Peptic Ulcer Causes, Symptoms, Diagnosis, Treatment, Prevention

Peptic Ulcer Causes, Symptoms, Diagnosis, Treatment, Prevention


What is a peptic ulcer?


A peptic ulcer is a break in the inner lining of the esophagus, stomach, or duodenum. A peptic ulcer of the stomach is called a gastric ulcer; of the duodenum, a duodenal ulcer; and of the esophagus, an esophageal ulcer. Peptic ulcers occur when the lining of these organs is corroded by the acidic digestive (peptic) juices which are secreted by the cells of the stomach. A peptic ulcer differs from an erosion because it extends deeper into the lining of the esophagus, stomach, or duodenum and excites more of an inflammatory reaction from the tissues that are eroded.

Peptic Ulcer Causes, Symptoms, Diagnosis, Treatment, Prevention
Peptic Ulcer


Peptic ulcer disease is common, affecting millions of Americans yearly. Moreover, peptic ulcers are a recurrent problem; even healed ulcers can recur unless treatment is directed at preventing their recurrence. The medical cost of treating peptic ulcer and its complications runs into billions of dollars annually. Recent medical advances have increased our understanding of ulcer formation. Improved and expanded treatment options now are available.

Read more: Link Between Diabetes And Periodontal Disease

What Is H. pylori?


Helicobacter pylori (H. pylori) is a type of bacteria. Researchers believe that H. pylori is responsible for the majority of peptic ulcers.

H. pylori infection is common in the United States: About 20 percent of people under 40 years old and half of those over 60 have it. Most infected people, however, do not develop ulcers. Why H. pylori does not cause ulcers in every infected person is not known. Most likely, infection depends on characteristics of the infected person, the type of H. pylori, and other factors yet to be discovered.

Researchers are not certain how people contract H. pylori, but they think it may be through food or water.

Researchers have found H. pylori in some infected people's saliva, so the bacteria may also spread through mouth-to-mouth contact such as kissing.

How Does H. pylori Cause a Peptic Ulcer?


H. pylori weakens the protective mucous coating of the stomach and duodenum, which allows acid to get through to the sensitive lining beneath. Both the acid and the bacteria irritate the lining and cause a sore, or ulcer.

H. pylori is able to survive in stomach acid because it secretes enzymes that neutralize the acid. This mechanism allows H. pylori to make its way to the "safe" area--the protective mucous lining. Once there, the bacterium's spiral shape helps it burrow through the lining.

What are the causes of peptic ulcers?


For many years, excess acid was believed to be the major cause of ulcer disease. Accordingly, the emphasis of treatment was on neutralizing and inhibiting the secretion of stomach acid. While acid is still considered necessary for the formation of ulcers, the two most important initiating causes of ulcers are infection of the stomach by a bacterium called "Helicobacter pyloricus" (H. pylori) and chronic use of anti-inflammatory medications, commonly referred to as NSAIDs (nonsteroidal anti-inflammatory drugs), including aspirin. Cigarette smoking also is an important cause of ulcer formation as well as failure of ulcer treatment.

Infection with H. pylori is very common, affecting more than a billion people worldwide. It is estimated that half of the United States population older than age 60 has been infected with H. pylori. Infection usually persists for many years, leading to ulcer disease in 10% to 15% of those infected. In the past, H. pylori was found in more than 80% of patients with gastric and duodenal ulcers. With increasing appreciation, diagnosis and treatment of this infection, however, the prevalence of infection with H. pylori as well as the proportion of ulcers caused by the bacterium has decreased; it is estimated that currently only 20% of ulcers are associated with the bacterium. While the mechanism by which H. pylori causes ulcers is complex, elimination of the bacterium by antibiotics has clearly been shown to heal ulcers and prevent the recurrence of ulcers.

NSAIDs are medications used for the treatment of arthritis and other painful inflammatory conditions in the body. Aspirin, ibuprofen (Motrin), naproxen (Naprosyn), and etodolac (Lodine) are a few of the examples of this class of medications. Prostaglandins are substances which are important in helping the linings of the esophagus, stomach, and duodenum to resist damage by the acidic digestive juices of the stomach. NSAIDs cause ulcers by interfering with prostaglandins in the stomach.

Cigarette smoking not only causes ulcers, but it also increases the risk of complications from the ulcers such as ulcer bleeding, stomach obstruction, and perforation. Cigarette smoking also is a leading cause of failure of treatment for ulcers.

Contrary to popular belief, alcohol, coffee, colas, spicy foods, and caffeine have no proven role in ulcer formation. Similarly, there is no conclusive evidence to suggest that life stresses or personality types contribute to ulcer disease.

What Are the Symptoms of Peptic Ulcer?


Abdominal discomfort is the most common symptom. 


This discomfort usually

  • is a dull, gnawing ache.
  • comes and goes for several days or weeks.
  • occurs 2 to 3 hours after a meal.
  • occurs in the middle of the night (when the stomach is empty).
  • is relieved by food.
  • is relieved by antacid medications.

Other symptoms include


  • weight loss
  • poor appetite
  • bloating
  • burping
  • nausea
  • vomiting
Some people experience only very mild symptoms, or none at all. 

Emergency Symptoms


If you have any of these symptoms, call your doctor right away:

  • sharp, sudden, persistent stomach pain
  • bloody or black stools
  • bloody vomit or vomit that looks like coffee grounds

They could be signs of a serious problem, such as


  • perforation - when the ulcer burrows through the stomach or duodenal wall.
  • bleeding - when acid or the ulcer breaks a blood vessel.
  • obstruction - when the ulcer blocks the path of food trying to leave the stomach.

How are peptic ulcers diagnosed?


The diagnosis of an ulcer is made by either a barium upper gastrointestinal X-ray (upper GI series) or an upper gastrointestinal endoscopy (EGD or esophagogastroduodenoscopy). The barium upper GI X-ray is easy to perform and involves no risk (other than exposure to radiation) or discomfort. Barium is a chalky substance that is swallowed. It is visible on X- rays, and allows the outline of the stomach to be seen on X-rays; however, barium X-rays are less accurate and may miss ulcers in up to 20% of the time.

An upper gastrointestinal endoscopy is more accurate than X-rays, but involves sedation of the patient and the insertion of a flexible tube through the mouth to inspect the esophagus, stomach, and duodenum. Upper endoscopy has the added advantage of having the capability of removing small tissue samples (biopsies) to test for H. pylori infection. Biopsies are also examined under a microscope to exclude a cancerous ulcer. While virtually all duodenal ulcers are benign, gastric ulcers can occasionally be cancerous. Therefore, biopsies often are performed on gastric ulcers to exclude cancer.

This allows the doctor to see the lining of the esophagus, stomach, and duodenum. The doctor can use the endoscope to take photos of ulcers or remove a tiny piece of tissue to view under a microscope. 

Diagnosing H. pylori


If an ulcer is found, the doctor will test the patient for H. pylori. This test is important because treatment for an ulcer caused by H. pylori is different from that for an ulcer caused by NSAIDs.

H. pylori is diagnosed through blood, breath, stool, and tissue tests. Blood tests are most common. They detect antibodies to H. pylori bacteria. Blood is taken at the doctor's office through a finger stick. 

Urea breath tests are mainly used after treatment to see whether it worked, but they can be used in diagnosis too. In the doctor's office, the patient drinks a urea solution that contains a special carbon atom. If H. pylori is present, it breaks down the urea, releasing the carbon. The blood carries the carbon to the lungs, where the patient exhales it. The breath test is 96 percent to 98 percent accurate.

Stool tests may be used to detect H. pylori infection in the patient's fecal matter. Studies have shown that the test, called the Helicobacter pylori stool antigen (HpSA) test, is accurate for diagnosing H. pylori.

Tissue tests are usually done using the biopsy sample that is removed with the endoscope. There are three types:

  • The rapid urease test detects the enzyme urease, which is produced by H. pylori.
  • A histology test allows the doctor to find and examine the actual bacteria.
  • A culture test involves allowing H. pylori to grow in the tissue sample.
In diagnosing H. pylori, blood, breath, and stool tests are often done before tissue tests because they are less invasive. However, blood tests are not used to detect H. pylori following treatment because a patient's blood can show positive results even after H. pylori has been eliminated. 

What is the treatment for peptic ulcers?


The goal of ulcer treatment is to relieve pain, heal the ulcer, and prevent complications. The first step in treatment involves the reduction of risk factors (NSAIDs and cigarettes). The next step is medications.

Antacids


Antacids neutralize existing acid in the stomach. Antacids such as Maalox, Mylanta, and Amphojel are safe and effective treatments. However, the neutralizing action of these agents is short-lived, and frequent dosing is required. Magnesium containing antacids, such as Maalox and Mylanta, can cause diarrhea, while aluminum containing agents like Amphojel can cause constipation. Ulcers frequently return when antacids are discontinued.

Proton-pump inhibitors (PPIs)


Proton-pump inhibitors such as omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), esomeprazole (Nexium), and rabeprazole (Aciphex) are more potent than H2 blockers in suppressing acid secretion. The different proton-pump inhibitors are very similar in action and there is no evidence that one is more effective than the other in healing ulcers. While proton-pump inhibitors are comparable to H2 blockers in effectiveness in treating gastric and duodenal ulcers, they are superior to H2 blockers in treating esophageal ulcers. Esophageal ulcers are more sensitive than gastric and duodenal ulcers to minute amounts of acid. Therefore, more complete acid suppression accomplished by proton-pump inhibitors is important for esophageal ulcer healing.

Proton-pump inhibitors are well tolerated. Side effects are uncommon; they include headache, diarrhea, constipation, nausea and rash. Interestingly, proton-pump inhibitors do not have any effect on a person's ability to digest and absorb nutrients. Proton-pump inhibitors have also been found to be safe when used long term, without serious adverse health effects. Although they may promote loss of bone (osteoporosis) and low magnesium levels, both of these side effects are easily identified and treated.

H. pylori treatment


Many people harbor H. pylori in their stomachs without ever having pain or ulcers. It is not completely clear whether these patients should be treated with antibiotics. More studies are needed to answer this question. Patients with documented ulcer disease and H. pylori infection should be treated for both the ulcer and the H. pylori. H. pylori can be very difficult to completely eradicate. Treatment requires a combination of several antibiotics, sometimes in combination with a proton-pump inhibitor, H2 blockers, or Pepto-Bismol. Commonly used antibiotics are tetracycline, amoxicillin, metronidazole (Flagyl), clarithromycin (Biaxin), and levofloxacin (Levaquin). Eradication of H. pylori prevents the return of ulcers (a major problem with all other ulcer treatment options). Elimination of this bacteria also may decrease the risk of developing gastric cancer in the future. Treatment with antibiotics carries the risk of allergic reactions, diarrhea, and sometimes severe antibiotic-induced colitis (inflammation of the colon).

H2 blockers


Studies have shown that a protein released in the stomach called histamine stimulates gastric acid secretion. Histamine antagonists (H2 blockers) are drugs designed to block the action of histamine on gastric cells and reduce the production of acid. Examples of H2 blockers are cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine (Pepcid). While H2 blockers are effective in ulcer healing, they have a limited role in eradicating H. pylori without antibiotics. Therefore, ulcers frequently return when H2 blockers are stopped.

Generally, H2 blockers are well tolerated and have few side effects even with long term use. In rare instances, patients report headache, confusion, lethargy, or hallucinations. Chronic use of cimetidine may rarely cause impotence or breast swelling. Both cimetidine and ranitidine can interfere with the body's ability to handle alcohol. Patients on these drugs who drink alcohol may have elevated blood alcohol levels. These drugs may also interfere with the liver's handling of other medications like phenytoin (Dilantin), warfarin (Coumadin), and theophylline. Frequent monitoring and adjustments of the dosages of these medications may be needed.

Sucralfate (Carafate) and misoprostol (Cytotec)


Sucralfate (Carafate) and misoprostol (Cytotec) are agents that strengthen the gut lining against attacks by acidic digestive juices. Sucralfate coats the ulcer surface and promotes healing. Sucralfate has very few side effects. The most common side effect is constipation and the interference with the absorption of other medications. Misoprostol is a prostaglandin-like substance commonly used to counteract the ulcerogenic effects of NSAIDs. Studies suggest that misoprostol may protect the stomach from ulceration among people who take NSAIDs chronically. Diarrhea is a common side effect. Misoprostol can cause miscarriages when given to pregnant women, and should be avoided by women of childbearing age.

Diet


There is no conclusive evidence that dietary restrictions and bland diets play a role in ulcer healing. No proven relationship exists between peptic ulcer disease and the intake of coffee and alcohol. However, since coffee stimulates gastric acid secretion, and alcohol can cause gastritis, moderation in alcohol and coffee consumption is recommended.

Prevention for Peptic Ulcer


You may reduce your risk of peptic ulcer if you:

Protect yourself from infections


It's not clear just how H. pylori spreads, but there's some evidence that it could be transmitted from person to person or through food and water.

You can take steps to protect yourself from infections, such as H. pylori, by frequently washing your hands with soap and water and by eating foods that have been cooked completely.

Use caution with pain relievers


If you regularly use pain relievers that increase your risk of peptic ulcer, take steps to reduce your risk of stomach problems. For instance, take your medication with meals.

Work with your doctor to find the lowest dose possible that still gives you pain relief. Avoid drinking alcohol when taking your medication, since the two can combine to increase your risk of stomach upset.

What are the complications of peptic ulcer?


Patients with ulcers generally function quite comfortably. Some ulcers probably heal even without medications (though they probably recur as well). Therefore, the major problems resulting from ulcers are related to ulcer complications. Complications include bleeding, perforation, and obstruction of the stomach.

Patients with ulcer bleeding may report passage of black tarry stools (melena), weakness, a sense of passing out upon standing (orthostatic syncope), and vomiting blood (hematemesis). Initial treatment involves rapid replacement of lost blood intravenously, usually with fluids. Patients with persistent or severe bleeding may require blood transfusions. An endoscopy is performed to establish the site of bleeding and to stop active ulcer bleeding with the aid of specialized endoscopic instruments.

Perforation through the stomach leads to the leakage of stomach contents into the abdominal (peritoneal) cavity, resulting in acute peritonitis (infection of the abdominal cavity). These patients report a sudden onset of extreme abdominal pain, which is worsened by any type of motion. Abdominal muscles become rigid and board-like. Urgent surgery usually is required. A duodenal ulcer that has perforated can burrow into adjacent organs such as the pancreas or behind the abdomen and into the back. An esophageal ulcer that perforates can cause severe inflammation of the tissues that surround it and the heart, and those that lie between the lungs (mediastinitis).

If an ulcer occurs in the narrow outlet from the stomach, it can obstruct the flow of stomach contents into the duodenum. Duodenal ulcers sometimes also may obstruct the flow of intestinal contents. Patients with obstruction often report increasing abdominal pain, vomiting of undigested or partially digested food, diminished appetite, and weight loss. The obstruction usually occurs at or near the pylorus that separates the stomach from the duodenum. Endoscopy is useful in establishing the diagnosis of obstruction from an ulcer and excluding gastric cancer as the cause of the obstruction. In some patients, gastric obstruction can be relieved by suction of the stomach contents with a tube for 72 hours, along with intravenous anti-ulcer medications, such as cimetidine (Tagamet) and ranitidine (Zantac). Patients with persistent obstruction require surgery.

Points To Remember


  • A peptic ulcer is a sore in the lining of the stomach or duodenum.
  • The majority of peptic ulcers are caused by the H. pylori bacterium. Many of the other cases are caused by NSAIDs. None are caused by spicy food or stress.
  • H. pylori can be transmitted from person to person through close contact and exposure to vomit.
  • Always wash your hands after using the bathroom and before eating.
  • A combination of antibiotics and other drugs is the most effective treatment for H. pylori peptic ulcers.

How Are H. pylori Peptic Ulcers Treated?


H. pylori peptic ulcers are treated with drugs that kill the bacteria, reduce stomach acid, and protect the stomach lining. Antibiotics are used to kill the bacteria. Two types of acid-suppressing drugs might be used: H2 blockers and proton pump inhibitors.

H2 blockers work by blocking histamine, which stimulates acid secretion. They help reduce ulcer pain after a few weeks. Proton pump inhibitors suppress acid production by halting the mechanism that pumps the acid into the stomach. H2 blockers and proton pump inhibitors have been prescribed alone for years as treatments for ulcers. But used alone, these drugs do not eradicate H. pylori and therefore do not cure H. pylori-related ulcers. Bismuth subsalicylate, a component of Pepto-Bismol, is used to protect the stomach lining from acid. It also kills H. pylori. 

Treatment usually involves a combination of antibiotics, acid suppressors, and stomach protectors. Antibiotic regimens recommended for patients may differ across regions of the world because different areas have begun to show resistance to particular antibiotics.

The use of only one medication to treat H. pylori is not recommended. At this time, the most proven effective treatment is a 2-week course of treatment called triple therapy. It involves taking two antibiotics to kill the bacteria and either an acid suppressor or stomach-lining shield. Two-week triple therapy reduces ulcer symptoms, kills the bacteria, and prevents ulcer recurrence in more than 90 percent of patients.

Unfortunately, patients may find triple therapy complicated because it involves taking as many as 20 pills a day. Also, the antibiotics used in triple therapy may cause mild side effects such as nausea, vomiting, diarrhea, dark stools, metallic taste in the mouth, dizziness, headache, and yeast infections in women. (Most side effects can be treated with medication withdrawal.) Nevertheless, recent studies show that 2 weeks of triple therapy is ideal.

Early results of studies in other countries suggest that 1 week of triple therapy may be as effective as the 2-week therapy, with fewer side effects.

Another option is 2 weeks of dual therapy. Dual therapy involves two drugs: an antibiotic and an acid suppressor. It is not as effective as triple therapy.

Two weeks of quadruple therapy, which uses two antibiotics, an acid suppressor, and a stomach-lining shield, looks promising in research studies. It is also called bismuth triple therapy.