Peptic Ulcer [Gastric Ulcer, Duodenal Ulcer]

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.


Causes

Most peptic ulcers are caused by the bacteria 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 the following:

• H. pylori bacteria
• NSAIDs, which hinder the body's ability to protect the stomach lining
• Diseases that cause an increase in acid production, 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 chances of getting a disease or condition.
Risk factors for ulcer from H. pylori infection include the following:

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

Risk factors for ulcer from anti-inflammatory drugs include the following:

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

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 the following:

• Gnawing pain

1.  May awaken you from sleep
2. May change when you eat
3. May last for a few minutes or several hours
4. Feels like unusually strong hunger pangs

• Nausea
• Vomiting
• Loss of appetite
• Bloating
• Burping

Ulcers can result in serious complications and severe abdominal pain. Complications include the following:

• Bleeding, which may occur with no other symptoms. Symptoms of bleeding include:

• Black, tarry stools
• Vomiting up 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 the passage of food through the digestive system. Symptoms of scar tissue blockage include the following:

• Vomiting
• Weight loss
• Intense pain

Diagnosis

The doctor will ask about your symptoms and medical history, and perform a physical exam. Tell your doctor about all medications that 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 the procedure, the doctor can take tissue samples to test for H. pylori infection or for cancer.

Treatment

The goals of treatment are to eliminate the source of the problem and heal the ulcer. Gastric ulcers may take longer to heal than duodenal ulcers.
Treatments include the following:

Medication
Some medications block or reduce acid production and some coat the ulcer, protecting it. If H. pylori caused the ulcer, you will need to take a combination of drugs to eliminate the bacteria. This usually consists of at least 2 to 3 antibiotics and a bismuth-containing drug and/or a proton-pump inhibitor. It is very important to take these drugs exactly as directed. The doctor may order tests 6 to 12 months after treatment to verify that the bacteria are gone.
Medications may include the following:
• Antacids (don't heal ulcers, but may provide some relief from heartburn.)
• Antibiotics (amoxicillin, tetracycline, clarithromycin)
• Bismuth-containing drug (Pepto-Bismol)
• Proton pump inhibitors (to decrease stomach acid production [omeprazole, lansoprazole])
• H2 blockers (to decrease stomach acid production [famotidine, ranitidine, cimetidine, nizatidine])
• Medications to protectively 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 increase 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

Surgery may be necessary if you have bleeding, a perforation, or an obstruction. Surgical options include the following:

• Endoscopic surgery – 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 area of bleeding to help stop the 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, a means of drainage must be created. Drainage may be done with one of the following:

1.  Pyloroplasty – widening of the opening between the stomach and the first part of the small intestine (called the duodenum), allowing stomach contents to flow more easily into the intestine.
2. Gastroduodenostomy – creation of a new opening to connect the stomach and the duodenum.
3. Gastrojejunostomy – creation of a new opening to connect the stomach and the jejunum (the second part of the small intestine).

• Highly elective vagotomy – a technique that cuts only part of the vagus nerve. This type of surgery does not require extra means of drainage.
• Vagotomy with antrectomy – cutting of the vagus nerve combined with removal of the lower part of the stomach (antrum). The antrum produces a chemical that promotes acid production. Without that chemical, acid production drops.

Prevention

To decrease 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 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 taking other drugs to protect your stomach and intestine lining.
• Don't smoke. Cigarette smoking increases the chances of getting an ulcer.