Peptic Ulcer
OVERVIEW
Peptic ulcer disease is a condition in which painful sores or ulcers develop in the lining of the stomach or the first part of the small intestine (the duodenum). Normally, a thick layer of mucus protects the stomach lining from the effect of its digestive juices. But many things can reduce this protective layer, allowing stomach acid to damage the tissue.
SYMPTOMS AND CAUSES
People used to think that stress or certain foods could cause ulcers. But researchers haven’t found any evidence to support those theories. Instead, studies have revealed two main causes of ulcers:
- Helicobacter pylori (H. pylori) bacteria.
- Pain-relieving NSAID medications.
H. pylori bacteria
H. pylori commonly infects the stomach. About 50% of the world’s population has an H. pylori infection, often without any symptoms. Researchers believe people can transmit H. pylori from person to person, especially during childhood.
The H. pylori bacteria stick to the layer of mucus in the digestive tract and cause inflammation (irritation), which can cause this protective lining to break down. This breakdown is a problem because your stomach contains strong acid intended to digest food. Without the mucus layer to protect it, the acid can eat into stomach tissue.
However, for most people the presence of H. pylori doesn’t have a negative impact. Only 10% to 15% of people with H. pylori end up developing ulcers .
Pain relievers
Another major cause of peptic ulcer disease is the use of NSAIDs, a group of medications used to relieve pain. NSAIDS can wear away at the mucus layer in the digestive tract. These medications have the potential to cause peptic ulcers to form:
- Aspirin (even those with a special coating).
- Naproxen (Aleve®, Anaprox®, Naprosyn® and others).
- Ibuprofen (Motrin®, Advil®, Midol® and others).
- Prescription NSAIDs (Celebrex®, Cambia® and others).
Acetaminophen (Tylenol®) is not an NSAID and won’t cause damage to your stomach. People who can’t take NSAIDs are often directed to take acetaminophen.
Not everyone who takes NSAIDs will develop ulcers. NSAID use coupled with an H. pylori infection is potentially the most dangerous. People who have H. pylori and who frequently use NSAIDs are more likely to have damage to the mucus layer, and their damage can be more severe. Developing an ulcer from NSAID use also increases if you:
- Take high doses of NSAIDs.
- Are 70 years or older.
- Are female.
- Use corticosteroids (drugs your doctor might prescribe for asthma, arthritis or lupus) at the same time as taking NSAIDs.
- Use NSAIDS continuously for a long time.
- Have a history of ulcer disease.
Rare causes
Infrequently, other situations cause peptic ulcer disease. People may develop ulcers after:
- Being seriously ill from various infections or diseases.
- Having surgery.
- Taking other medications, such as steroids.
Peptic ulcer disease can also occur if you have a rare condition called Zollinger-Ellison syndrome (gastrinoma). This condition forms a tumor of acid-producing cells in the digestive tract. These tumors can be cancerous or noncancerous. The cells produce excessive amounts of acid that damages stomach tissue.
What are some ulcer symptoms?
Some people with ulcers don’t experience any symptoms. But signs of an ulcer can include:
- Gnawing or burning pain in your middle or upper stomach between meals or at night.
- Pain that temporarily disappears if you eat something or take an antacid.
- Bloating.
- Heartburn.
- Nausea or vomiting.
In severe cases, symptoms can include:
- Dark or black stool (due to bleeding).
- Vomiting.
- Weight loss.
- Severe pain in your mid- to upper abdomen.
Risk factors
In addition to having risks related to taking NSAIDs, you may have an increased risk of peptic ulcers if you:
- Smoke. Smoking may increase the risk of peptic ulcers in people who are infected with H. pylori.
- Drink alcohol. Alcohol can irritate and erode the mucous lining of your stomach, and it increases the amount of stomach acid that’s produced.
- Have untreated stress.
- Eat spicy foods.
DIAGNOSIS AND TESTS
Your healthcare provider may be able to make the diagnosis just by talking with you about your symptoms. If you develop an ulcer and you’re not taking NSAIDs, the cause is likely an H. pylori infection. To confirm the diagnosis, you’ll need one of these tests:
Endoscopy
If you have severe symptoms, your provider may recommend an upper endoscopy to determine if you have an ulcer. In this procedure, the doctor inserts an endoscope (a small, lighted tube with a tiny camera) through your throat and into your stomach to look for abnormalities.
H. Pylori tests
Tests for H. pylori are now widely used and your provider will tailor treatment to reduce your symptoms and kill the bacteria. A breath test is the easiest way to discover H. pylori. Your provider can also look for it with a blood or stool test, or by taking a sample during an upper endoscopy.
Imaging tests
Less frequently, imaging tests such as X-rays and CT scans are used to detect ulcers. You have to drink a specific liquid that coats the digestive tract and makes ulcers more visible to the imaging machines.
Treatment
Treatment for peptic ulcers depends on the cause. Usually treatment will involve killing the H. pylori bacterium if present, eliminating or reducing use of NSAIDs if possible, and helping your ulcer to heal with medication.
Medications can include:
- Antibiotic medications to kill H. pylori. If H. pylori is found in your digestive tract, your doctor may recommend a combination of antibiotics to kill the bacterium. These may include amoxicillin (Amoxil), clarithromycin (Biaxin), metronidazole (Flagyl), tinidazole (Tindamax), tetracycline and levofloxacin.The antibiotics used will be determined by where you live and current antibiotic resistance rates. You’ll likely need to take antibiotics for two weeks, as well as additional medications to reduce stomach acid, including a proton pump inhibitor and possibly bismuth subsalicylate (Pepto-Bismol).
- Medications that block acid production and promote healing. Proton pump inhibitors — also called PPIs — reduce stomach acid by blocking the action of the parts of cells that produce acid. These drugs include the prescription and over-the-counter medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium) and pantoprazole (Protonix).Long-term use of proton pump inhibitors, particularly at high doses, may increase your risk of hip, wrist and spine fracture. Ask your doctor whether a calcium supplement may reduce this risk.
- Medications to reduce acid production. Acid blockers — also called histamine (H-2) blockers — reduce the amount of stomach acid released into your digestive tract, which relieves ulcer pain and encourages healing.Available by prescription or over the counter, acid blockers include the medications famotidine (Pepcid AC), cimetidine (Tagamet HB) and nizatidine (Axid AR).
- Antacids that neutralize stomach acid. Your doctor may include an antacid in your drug regimen. Antacids neutralize existing stomach acid and can provide rapid pain relief. Side effects can include constipation or diarrhea, depending on the main ingredients.Antacids can provide symptom relief but generally aren’t used to heal your ulcer.
- Medications that protect the lining of your stomach and small intestine. In some cases, your doctor may prescribe medications called cytoprotective agents that help protect the tissues that line your stomach and small intestine.Options include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec).
Ulcers that fail to heal
Peptic ulcers that don’t heal with treatment are called refractory ulcers. There are many reasons why an ulcer may fail to heal, including:
- Not taking medications according to directions
- The fact that some types of H. pylori are resistant to antibiotics
- Regular use of tobacco
- Regular use of pain relievers — such as NSAIDs — that increase the risk of ulcers
Less often, refractory ulcers may be a result of:
- Extreme overproduction of stomach acid, such as occurs in Zollinger-Ellison syndrome
- An infection other than H. pylori
- Stomach cancer
- Other diseases that may cause ulcerlike sores in the stomach and small intestine, such as Crohn’s disease