Definition

Peptic ulcer is a sore in the lining of the stomach or the first part of the small intestine (called the duodenum). Ulcers in the stomach are often called gastric ulcers. Ulcers in the duodenum are called duodenal ulcers.

Gastric Ulcer

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Causes

Most peptic ulcers are caused by the bacterium Helicobacter pylori (H pylori) or by using nonsteroidal anti-inflammatory drugs (NSAIDs). People infected with H pylori and people who take NSAIDs do not all develop ulcers though.

Anything that upsets the balance of stomach acid and digestive juices can lead to an ulcer, such as:

  • H pylori bacteria
  • NSAIDs, which blocks the body's ability to protect the stomach lining
  • Diseases that cause acid production to increase, such as Zollinger-Ellison syndrome

Rare causes include radiation therapy, bacterial or viral infections, alcohol abuse, injury, and severe stress such as surgery, trauma, head injury, shock, or burns.

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition.

Risk factors for ulcer from H pylori infection include:

  • Age: 60 or older
  • Sex: male
  • Race: Black and Hispanic
  • Lower socio-economic group
  • A crowded and unsanitary living environment
  • Cigarette smoking
  • Family history of ulcer disease
  • Type O blood

Risk factors for ulcer from anti-inflammatory drugs include:

  • Age: 60 or older
  • Sex: male
  • History of stomach upset from NSAIDs
  • Prior peptic ulcer disease
  • Cigarette smoking
  • Alcohol abuse

Symptoms

Peptic ulcers do not always cause symptoms. Symptoms may come and go. Food may increase gastric ulcer pain, but food usually relieves duodenal ulcer pain.

Symptoms include:

  • Gnawing pain
    • May awaken you from sleep
    • May change when you eat
    • May last for a few minutes or several hours
    • Feels like unusually strong hunger pangs
  • Nausea
  • Vomiting
  • Loss of appetite
  • Bloating
  • Burping

Ulcers can cause serious problems and severe abdominal pain. Problems include:

  • Bleeding, which may occur with no other symptoms
    • Symptoms of bleeding include:
      • Black, tarry stools
      • Vomiting what looks like coffee grounds
      • Weakness
      • Dizziness
      • Anemia
  • Breaking through the wall of the stomach or duodenum (called a perforated ulcer)
    • Sudden and severe pain is a common symptom of a perforated ulcer.
  • Scar tissue that narrows and eventually closes off the outlet of the stomach to the intestines
    • This blocks food from passing through the digestive system. Symptoms of scar tissue blockage include:
      • Vomiting
      • Weight loss
      • Intense pain

Duodenal Ulcer

duodenal ulcer

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Diagnosis

The doctor will ask about your symptoms and medical history, and perform a physical exam. Tell your doctor about all medications you are taking.

Tests may include:

  • Rectal exam and stool guaiac test—to test for hidden blood
  • Blood test or breath test—to check for H pylori infection
    • A blood test can also check for gastrin levels if Zollinger-Ellison syndrome is suspected.
  • Upper GI series—a series of x-rays of the upper digestive system taken after drinking a barium solution
  • Endoscopy—a thin, lighted tube inserted down the throat to look inside the digestive tract
    • During this procedure, the doctor can take tissue samples to test for H pylori infection or for cancer. Endoscopy is also helpful to eliminate other serious causes of gastrointestinal symptoms.

Treatment

The goals of treatment are to remove the source of the problem and heal the ulcer. Gastric ulcers may take longer to heal than duodenal ulcers.

Treatments include:

Medication

Some medications block or reduce acid production. Some coat the ulcer to protect it. If H pylori caused the ulcer, you will need to take a combination of drugs to kill the bacteria. This usually consists of antibiotics and a proton-pump inhibitor. It is very important to take these drugs as directed. The doctor may order tests 6-12 months after treatment to check that the bacteria are gone.

Medications may include:

  • Antacids—they do not heal ulcers, but may provide some relief from heartburn
  • Antibiotics (amoxicillin, tetracycline, and clarithromycin)
  • Bismuth-containing drug (Pepto-Bismol)
  • Proton pump inhibitors—to decrease stomach acid production (omeprazole, lansoprazole)
  • H 2 blockers—to decrease stomach acid production (famotidine, ranitidine, cimetidine, nizatidine)
  • Medications to coat ulcer (sucralfate)
  • Medications to protect stomach against NSAID damage (misoprostol)

Lifestyle Changes

  • If you smoke, quit. Smoking interferes with ulcer healing.
  • Do not drink alcoholic beverages.
  • Avoid NSAIDS, including over-the-counter drugs like aspirin and ibuprofen.
  • If spicy or fatty foods worsen symptoms, you can temporarily stop eating them. Keep in mind they did not cause the ulcer and probably do not affect ulcer healing.
  • If stress increases ulcer pain, learn and practice stress-management techniques.

Surgery and Endoscopy

You may need surgery if you have bleeding, a perforation, or an obstruction. Surgical options include:

  • Endoscopy—This may be done to stop bleeding. In this procedure, a thin, lighted tube is inserted down the throat into the stomach or intestine. Then, heat, electricity, epinephrine, or a substance called “fibrin glue” can be applied to the bleeding area to stop blood flow.
  • Vagotomy and drainage—Vagotomy is the cutting of branches of the vagus nerve. Cutting the vagus nerve can greatly reduce acid production. Cutting through the entire nerve, though, can also interfere with the stomach’s ability to empty itself. Therefore, drainage must be created. Drainage may be done with one of the following:
    • 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
    • Gastrojejunostomy—Creating a new opening to connect the stomach and the jejunum (the second part of the small intestine)
  • Highly elective vagotomy—This is a technique that cuts only part of the vagus nerve. This surgery does not require extra drainage.
  • Vagotomy with antrectomy—This involves cutting the vagus nerve combined with removing the lower part of the stomach (antrum). The antrum makes a chemical that promotes acid production. Without that chemical, acid production drops.

Prevention

To decrease the risk of ulcer from H pylori infection:

  • Wash your hands after using the bathroom and before eating or preparing food.
  • Drink water from a safe source.
  • Don't smoke. Cigarette smoking increases the chances of getting an ulcer.

To decrease the risk of ulcer from NSAIDs:

  • Use other drugs when possible for managing pain.
  • Take the lowest possible dose.
  • Do not take drugs longer than needed.
  • Do not drink alcohol while taking the drugs.
  • Ask your doctor about switching to a newer NSAID that is less likely to cause ulcers, or about taking other drugs to protect your stomach and intestine lining.
  • Don't smoke. Cigarette smoking increases the chances of getting an ulcer.