Peptic Ulcers

Overview

By Tina Shahian, PhD

A peptic ulcer is an open sore that results when sensitive tissue in the digestive tract is exposed to acid. Peptic ulcers are typically found in the stomach (where they are called gastric ulcers) and duodenum (the beginning of the small intestine, where they are called duodenal ulcers), but can also less commonly occur in the esophagus.

The two most common causes of peptic ulcers in the United States are bacterial infection and a specific class of anti-inflammatory drugs, both of which compromise the protective lining of the gastrointestinal tract. In severe cases, peptic ulcers can obstruct the passage of food into the duodenum, or lead to cancer. Half a million Americans develop peptic ulcer disease each year.

Causes and Risk Factors

Cross-section of stomach and duodenumThe main causes of peptic ulcers are the bacterium Helicobacter pylori (H. pylori), and a class of drugs referred to as nonsteroidal anti-inflammatory drugs (NSAIDs). Smoking and alcohol use increase the chances of developing ulcers, especially when combined with the above risk factors. Despite common belief, spicy foods do not cause ulcers; they only worsen the symptoms of existing ulcers.

  • H. pylori. This Gram-negative bacterium is responsible for roughly 50% of peptic ulcers, but not every infected individual develops an ulcer. Following an infection, H. pylori colonizes on the stomach wall where it damages the mucous membrane. Without this protective barrier the sensitive lining of the stomach and duodenum are exposed to digestive acids, resulting in ulcers.
  • NSAIDs. Frequent use of aspirin, ibuprofen, naproxen and other NSAIDs - used to treat inflammation, pain, and fever - can lead to ulcers, mainly in the stomach. In fact, regular use of NSAIDs is associated with a five times greater risk of developing peptic ulcers. NSAIDs act by blocking the activity of cyclo-oxygenase enzymes, which produce pain-promoting prostaglandins. However, by doing so they also prevent the synthesis of prostaglandins that serve a protective role in the stomach’s lining, hence the higher risk of peptic ulcers. This risk increases depending on the number of NSAIDs, dosage, age, sex, medical history, and other habits like alcohol use and smoking.

Symptoms

Abdominal pain is the most common symptom of peptic ulcer disease. The pain may follow meals, last for varying lengths of time, and be reoccurring. Patients also experience nighttime pain that can be managed by eating, or taking antacids. Other symptoms include:

  • Nausea and vomiting
  • Poor appetite
  • Weight loss
  • Bloating
  • Burping

Symptoms that require immediate medical attention are associated with bleeding and they include:

  • Sudden sharp abdominal pain
  • Blood in the stool or vomit
  • Dark-colored stool or vomit
  • Fatigue
  • Lightheadedness

Diagnosis and Treatment

Peptic ulcers are diagnosed based on the symptoms, and in some cases, using invasive techniques that survey the upper gastrointestinal (GI) tract. If the patient is not taking NSAIDs, various techniques are used to test for the presence of H. pylori.

  • Endoscopy. An esophagogastroduodenoscopy (EGD), also known as upper endoscopy, is performed to inspect the stomach and duodenum for ulcers. The procedure uses a long flexible tube to deliver a small, lighted camera down the GI tract. If necessary, a small tissue sample is removed for further study, or medicine is delivered to stop bleeding.
  • Upper GI series (barium swallow). This outpatient procedure uses X-ray imaging to examine the upper GI tract for ulcers. Prior to the X-ray, the patient drinks a thick chalky liquid contrast agent containing barium, to allow for visualization.
  • H. pylori. To confirm an H. pylori infection in patients not taking NSAIDs, one of three non-invasive methods is performed. A blood test checks for the presence of anti-H. pylori antibodies. Stool tests check for the presence of H. pylori antigens (proteins that elicit a host immune response). In a “urea breath test,” the patient drinks carbon-labeled urea, which is processed by the gut H. pylori into ammonia and carbon dioxide. This carbon dioxide carries the labeled carbon and is detected when exhaled.

Peptic ulcers are fully treatable by removing their main cause (H. pylori or NSAIDs) and controlling their acidic environment.

  • Antimicrobials. H. pylori is treated with a 10-14 day course of antibiotics. Completing the course is critical for preventing the emergence of antibiotic-resistance strains of H. pylori.
  • Medication switching. Patients taking NSAIDs must reduce their daily dosage, or switch to alternate medication in order to promote healing and prevent reoccurrence.
  • Other medication. Prescription proton-pump inhibitors and H2-receptor blockers lessen pain and allow healing by reducing acid production in the stomach. They are often prescribed in conjunction with other therapies for peptic ulcers.

Prevention

Peptic ulcers are best prevented by reducing the risk of infection with H. pylori. Frequent handwashing and proper food handling help prevent the spread of harmful bacterial, including H. pylori. If NSAIDs cannot be avoided, then the lowest effective dosage is recommended. Smoking and excessive alcohol consumption are not advisable.

Sources

  • “NSAIDs and Peptic Ulcers". National Digestive Diseases Information Clearinghouse (NDDIC). NIH. Nov 2013. Retrieved Apr 22, 2014. http://digestive.niddk.nih.gov/ddiseases/pubs/nsaids/#5.
  • “H. pylori and Peptic Ulcers". National Digestive Diseases Information Clearinghouse (NDDIC). NIH. Oct 2013. Retrieved Apr 22, 2014. http://digestive.niddk.nih.gov/ddiseases/pubs/hpylori/#6.
  • "Peptic Ulcer Disease". American College of Gastroenterology. Dec 2012. Retrieved Apr 22, 2014. http://patients.gi.org/topics/peptic-ulcer-disease/.
  • Ramakrishnan K. and Salinas R.C. Peptic ulcer disease. Am Fam Physician. 2007. 7:1005-12.