Also called as duodenal ulcer, peptic ulcer.
Alternative Names: Ulcer - peptic; Ulcer - duodenal; Ulcer - gastric; Duodenal ulcer; Gastric ulcer.
An ulcer of the upper digestive tract, usually in the stomach or duodenum, where the mucous membrane is exposed to gastric secretions.
A peptic ulcer is an open sore or raw area that tends to develop in one of two places:
- The lining of the stomach (gastric ulcer).
- The upper part of the small intestine -- the duodenum (duodenal ulcer).
Ulcers average between one-quarter and one-half inch in diameter. They develop when digestive juices produced in the stomach, intestines, and digestive glands damage the lining of the stomach or duodenum.
The two important digestive juices components are hydrochloric acid and the enzyme pepsin. Both substances are critical in the breakdown and digestion of starches, fats, and proteins in food. They play different roles in ulcers:
- Hydrochloric acid: A common misbelief is that excess hydrochloric acid, which is secreted in the stomach, is solely responsible for producing ulcers. Patients with duodenal ulcers do tend to have higher-than-normal levels of hydrochloric acid, but most patients with gastric ulcers have normal or lower-than-normal acid levels. Some stomach acid is important for protecting against H. pylori, the bacteria that causes most peptic ulcers. [Note: An exception is ulcers that occur in Zollinger-Ellison syndrome. This is a rare genetic condition in which very high levels of gastrin, a hormone that stimulates secretions of hydrochloric acid, are secreted by tumors in the pancreas or duodenum.
- Pepsin: Pepsin is an enzyme that breaks down proteins in food. Since the stomach and duodenum are also composed of protein, they are also susceptible to the actions of pepsin. Pepsin is, therefore, also an important factor in the formation of ulcers.
Fortunately, the body has a defense system to protect the stomach and intestine against these two powerful substances:
The mucous layer, which coats the stomach and duodenum, forms the first line of defense. Bicarbonate, which the mucous layer secretes, neutralizes the digestive acids. Hormone-like substances called prostaglandins help dilate the blood vessels in the stomach, to ensure good blood flow and protect against injury. Prostaglandins are also believed to stimulate bicarbonate and mucus production. Disrupting any of these defense mechanisms makes the stomach and intestine lining susceptible to the actions of acid and pepsin, increasing the risk for ulcers.
About 25 million people in the U.S. are expected to develop peptic ulcers at some point in their lives. Peptic ulcer disease affects all age groups, but is rare in children. Men have twice the risk of ulcers as women. The risk of duodenal ulcers tends to rise beginning around age 25 and continues until age 75; gastric ulcers peak at age 55 - 65.
Peptic ulcers are less common than they once were. Research suggests that ulcer rates have even declined in areas with widespread H. pylori infection. The increased use of proton-pump inhibitor (PPI) drugs may be responsible for this trend.
Causes and Risk factors:
Your stomach normally produces acid to help with the digestion of food and to kill bacteria. This acid is corrosive so some cells on the inside lining of the stomach and duodenum produce a natural mucus barrier which protects the lining of the stomach and duodenum. There is normally a balance between the amount of acid that you make and the mucus defense barrier. An ulcer may develop if there is an alteration in this balance allowing the acid to damage the lining of the stomach or duodenum. Causes of this include the following:
Infection with Helicobacter pylori: Infection by Helicobacter pylori (commonly just called H. pylori) is the cause in about 19 in 20 cases of duodenal ulcer. More than a quarter of people in the UK become infected with H. pylori at some stage in their life. Once you are infected, unless treated, the infection usually stays for the rest of your life. In many people it causes no problems and a number of these bacteria just live harmlessly in the lining of the stomach and duodenum. However, in some people this bacterium causes an inflammation in the lining of the stomach or duodenum. This causes the defense mucus barrier to be disrupted (and in some cases the amount of acid to be increased) which allows the acid to cause inflammation and ulcers.
Anti-inflammatory drugs - including aspirin: Anti-inflammatory drugs are sometimes called non-steroidal anti inflammatory drugs (NSAIDs). There are various types and brands. For example: aspirin, ibuprofen, diclofenac, etc. Many people take an anti-inflammatory drug for arthritis, muscular pains, etc. Aspirin is also used by many people to protect against blood clots forming. However, these drugs sometimes affect the mucus barrier of the duodenum and allow acid to cause an ulcer. About 1 in 20 duodenal ulcers are caused by anti-inflammatory drugs.
Other causes and factors: Other causes are rare, for example, the Zollinger-Ellison syndrome, in this rare condition, much more acid than usual is made by the stomach. Other factors such as smoking, stress, and drinking heavily may possibly increase the risk of having a duodenal ulcer. However, these are not usually the underlying cause of duodenal ulcers.
Other Risk Factors Include:
Stress and Psychological Factors: Although stress is no longer considered a cause of ulcers, studies still suggest that stress may predispose a person to ulcers or prevent existing ulcers from healing. Some even believe that the anecdotal relationship between stress and ulcers is so strong that treatment of psychological factors is warranted in people with ulcers.
Smoking: Smoking increases acid secretion, reduces prostaglandin and bicarbonate production, and decreases mucosal blood flow. Results of studies on the actual effect of smoking on ulcers, however, are mixed. Some evidence suggests that smoking delays the healing of gastric and duodenal ulcers. Other studies have found no increased risk for ulcers in smokers. In any case, any impact of smoking on ulcers does not seem to be affected by the presence of H. pylori. Tobacco use and exposure may cause an acceleration of coronary artery disease and peptic ulcer disease. It is also linked to reproductive disturbances, esophageal reflux, hypertension, fetal illness and death, and delayed wound healing.
Medical and Family History: The doctor will ask for a thorough report of a patient's dyspepsia and other important symptoms, such as weight loss or fatigue, present and past medication use (especially chronic use of NSAIDs), family members with ulcers, and drinking and smoking habits.
A test to detect H. Pylori: A test to detect the H. pylori bacterium is usually done if you have a duodenal ulcer. If H. pylori is found then it is likely to be the cause of the ulcer. See separate leaflet on Helicobacter Pylori Infection for more detail and how it can be diagnosed. Briefly, it can be detected in a sample of faeces, or in a 'breath test', or from a blood test, or from a biopsy sample taken during an endoscopy.
In order to detect an ulcer, you may have to undergo diagnostic tests, such as:
Blood test: This test checks for the presence of H. pylori antibodies. A disadvantage of this test is that it sometimes can't differentiate between past exposure and current infection. Additionally, a false-negative is possible if you've recently been taking certain drugs, such as antibiotics or proton pump inhibitors.
Breath test: This procedure uses a radioactive carbon atom to detect H. pylori. For the test, you drink a small glass of clear, tasteless liquid. The liquid contains radioactive carbon as part of a substance (urea) that will be broken down by H. pylori. Less than an hour later, you blow into a bag, which is then sealed. If you're infected with H. pylori, your breath sample will contain the radioactive carbon in the form of carbon dioxide.
The advantage of the breath test is that it can monitor the effectiveness of treatment used to eradicate H. pylori, detecting whether the bacteria have been killed or eradicated.
Stool antigen test: This test checks for H. pylori in stool samples. It's useful both in helping to diagnose H. pylori infection and in monitoring the success of treatment.
Upper gastrointestinal (upper GI) X-ray: This test outlines your esophagus, stomach and duodenum. During the X-ray, you swallow a white, metallic liquid (containing barium) that coats your digestive tract and makes an ulcer more visible. An upper GI X-ray can detect some ulcers, but not all.
Endoscopy: This procedure may follow an upper GI X-ray if the X-ray suggests a possible ulcer, or your doctor may perform endoscopy first. In this more sensitive procedure, a long, narrow tube with an attached camera is threaded down your throat and esophagus into your stomach and duodenum. With this instrument, your doctor can view your upper digestive tract and identify an ulcer. Your doctor will perform this test if you have other signs or symptoms, such as difficulty swallowing, weight loss, vomiting (particularly vomiting red or black material that looks like coffee grounds), black stools or anemia.
- Pain in the upper abdomen just below the sternum (breastbone) is the common symptom. It usually comes and goes. It may occur most before meals, or when you are hungry. It may be eased if you eat food, or take antacid tablets. The pain may wake you from sleep.
- Other symptoms which may occur include: bloating, retching, and feeling sick. You may feel particularly 'full' after a meal. Sometimes food makes the pain worse.
- Complications occur in some cases, and can be serious this include bleeding ulcer.
- Perforation: This is where the ulcer goes right through ('perforates') the wall of the duodenum. Food and acid in the duodenum then leak into the abdominal cavity. This usually causes severe pain and is a medical emergency.
Deciding which treatment is best for patients with symptoms of dyspepsia or peptic ulcer disease depends on a number of factors. An endoscopy to identify any ulcers, and to perform the most accurate test for H. pylori, probably gives the best guidance for treatment. However, dyspepsia is such a common reason for a doctor's visit that many people are treated initially based on symptoms and blood or breath H. pylori test results. This approach (called test and treat) is considered an appropriate option for most patients. Those with any evidence of bleeding, with other alarm symptoms, and who are older than 55 years of age should have an endoscopy performed first.
Acid suppressing medication: A 4-8 week course of a drug that greatly reduces the amount of acid that your stomach makes is usually advised. The most commonly used drug is a proton pump inhibitor (PPI). These are a class (group) of drugs that work on the cells that line the stomach, reducing the production of acid. They include: esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole, and come in various brand names. Sometimes a drug from another class of drugs called H2 blockers is used. H2 blockers work in a different way on the cells that line the stomach, reducing the production of acid. They include: cimetidine, famotidine, nizatidine and ranitidine, and come in various brand names. As the amount of acid is greatly reduced, the ulcer usually heals. However, this is not the end of the story.
If your ulcer was caused by H. pylori: Nearly all duodenal ulcers are caused by infection with H. pylori. Therefore, a main part of the treatment is to clear this infection. If this infection is not cleared, the ulcer is likely to return once you stop taking acid-suppressing medication. Two antibiotics are needed. In addition, you need to take an acid-suppressing drug to reduce the acid in the stomach. This is needed to allow the antibiotics to work well. You need to take this 'combination therapy' (sometimes called 'triple therapy') for a week.
One course of combination therapy clears H. pylori infection in up to 9 in 10 cases. If H. pylori is cleared, the chance of a recurrence of a duodenal ulcer is greatly reduced. However, in a small number of people H. pylori infection returns at some stage in the future.
After treatment, a test to check that H. Pylori has gone may be advised. If it is done it needs to be done at least four weeks after the course of combination therapy has finished. In most cases, the test is 'negative' meaning that the infection has gone. If it has not gone, then a repeat course of combination therapy with a different set of antibiotics may be advised. Some doctors say that for people with a duodenal ulcer, this 'confirmation' test is not necessary if symptoms have gone. The fact that symptoms have gone usually indicates that the ulcer and the cause (H. pylori) have gone. But, some doctors say it is needed to play safe. Your own doctor will advise if you should have it. (Note: a test to confirm that H pylori has gone is usually always recommended if you have a stomach ulcer.)
If your ulcer was caused by an anti-inflammatory drug: If possible, you should stop the anti-inflammatory drug. This allows the ulcer to heal. You will also normally be prescribed an acid-suppressing drug for several weeks (as mentioned above). This stops the stomach from making acid and allows the ulcer to heal.
However, in many cases the anti-inflammatory drug is needed to ease symptoms of arthritis or other painful conditions, or aspirin is needed to protect against blood clots. In these situations, one option is to take an acid-suppressing drug each day indefinitely. This reduces the amount of acid made by the stomach, and greatly reduces the chance of an ulcer forming again.
Surgery: In the past, surgery was commonly needed to treat a duodenal ulcer. This was before it was discovered that H. pylori was the cause of most duodenal ulcers, and before modern acid-suppressing drugs became available. Surgery is now usually only needed if a complication of a duodenal ulcer develops such as severe bleeding or a perforation.
Duodenal ulcers respond well to treatment, but changes in lifestyle may be recommended to prevent reoccurrences. Patients should consider not smoking or using other tobacco products and reduce their alcohol consumption and caffeine intake. Patients may also want to avoid drugs that cause stomach inflammation, such as aspirin, ibuprofen and naproxen. Other lifestyle changes may include eating balanced, nutritious meals, learning how to manage stress, and getting plenty of rest and exercise.
Medicine and medications:
The following drugs are sometimes used in the treatments of peptic ulcers caused by either NSAIDs or H. pylori.
: Many antacids are available without prescription and are the first drugs recommended to relieve heartburn and mild dyspepsia. They play no major role in either the prevention or healing of ulcers, but help in the following ways:
- They neutralize stomach acid by relying on various combinations of three basic compounds -- magnesium, calcium, or aluminum.
- They may defend the stomach by increasing bicarbonate and mucus secretion. (Bicarbonate is an acid-buffering substance.)
: H. pylori is usually highly sensitive to certain antibiotics, particularly amoxicillin, and to antibiotics in the macrolide class, such as clarithromycin. Either class of antibiotics serves effectively as a second antibiotic in a three-drug regimen. Other antibiotics that are sometimes used include tetracycline, metronidazole, and ciprofloxacin.
- Amoxicillin is a form of penicillin. It is inexpensive, but some people are allergic to it.
- Clarithromycin (Biaxin) is a macrolide and is the most expensive antibiotic used against H. pylori. It is very effective, but there is growing bacterial resistance to this drug. Resistance rates tend to be higher in women and increase with age. Researchers fear that resistance will increase as more people use the drug.
- Tetracycline is effective, but this medicine has unique side effects, including tooth discoloration in children. Pregnant women cannot take tetracycline.
- Ciprofloxacin (Cipro), a fluoroquinolone, is also sometimes used in ulcer regimens.
- Metronidazole (Flagyl) was the mainstay in initial combination regimens for H. pylori. As with clarithromycin, however, there continues to be growing bacterial resistance to the drug. Today, about 25 - 35% of H. pylori bacteria are metronidazole-resistant.
Side Effects of Antibiotics:
The most common side effects of nearly all antibiotics are gastrointestinal problems such as cramps, nausea, vomiting, and diarrhea. Allergic reactions can also occur with all antibiotics, but are most common with medications derived from penicillin or sulfa. These reactions can range from mild skin rashes to rare, but severe -- even life-threatening -- anaphylactic shock.
3. Proton-Pump Inhibitors (PPIs):
PPIs are the drugs of choice for managing patients with peptic ulcers, regardless of the cause. They suppress the production of stomach acid by blocking the gastric acid pump -- the molecule in the stomach glands that is responsible for acid secretion.
PPIs can be used either as part of a multidrug regimen for H. pylori or alone for preventing and healing NSAID-caused ulcers. They are also useful in treating ulcers caused by Zollinger-Ellison syndrome. They are considered to be more effective than H2 blockers (see below).
Standard Brands. Most PPIs are available by prescription as oral drugs. Brands approved for ulcer prevention and treatment include:
- Omeprazole (generic, Prilosec OTC).
- Esomeprazole (Nexium).
- Lansoprazole (Prevacid).
- Rabeprazole (Aciphex).
Possible Adverse Effects: Side effects are uncommon, but may include headache, diarrhea, constipation, nausea, and itching. Pregnant women and nursing mothers should avoid taking PPIs. Although recent studies suggest that these drugs do not increase the risk of birth defects, their safety during pregnancy is not yet proven. PPIs may interact with certain drugs, such as antiseizure agents (such as phenytoin), antianxiety drugs (such as diazepam), and blood thinners (such as warfarin). Long-term use of high-dose PPIs may produce vitamin B12 deficiency, but more studies are needed to confirm this risk.
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.
4. H2 Blockers
: H2 blockers interfere with acid production by blocking histamine, a substance produced by the body that encourages acid secretion in the stomach. H2 blockers were the standard treatment for peptic ulcers until proton pump inhibitor and antibiotic regimens against H. pylori were developed. These drugs cannot cure ulcers, but they are useful in certain cases. They are effective only for duodenal ulcers, however.
Four H2 blockers are currently available over-the-counter in the U.S.: famotidine (Pepcid AC), cimetidine (Tagamet), ranitidine (Zantac), and nizatidine (Axid). All have good safety profiles and few side effects.
: Misoprostol (Cytotec) increases prostaglandin levels in the stomach lining, which protects against the major intestinal toxicity of NSAIDs.
Misoprostol can reduce the risk of NSAID-induced ulcers in the upper small intestine by two-thirds and in the stomach by three-fourths. It does not neutralize or reduce acid, so although the drug is helpful for preventing NSAID-induced ulcers, it is not useful in healing existing ulcers.
Side Effects: Misoprostol can induce abortion or cause birth defects and should not be taken by pregnant women. If pregnancy occurs during treatment, the drug should be discontinued at once and the doctor contacted immediately. Diarrhea and other gastrointestinal problems are severe enough to cause 20% of patients to stop taking the drug. Taking misoprostol after meals should minimize these effects. One study indicated that taking the drug 2 - 3 times a day, instead of the standard regimen of 4 times, may prove to be just as effective and cause fewer side effects.
Sucralfate: Sucralfate (Carafate) seems to work by adhering to the ulcer crater and protecting it from further damage by stomach acid and pepsin. It also promotes the defensive processes of the stomach. Sucralfate has an ulcer-healing rate similar to that of H2 blockers. Other than constipation, which occurs in 2.2% of patients, the drug has few side effects. Sucralfate does interact with a wide variety of drugs, however, including warfarin, phenytoin, and tetracycline.