Peptic Ulcers

The causes of Peptic Ulcer include the bacterium name H pylori, aspirin, and nonsteroidal anti-inflammatory drugs.

• A peptic ulcer is an open sore in the upper digestive tract. There are two types of peptic ulcers, a gastric ulcer, which forms in the lining of the stomach, and a duodenal ulcer, which forms in the upper part of the small intestine.
• Causes of peptic ulcers include
  • the bacterium named Helicobacter pylori (H pylori),
  • aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs),
    • alcohol,
    • physical or emotional stress,
    • caffeine,
    • smoking, or
    • radiation therapy.
• Some people may have no symptoms of an ulcer, but common symptoms include
  • abdominal pain,
  • nausea,
  • vomiting,
  • loss of appetite,
  • weight loss, and
  • in severe cases, bleeding in the stomach or duodenum.
• Treatment of a peptic ulcer depends on the cause. Treatments include lifestyle changes such as quitting smoking, avoiding alcohol, aspirin, and NSAIDs; acid-blocking medications; medications that protect the lining of the stomach and duodenum; and "triple-therapy" or "dual-therapy" regimens for ulcers caused by H pylori.
• Surgery may be performed in some cases that do not respond to medical treatment.
• The prognosis for peptic ulcers is generally good, and most individuals will improve with the appropriate medicine.
• Complications of peptic ulcers include bleeding, perforation, and obstruction.

Abdominal pain above the belly button can indicate an ulcer.

Ulcers do not always cause symptoms. Sometimes, a serious complication such as bleeding or a sudden, bad upper abdominal pain is the first sign of an ulcer.

The most common symptom of peptic ulcers is abdominal pain.

• The pain is usually in the upper middle part of the abdomen, above the belly button (navel) and below the breastbone.
• The ulcer pain can feel like burning, or gnawing, and it may go through to the back.
• Pain often comes several hours after a meal when the stomach is empty.
• The pain is often worse at night and early morning.
• It can last anywhere from a few minutes to several hours.
• The ulcer pain may be relieved by food, antacids, or vomiting.

Other symptoms of peptic ulcers include the following:

• Nausea
• Vomiting
• Loss of appetite
• Loss of weight

Severe ulcers may cause bleeding in the stomach or duodenum. Bleeding is sometimes the only symptom of an ulcer. This bleeding can be fast or slow. Fast bleeding reveals itself in one of the following ways:

• Vomiting of blood or dark material that looks something like coffee grounds: This is an emergency and warrants an immediate visit to an emergency department.
• Blood in the stool or black, tarry, sticky-looking stools

Slow bleeding is often more difficult to detect, because it has no dramatic symptoms.

• The usual result is low blood cell count (anemia).
• The symptoms of anemia are tiredness (fatigue), lack of energy (lethargy), weakness, rapid heartbeat (tachycardia), and pale skin (pallor).

When stomach acids erode the mucosal wall, ulcers develop.

When you eat, your stomach produces hydrochloric acid and an enzyme called pepsin to digest the food.

• The food is partially digested in the stomach and then moves on to the duodenum to continue the process.
• Peptic ulcers occur when the acid and enzyme overcome the defense mechanisms of the gastrointestinal tract and erode the mucosal wall.

In the past it was thought that ulcers were caused by lifestyle factors such as eating habits, cigarette smoking, and stress.

• Now it is understood that people with ulcers have an imbalance between acid and pepsin coupled with the digestive tract's inability to protect itself from these harsh substances.
• Research done in the 1980s showed that some ulcers are caused by infection with a bacterium named Helicobacter pylori, usually called H pylori.
• Not everyone who gets an ulcer is infected with H pylori. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) can cause ulcers if taken regularly.

Some types of medical therapy can contribute to ulcer formation. The following factors can weaken the protective mucosal barrier of the stomach increasing the chances of getting an ulcer and slow the healing of existing ulcers.

• Aspirin, nonsteroidal anti-inflammatory drugs (such as ibuprofen and naproxen), and newer anti-inflammatory medications (such as celecoxib [Celebrex])
• Alcohol
• Stress: physical (severe injuries or burns, major surgery)
• Caffeine
• Cigarette smoking
• Radiation therapy:-used for diseases such as cancer

People who take aspirin or other anti-inflammatory medications are at an increased risk even if they do not have H pylori infection.

• Elderly people with conditions such as arthritis are especially vulnerable.
• People who have had prior ulcers or intestinal bleeding are at a higher-than-normal risk.
• If a person takes these medications regularly, alternatives should be discussed with a health-care professional. This is especially true if the affected individual has an upset stomach or heartburn after taking these medications.

H pylori bacteria is spread through the stools (feces) of an infected person.

• The stool contaminates food or water (usually through poor personal hygiene).
• The bacteria in the stool make their way into the digestive tracts of people who consume this food or water.
• This is called fecal-oral transmission and is a common way for infections to spread.

The bacteria are found in the stomach, where they are able to penetrate and damage the lining of the stomach and duodenum.

• Many people who are exposed to the bacteria never develop ulcers.
• People who are newly infected usually develop symptoms within a few weeks.
• Researchers are trying to discover what is different about the people who develop ulcers.

Infection with H pylori occurs in all ages, races, and socioeconomic classes.

• It is more common in older adults, although it is thought that many people are infected in childhood and carry the bacteria throughout their lifetimes.
• It is also more common in lower socioeconomic classes because these households tend to have more people living together, sharing bathrooms and kitchen facilities.
• African Americans and Hispanic Americans are more likely to have the bacteria than Caucasians and Asian Americans.

It is important to distinguish between ulcers caused by H pylori and those caused by medications because the treatment is completely different.

Ulcers can be linked with other medical conditions.

• People who worry excessively are usually thought to have a condition called generalized anxiety disorder. This disorder has been linked with peptic ulcers.
• A rare condition called Zollinger-Ellison syndrome causes peptic ulcers as well as tumors in the pancreas and duodenum.

• If you suspect you may have a peptic ulcer, you may first be diagnosed by your family practitioner or internist.
• Children or teenagers may see a pediatrician.
• For further treatment you will likely be referred to a gastroenterologist, a specialist in disorders of the digestive tract.
• If you have an emergency such as vomiting or severe abdominal pain you will be seen by an emergency medicine specialist in an emergency room.
• In the rare case where surgery is needed, you may see a general surgeon.

• If you have burning pain in your upper stomach that is relieved by eating or taking antacids, call a health-care professional for an appointment. Don't assume you have an ulcer. Certain other conditions can cause similar symptoms.
• If you vomit blood or have other signs of gastrointestinal bleeding, go to an emergency department right away. Peptic ulcers can cause massive bleeding, which requires blood transfusion or surgery.
• Severe abdominal pain suggests perforation or tearing of an ulcer. This is an emergency that may require surgery to fix a hole in your stomach.
• Vomiting and abdominal pain also can be a sign of an obstruction, another complication of peptic ulcers. This also may require emergency surgery.

A barium swallow can show ulcers on an X-ray.

To confirm a person has an ulcer a diagnostic imaging test will usually be ordered. The two most widely used tests are:

• Upper GI series (UGI): This is a type of X-ray. The patient is given a chalky liquid to drink that increases the contrast on the X-ray, making certain features easier to see. Because this liquid contains barium, this test is sometimes called a barium swallow.
• Endoscopy (EGD): An endoscope is a thin, flexible tube with a tiny camera at the end. The patient is given a mild sedative, and then the tube is passed through the mouth into the stomach. The doctor can see the lining of the stomach to diagnose a peptic ulcer. Tiny samples of the tissue will be taken (biopsy), which are examined under a microscope.

If a diagnostic imaging test reveals an ulcer, the patient will most likely have a test to see if H pylori bacteria are present.

• It is important to be certain about this, because treatment of the H pylori is likely to heal the ulcer.
• Ulcers caused by H pylori are treated differently than ulcers caused by medications.

Three types of tests are available to detect H pylori.

• Blood tests: These tests detect the bacteria by measuring antibodies to the bacteria. Antibodies are proteins produced by the immune system to defend against an "invader" such as H pylori. The blood test is inexpensive and can be done in a medical office. The downside is that it can be positive in a person who had an ulcer in the past and was already treated for it.
• Breath test: This test detects H pylori by measuring carbon dioxide in the breath of a person who has drunk a special liquid. H pylori bacteria break down the liquid, increasing the amount of carbon in the blood. The body gets rid of this carbon by breathing it out as carbon dioxide. This test is more accurate than the blood test but is more difficult to carry out. It is often used after treatment to check whether H pylori bacteria have been eradicated.
• Tissue tests: These tests are used only if an endoscopic biopsy has been done, because a sample of tissue from the stomach is needed to detect the bacteria.

Home care for peptic ulcers often centers on neutralizing the stomach acid.

• Don't smoke, and avoid coffee and alcohol. These habits increase gastric acid production and weaken the mucosal barrier of the GI tract promoting ulcer formation and slowing ulcer healing.
• Don't take aspirin or nonsteroidal anti-inflammatory medications. Acetaminophen is a good substitute for some conditions. If acetaminophen doesn't help, talk to your health-care professional about alternatives.
• If your symptoms are mild, try an over-the-counter antacid or nonprescription histamine (H2) blocker to neutralize stomach acid. Usually stronger prescription medications are needed.

No particular diet is helpful for people with peptic ulcers. At one time, a bland diet and avoidance of spicy or greasy foods was recommended. Milk and dairy food have been used in the past for ulcer symptoms, but have not been proven to be effective. We now know diet has little effect on ulcers. In some people, however, certain foods seem to aggravate stomach ulcer symptoms. Keep a food diary with your intake and the resulting symptoms and avoid eating any foods that aggravate symptoms.

The choice of treatment depends on whether or not the ulcer is caused by infection with H pylori. Correct diagnosis is key to whether a treatment works or not. If the bacteria are the cause, treatment focuses on killing the infection. Regardless of whether the bacteria are the cause, reducing acid in the stomach is another important focus of treatment.

The following treatments are recommended for ulcers:

• Lifestyle changes: Quit smoking, avoid alcohol, aspirin, and NSAIDs
• Acid-blocking medications
• Medications that protect the lining of the stomach and duodenum
• "Triple-therapy" or "dual-therapy" regimens for ulcers caused by H pylori

No single medication works to get rid of H pylori infection. Two combinations have been found that work well in most people.

• Triple therapy: The combination of bismuth subsalicylate (for example, Pepto-Bismol) and the antibiotics tetracycline and metronidazole are effective in 80%-95% of people and is the current standard of therapy. All are taken as pills. The bismuth subsalicylate and tetracycline have to be taken 4 times a day and metronidazole 3 times a day. This complicated schedule is difficult for many people to follow.
• Dual therapy: This therapy was developed as a response to the complexity and side effects of triple therapy. It comprises 2 antibiotics, amoxicillin and metronidazole, both taken as pills 3 times a day; and a proton pump inhibitor (PPI). This simplified schedule is preferred by many people.
  • Clarithromycin can be substituted for the 15%-25% of people whose infections are resistant to metronidazole.
  • Usually a proton pump inhibitor such as omeprazole (Prilosec, Prilosec OTC) is added to the treatment.

These treatments are generally given for two weeks.

Once H pylori bacteria are eradicated from a person's digestive tract, usually it will not come back. The ulcers usually heal completely and do not return.

Treatment for bleeding ulcers depends on the severity of blood loss and includes:

• IV fluids
• Bowel rest: Bed rest and clear fluids with no food at all for a few days. This gives the ulcer a chance to start healing without being irritated.
• Nasogastric tube: Placement of a thin, flexible tube through the nose and down into the stomach. This also relieves pressure on the stomach and helps it heal.
• Urgent endoscopy or surgery, if indicated: Damaged, bleeding blood vessels can usually be cauterized with an endoscope. The endoscope has a small heating device at the end that is used to cauterize a blood vessels.

It is important to remember that treatment may not work if the diagnosis is not correct. If the doctor diagnoses an ulcer, it is important to determine whether the ulcer is caused by infection with H pylori.

Several types of medications are used to treat ulcers.

Antacids: These nonprescription medications simply neutralize acid.

• Most include aluminum hydroxide combined with magnesium or calcium. Examples are Maalox, Mylanta, Tums, and Rolaids.
• These can cause constipation, although those containing magnesium can cause diarrhea.
• These side effects are especially likely if the medications are taken regularly.

Histamine (H2) blockers: These are acid-blocking medications widely used in the treatment of peptic ulcers.

• H2 blockers include cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), and nizatidine (Axid).
• They prevent production of acid by blocking histamine, a chemical that promotes acid production.
• Nonprescription strengths are available, but for most people with stomach ulcers the stronger prescription versions are needed.
• H2 blockers work very well in reducing acid and pain. (Reducing acid helps the ulcers heal.)
• They may take a few days to start having an effect.
• Treatment with H2 blockers usually takes 6-8 weeks.

Acid pump inhibitors: These drugs are also known as proton pump inhibitors (PPIs).

• This group includes omeprazole (Prilosec, Prilosec OTC, Zegerid), lansoprazole (Prevacid, Prevacid 24-Hour), rabeprazole (Aciphex), and pantoprazole (Protonix), dexlansoprazole (Dexilant, Kapidex), and esomeprazole (Nexium).
• Proton pump inhibitors are even stronger than H2 blockers.
• They work by stopping the "pump" that secretes acid into the stomach.
• They are being used increasingly in triple and double regimens for infection.

Protective agents: These drugs do not affect the amount of acid in the stomach; instead, they protect the mucous lining of the stomach from acid.

• One type is very thick and sticks to the ulcer, forming a physical barrier between the ulcer and the acid. An example is sucralfate (Carafate).
• The other type increases the amount of mucus, which forms a physical barrier, and bicarbonate, which helps neutralize the acid. An example is misoprostol (Cytotec); this agent is used only for treatment of ulcers caused by medication.
• Antacids and products containing bismuth subsalicylate (such as Pepto-Bismol) also have protective effects.

Antibiotics: As part of a combination regimen, antibiotics eradicate H pylori, the bacteria that causes ulcers in many people.

• A 2 week triple therapy that includes two antibiotics and bismuth subsalicylate is the most effective regimen. It eliminates the bacteria and prevents recurrence of ulcers in 90% of people who receive this treatment. Unfortunately, triple therapy has side effects such as upset stomach, nausea, vomiting, bad taste in the mouth, loose or dark stools, dizziness, and yeast infections in women.
• Any of the several 2 week dual therapy regimens are simpler to follow, have fewer side effects, and work in about 80% of people who take them.
• A newer triple therapy combining antibiotics and rabeprazole (Aciphex) works in just 1 week to eradicate H pylori.

Medical therapy works in most people with peptic ulcers. Sometimes, medical therapy does not work, or a person can't take the therapy for some reason. Surgery is an alternative to medical therapy for these people.

Surgical operations often used in peptic ulcers include the following:

• Vagotomy: Cutting the vagus nerve, which transmits messages from the brain to the stomach, can reduce acid secretion. However, this can also interfere with other functions of the stomach. A newer operation cuts only the part of the nerve that affects acid secretion.
• Antrectomy: This is often done in conjunction with a vagotomy. It involves removing the lower part of the stomach (the antrum). This part of the stomach produces a hormone that increases production of stomach acid. Adjacent parts of the stomach may also be removed.
• Pyloroplasty: This procedure also is sometimes done with vagotomy. It enlarges the opening between the stomach and duodenum (the pylorus) to encourage passage of partially digested food. Once the food has passed, acid production normally stops.
• Tying off an artery: If bleeding is a problem, cutting off the blood supply (artery) to the ulcer can stop the bleeding.

The prognosis for appropriately treated peptic ulcers is good with most people getting a full recovery and very few cases re-occur. Treatment for H pylori bacteria usually is successful if you take the medications as prescribed.

With appropriate treatment, symptoms are relieved within a few days to weeks but the actual healing of the lining of the intestine or stomach may take a few weeks longer. Although ulcers can cause discomfort, they are rarely life threatening. However, an ulcer that does not heal may be a sighn that there is another cause for the ulcer rather than a peptic ulcer. These causes include cancer and should be followed up with your doctor.

Severe ulcers can have several complications. These usually develop in people who do not receive appropriate treatment. Complications of ulcers may require emergency treatment including endoscopy or surgery. Complications can even result in death if not treated promptly.

Bleeding: Ulcers in the stomach or duodenum may bleed.

• Usually, this is because the blood vessel (artery) supplying the area of the ulcer has been damaged by stomach acid.
• Sometimes this is the only sign of an ulcer.
• Bleeding may be slow or fast.
• Slow bleeding is typically from a small blood vessel; the usual result is low blood count (anemia), and the symptoms are tiredness (fatigue), lethargy, and pallor.
• Fast bleeding is typically from a larger artery, and symptoms including vomiting acidified blood, which looks something like coffee grounds, or passage of bloody or black, tarry stools.

Perforation: When an ulcer gets very bad, it can eat all the way through the stomach or intestinal wall.

• The resulting hole in the gastrointestinal tract is called perforation.
• The contents of the intestine (food, bacteria, and digestive juices) can then spill out.
• These substances can injure other tissues and cause serious infection.

Obstruction: An ulcer causes inflammation.

• If this inflammation becomes chronic (ongoing, long lasting), it can cause swelling and scarring.
• Over time, this scarring can completely block off the digestive tract.
• This blocks food from passing, causing vomiting and weight loss.

Peptic ulcers can be prevented by avoiding things that break down the stomach's protective barrier and increase stomach acid secretion. These include alcohol, smoking, aspirin, nonsteroidal anti-inflammatory drugs, and caffeine.

Preventing infection with H pylori is a matter of avoiding contaminated food and water and adhering to strict standards of personal hygiene. Wash hands carefully with warm water and soap every time the bathroom is used, diaper changed, and before and after preparing food.

If you need the pain relief and anti-inflammatory action of aspirin or an NSAID, you can reduce your risk of ulcers by trying the following:

• Try a different NSAID, one that is easier on the stomach.
• Reduce the dose or the number of times you take the medication.
• Substitute another medication, such as acetaminophen (Tylenol).
• Talk to your health*care professional about how you can protect yourself.

Following the treatment recommendations of your health-care professional can help prevent recurrence of ulcers. This includes taking all medications as prescribed, especially if you have H pylori infection.