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Peptic ulcer (stomach, duodenum) definition and facts
- Peptic ulcer (stomach, duodenum) are sores in the lining of the stomach or duodenum.
- Peptic ulcer formation is related to H. pylori bacteria in the stomach and nonsteroidal anti-inflammatory medications (NSAIDs) in 50% of patients. For the remaining 50% there are miscellaneous causes such as drugs, lifestyle factors (smoking), severe physiological stress, and genetic factors; or the cause is unknown.
- Ulcer pain may not correlate with the presence or severity of ulceration.
- The main symptom of a stomach or duodenal ulcer is upper abdominal pain which can be dull, sharp, or burning (a hunger-like feeling). (Bloating and burping are not symptoms of peptic ulcer, and vomiting, poor appetite, and nausea are uncommon symptoms of peptic ulcer.) Other symptoms may include:
- Diagnosis of an ulcer can be made with an upper GI series or endoscopy.
- Treatment of stomach or duodenal ulcers is to relieve pain, heal the ulcer, and prevent complications. Medical treatment involves antibiotic combinations along with stomach acid suppression medication, for example, antacids, proton pump inhibitors (PPIS), or H2 blockers to eradicate H. pylori, or eliminate precipitating factors such as NSAIDs and stomach acid suppression with medications alone.
- Complications of duodenal or stomach ulcers include bleeding, perforation, and blockage of the stomach (gastric obstruction).
- If a person with peptic ulcers smokes or take NSAIDs, the ulcers may recur after treatment.
What is a peptic ulcer?
A peptic ulcer (stomach or duodenal) 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 incites more of an inflammatory reaction from the tissues that are involved. Peptic ulcer also is referred to as peptic ulcer disease.
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.
Bleeding Ulcers: Symptoms and Causes
Bleeding ulcers are a big deal. Often having endoscopy is diagnostic and therapeutic. A gastroenterologist can use a fiberoptic camera to view the inside of the stomach and duodenum, searching for a source of bleeding.
Symptoms of a bleeding ulcer include:
- Abdominal discomfort after eating
- Upper abdominal burning or hunger pain 1 to 3 hours after eating or in the middle of the night
Read more about bleeding ulcers symptoms and causes. »
What are the signs and symptoms of peptic ulcers?
Symptoms of duodenal or stomach ulcer disease vary. Many people with ulcers experience minimal indigestion, abdominal discomfort that occurs after meals, or no discomfort at all. Some complain of upper abdominal burning or hunger pain one to three hours after meals or in the middle of the night. These symptoms often are promptly relieved by food or antacids that neutralize stomach acid. The pain of ulcer disease correlates poorly with the presence or severity of active ulceration. Some individuals have persistent pain even after an ulcer is almost completely healed by medication. Others experience no pain at all. Ulcers often come and go spontaneously without the individual ever knowing that they are present unless a serious complication (like bleeding or perforation) occurs.
What causes 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 and its suppression is still the primary treatment, the two most important initiating causes of ulcers are infection of the stomach by a bacterium named "Helicobacter pyloricus" (H. pylori) and chronic use of nonsteroidal anti-inflammatory medications or NSAIDs, including aspirin. Cigarette smoking also is an important cause of ulcers 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, 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 their recurrence.
NSAIDs are medications used for the treatment of arthritis and other painful inflammatory conditions in the body. Aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), and etodolac (Lodine) are a few 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 the production of prostaglandins in the stomach.
Cigarette smoking not only causes ulcers, but it also increases the risk of complications from 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 does a stomach ulcer look like?
Which specialties of doctors treat peptic ulcers?
Doctors who commonly treat peptic ulcer disease include primary care providers, such as general medicine physicians, family medicine doctors, and internists. Specialists in the diagnosis and treatment of peptic ulcer disease are gastroenterologists.
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 gastrointestinal (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 up to 20% of the time.
An upper gastrointestinal endoscopy is more accurate than X-rays, but usually 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.
Is there a special diet for peptic ulcer disease?
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.
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 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.
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 also may interfere with the liver's handling of other medications like phenytoin (Dilantin), warfarin (Jantoven, Coumadin), and theophylline. Frequent monitoring and adjustments of the dosages of these medications may be needed.
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.
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.
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).
What are the complications of peptic ulcers?
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 emptying of the stomach.
Patients with bleeding ulcers 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 fluids. Patients with persistent or severe bleeding may require blood transfusions. An endoscopy is performed to establish cipro antibiotic and alcohol consumption 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 (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 of the stomach. 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.
What is the prognosis for a person with peptic ulcer disease?
With modern treatment, people with ulcer disease can lead normal lives without lifestyle changes or dietary restrictions. Cigarette smokers have been found to have more complications from ulcers and treatment failure. Eradication of the bacteria H. pylori not only heals ulcers but also prevents the recurrence of ulcer disease.
Medically reviewed by a Board-Certified Family Practice Physician
Anand, BS, MD. "Peptic Ulcer Disease." Medscape. Updated Jan 09, 2016.
Reviewed on 8/3/2016
Anand, BS, MD. "Peptic Ulcer Disease." Medscape. Updated Jan 09, 2016.
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