Peptic ulcer

Definition

A peptic ulcer is erosion in the lining of the stomach or the first part of the small intestine, an area called the duodenum.

If the peptic ulcer is located in the stomach it is called a gastric ulcer.

See also:

• Gastritis
• Gastroesophageal reflux disease (GERD)

Alternative Names

Ulcer - peptic; Ulcer - duodenal; Ulcer - gastric; Duodenal ulcer; Gastric ulcer; Dyspepsia - ulcers

Causes, incidence, and risk factors

Normally, the lining of the stomach and small intestines are protected against the irritating acids produced in your stomach. If this protective lining stops working correctly, and the lining breaks down, it results in inflammation (gastritis) or an ulcer.

Most ulcers occur in the first layer of the inner lining. A hole that goes all the way through the stomach or duodenum is called a perforation. A perforation is a medical emergency.

The most common cause of such damage is infection of the stomach by bacteria called Helicobacter pylori (H.pylori). Most people with peptic ulcers have these bacteria living in their gastrointestinal (GI) tract. Yet, many people who have such bacteria in their stomach do not develop an ulcer.

The following also raise your risk for peptic ulcers:

• Drinking too much alcohol
• Regular use of aspirin, ibuprofen, naproxen, or other nonsteroidal anti-inflammatory drugs (NSAIDs). Taking aspirin or NSAIDs once in awhile is safe for most people.
• Smoking cigarettes or chewing tobacco
• Being very ill, such as being on a breathing machine
• Radiation treatments

A rare condition called Zollinger-Ellison syndrome causes stomach and duodenal ulcers. Persons with this disease have a tumor in the pancreas that releases high levels of a hormone, which causes an increase in stomach acid.

Many people believe that stress causes ulcers. It is not clear if this is true, at least for everyday stress at home.

Symptoms

Small ulcers may not cause any symptoms. Some ulcers can cause serious bleeding.

Abdominal pain is a common symptom but it doesn't always occur. The pain can differ a lot from person to person.

• Feeling of fullness -- unable to drink as much fluid
• Hunger and an empty feeling in the stomach, often 1 - 3 hours after a meal
• Mild nausea (vomiting may relieve symptom)
• Pain or discomfort in the upper abdomen
• Upper abdominal pain that wakes you up at night

Other possible symptoms include:

• Bloody or dark tarry stools
• Chest pain
• Fatigue
• Vomiting, possibly bloody
• Weight loss

Signs and tests

To diagnose an ulcer, your doctor will order one of the following tests:

• Esophagogastroduodenoscopy (EGD) is a special test performed by a gastroenterologist in which a thin tube with a camera on the end is inserted through your mouth into the GI tract to see your stomach and small intestine. During an EGD, the doctor may take a biopsy from the wall of your stomach to test for H. pylori.
• Upper GI is a series of x-rays taken after you drink a thick substance called barium.

Your doctor may also order these tests:

• Hemoglobin blood test to check for anemia
• Stool guaiac to test for blood in your stool

Treatment

Treatment involves a combination of medications to kill the H. pylori bacteria (if present), and reduce acid levels in the stomach. This strategy allows your ulcer to heal and reduces the chance it will come back.

Take all of your medications exactly as prescribed.

If you have a peptic ulcer with an H. pylori infection, the standard treatment uses different combinations of the following medications for 5 - 14 days:

• Two different antibiotics to kill H. pylori, such as clarithromycin (Biaxin), amoxicillin, tetracycline, or metronidazole (Flagyl)
• Proton pump inhibitors such as omeprazole (Prilosec), lansoprazole (Prevacid), or esomeprazole (Nexium)
• Bismuth (the main ingredient in Pepto-Bismol) may be added to help kill the bacteria

If you have an ulcer without an H. pylori infection, or one that is caused by taking aspirin or NSAIDs, your doctor will likely prescribe a proton pump inhibitor for 8 weeks.

You may also be prescribed this type of medicine if you must continue taking aspirin or NSAIDs for other health conditions.

Other medications that may be used for ulcer symptoms or disease are:

• Misoprostol, a drug that may help prevent ulcers in people who take NSAIDs on a regular basis
• Medications that protect the tissue lining (such as sucralfate)

If a peptic ulcer bleeds a lot, an EGD may be needed to stop the bleeding. Surgery may be needed if bleeding cannot be stopped with an EGD, or if the ulcer has caused a perforation.

Support Groups

Expectations (prognosis)

Peptic ulcers tend to come back if untreated. If you follow your doctor's treatment instructions and take all of your medications as directed, the H. pylori infection will be cured and you'll be much less likely to get another ulcer.

Complications

• Bleeding inside the body (internal bleeding)
• Gastric outlet obstruction
• Inflammation of the tissue that lines the wall of the abdomen (peritonitis)
• Perforation of the stomach and intestines

Calling your health care provider

Call 911 if you:

• Develop sudden, sharp abdominal pain
• Have a rigid, hard abdomen that is tender to touch
• Have symptoms of shock such as fainting, excessive sweating, or confusion
• Vomit blood or have blood in your stool (especially if it's maroon or dark, tarry black)

Call your doctor if:

• You feel dizzy or light-headed
• You have ulcer symptoms

Prevention

Avoid aspirin, ibuprofen, naproxen, and other NSAIDs. Try acetaminophen instead. If you must take such medicines, talk to your doctor first. Your doctor may:

• Test you for H. pylori first
• Have you take proton pump inhibitors (PPIs) or an acid blocker
• Have you take a drug called Misoprostol

The following lifestyle changes may help prevent peptic ulcers:

• Do not smoke or chew tobacco.
• Limit alcohol to no more than two drinks per day.

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References

Ramakrishnan K, Salinas RC. Peptic ulcer disease. Am Fam Physician. 2007;76(7):1005-12.

Chey WD, Wong BC. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. Aug 2007;102(8):1808-25.

Malagelada JR, Kuipers EJ, Blaser MJ. Acid peptic disease: clinical manifestations, diagnosis, treatment, and prognosis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 142.

Lanza FL, Chan FK, Quigley EM: Practice Parameters Committee of the American College of Gastroenterology. Guidelines for prevention of NSAID-related ulcer complications. Am J Gastroenterol. 2009;104:728-738.