Because many peptic ulcers are caused by a bacterial infection (H. pylori), researchers are hopeful that a vaccine will be found to prevent ulcers. In the meantime, however, the following may provide some benefit:

Practicing good hygiene. Because peptic ulcers are sometimes caused by infection with H. pylori, persons should practice good hygiene to decrease their risk of becoming infected. This includes washing one’s hands well and regularly and avoiding contact with the vomit or stool of other persons. If cleaning up after another person is necessary, one should wear gloves and then wash hands well.

Stopping smoking. Individuals who smoke are urged to quit because smoking has been associated with the development of peptic ulcers. Furthermore, ulcers that do form are slower to heal in persons who smoke.

Decreasing or stopping alcohol consumption. Overuse of alcohol, especially in combination with NSAIDs, is thought to increase the risk of peptic ulcers. NSAIDs are proven causes of ulcers, but the causal role of alcohol remains somewhat uncertain, especially in combination with smoking. However, alcohol misuse is a serious health problem regardless of its relationship to ulcer disease.

Reducing intake of caffeine and acidic foods. Some research suggests that foods and drinks high in caffeine (such as coffee) and acid (such as orange and tomato products) may cause increased stomach acid, which will increase a person’s susceptibility to peptic ulcers caused by H. pylori.

Practicing stress management. Although most researchers do not think that stress increases the risk of peptic ulcers, others think that stress can increase stomach acid production. This may make one more susceptible to the effects of H. pylori infection.

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