Peptic Ulcer

Peptic Ulcer Definition Too much stress, too much spicy food, and you may be headed for an ulcer — that was the way the thinking used to go. Peptic ulcers are open sores that develop on the inside lining of your stomach, upper small intestine or esophagus. The most common symptom of a peptic ulcer is pain. Not long ago, the common belief was that peptic ulcers were a result of lifestyle. Doctors now know that a bacterial infection or some medications — not stress or diet — cause most ulcers of the stomach and upper part of the small intestine (duodenum). Esophageal ulcers also may occur and are typically associated with the reflux of stomach acid. Peptic ulcers are common, and oftentimes successful treatment of peptic ulcers takes just a few weeks.

Symptoms Burning pain is the most common peptic ulcer symptom. The pain is caused by the ulcer and is aggravated by stomach acid coming in contact with the ulcerated area. The pain typically may:      

Be felt anywhere from your navel to your breastbone Last from a few minutes to many hours Be worse when your stomach is empty Flare at night Often be temporarily relieved by eating certain foods that buffer stomach acid or by taking an acid-reducing medication Come and go for a few days or weeks

Less often, ulcers may cause severe signs or symptoms such as:     

The vomiting of blood — which may appear red or black Dark blood in stools or stools that are black or tarry Nausea or vomiting Unexplained weight loss Chest pain

Causes Ulcers

Depending on their location, peptic ulcers have different names:   

Gastric ulcer. This is a peptic ulcer that occurs in your stomach. Duodenal ulcer. This type of peptic ulcer develops in the first part of the small intestine (duodenum). Esophageal ulcer. An esophageal ulcer is usually located in the lower section of your esophagus. It's often associated with chronic gastroesophageal reflux disease (GERD).

The culprit in most cases Although stress and spicy foods were once thought to be the main causes of peptic ulcers, doctors now know that the cause of most ulcers is the corkscrew-shaped bacterium Helicobacter pylori (H. pylori). H. pylori lives and multiplies within the mucous layer that covers and protects tissues that line the stomach and small intestine. Often, H. pylori causes no problems. But sometimes it can disrupt the mucous layer and inflame the lining of the stomach or duodenum, producing an ulcer. One reason may be that people who develop peptic ulcers already have damage to the lining of the stomach or small intestine, making it easier for bacteria to invade and inflame tissues. H. pylori is a common gastrointestinal infection around the world. In the United States, one in five people younger than 30 and half the people older than 60 are infected. Although it's not clear exactly how H. pylori spreads, it may be transmitted from person to person by close contact, such as kissing. People may also contract H. pylori through food and water. H. pylori is the most common, but not the only, cause of peptic ulcers. Besides H. pylori, other causes of peptic ulcers, or factors that may aggravate them, include:

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Regular use of pain relievers. Nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate or inflame the lining of your stomach and small intestine. The medications are available both by prescription and over-thecounter. Nonprescription NSAIDs include aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve) and ketoprofen (Orudis KT). To help avoid digestive upset, take NSAIDs with meals. NSAIDs inhibit production of an enzyme (cyclooxygenase) that produces prostaglandins. These hormone-like substances help protect your stomach lining from chemical and physical injury. Without this protection, stomach acid can erode the lining, causing bleeding and ulcers.

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Smoking. Nicotine in tobacco increases the volume and concentration of stomach acid, increasing your risk of an ulcer. Smoking may also slow healing during ulcer treatment. Excessive alcohol consumption. Alcohol can irritate and erode the mucous lining of your stomach and increases the amount of stomach acid that's produced. It's uncertain, however, whether this alone can progress into an ulcer or whether other contributing factors must be present, such as H. pylori bacteria or ulcer-causing medications, such as NSAIDs. Stress. Although stress per se isn't a cause of peptic ulcers, it's a contributing factor. Stress may aggravate symptoms of peptic ulcers and, in some cases, delay healing. You may undergo stress for a number of reasons — an emotionally disturbing circumstance or event, surgery, or a physical trauma, such as a burn or other severe injury.

When to seek medical advice An ulcer isn't something that you should treat on your own, without a doctor's help. Over-the-counter antacids and acid blockers may relieve the gnawing pain, but the relief is short-lived. If you have signs or symptoms of an ulcer, see your doctor. With a doctor's help, you can find prompt relief of ulcer pain as well as a complete healing of the ulcer.

Tests and diagnosis In order to detect an ulcer, your doctor may have you undergo the following diagnostic tests: 

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Upper gastrointestinal (upper GI) X-ray. Your doctor may begin with this test, which outlines your esophagus, stomach and duodenum. During the Xray, 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.

If your doctor detects an ulcer, he or she may remove small tissue samples (biopsy) near the ulcer. These samples are examined under a microscope to rule out cancer. A

biopsy can also identify the presence of H. pylori in your stomach lining. Depending on where the ulcer is found, your doctor may recommend a repeat endoscopy after two to three months to confirm that the ulcer is healing. Additional tests In addition to a biopsy, these other tests can determine if the cause of your ulcer is H. pylori infection: 

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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. After H. pylori bacteria have been eradicated, you may still have a positive result for many months. Breath test. This procedure uses a radioactive carbon atom to detect H. pylori. First, you blow into a small plastic bag, which is then sealed. Then, 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. Thirty minutes later, you blow into a second bag, which also is sealed. If you're infected with H. pylori, your second 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 when the bacteria have been killed or eradicated. With the blood test, H. pylori antibodies may sometimes still be present a year or more after the infection is gone.

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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.

Complications Left untreated, peptic ulcers can cause internal bleeding and can eat a hole through the wall of your stomach or small intestine, putting you at risk of serious infection of your abdominal cavity (peritonitis). Peptic ulcers can also produce scar tissue that can obstruct passage of food through the digestive tract, causing you to become full easily, to vomit and to lose weight.

Treatments and drugs Because many ulcers stem from H. pylori bacteria, doctors use a two-pronged approach to peptic ulcer treatment:  

Kill the bacteria. Reduce the level of acid in your digestive system to relieve pain and encourage healing.

Accomplishing these two goals requires the use of at least two, and sometimes three or four, of the following medications:

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Antibiotic medications. Doctors use combinations of antibiotics to treat H. pylori because one antibiotic alone isn't sufficient to kill the organism. For the treatment to work, it's essential that you follow your doctor's instructions precisely. Antibiotics commonly prescribed for treatment of H. pylori include amoxicillin (Amoxil), clarithromycin (Biaxin) and metronidazole (Flagyl). Some companies package a combination of two antibiotics together, with an acid suppressor or cytoprotective agent specifically for treatment of H. pylori infection. These combination treatments are sold under the names Prevpac and Helidac. You'll likely need to take antibiotics for two weeks, depending on their type and number. Other medications prescribed in conjunction with antibiotics generally are taken for a longer period. Acid blockers. Acid blockers — also called histamine (H-2) blockers — reduce the amount of hydrochloric acid released into your digestive tract, which relieves ulcer pain and encourages healing. Acid blockers work by keeping histamine from reaching histamine receptors. Histamine is a substance normally present in your body. When it reacts with histamine receptors, the receptors signal acid-secreting cells in your stomach to release hydrochloric acid. Available by prescription or over-the-counter (OTC), acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet) and nizatidine (Axid). Antacids. Your doctor may include an antacid in your drug regimen. An antacid may be taken in addition to an acid blocker or in place of one. Instead of reducing acid secretion, antacids neutralize existing stomach acid and can provide rapid pain relief. Proton pump inhibitors. Another way to reduce stomach acid is to shut down the "pumps" within acid-secreting cells. Proton pump inhibitors reduce acid by blocking the action of these tiny pumps. These drugs include the prescription medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex) and esomeprazole (Nexium). The drug pantoprozole (Protonix) can be taken orally or administered intravenously in the hospital. Proton pump inhibitors are frequently prescribed to promote the healing of peptic ulcers. If you are admitted to the hospital with a bleeding ulcer, taking intravenous proton pump inhibitors decreases the chance that bleeding will recur. Proton pump inhibitors also appear to inhibit H. pylori. However, long-term use of proton pump inhibitors, particularly at high doses, may increase your risk of hip fracture. Cytoprotective agents. In some cases, your doctor may prescribe these medications that help protect the tissues that line your stomach and small intestine. They include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec). Another nonprescription cytoprotective agent is bismuth subsalicylate (Pepto-Bismol). In addition to protecting the lining of your stomach and intestines, bismuth preparations appear to inhibit H. pylori activity.

If H. pylori isn't identified in your system, then it's likely that your ulcer is due to NSAIDs — which you should quit using, if possible — or acid reflux, which can cause esophageal ulcers. In both cases, your doctor will try to reduce acid levels — through use of acid blockers, antacids or proton pump inhibitors — and may also have you use cytoprotective drugs.

Ulcers that fail to heal Peptic ulcers that don't heal with treatment are called refractory ulcers. There are many reasons why an ulcer may fail to heal. Not taking medications according to directions is one reason. Another is that some types of H. pylori are resistant to antibiotics. Other factors that can interfere with the healing process include regular use of tobacco, alcohol or nonsteroidal anti-inflammatory drugs (NSAIDs). Sometimes the problem is accidental: People are unaware that a medication they're taking contains an NSAID. In rare cases, refractory ulcers may be a result of:    

Extreme overproduction of stomach acid, such as occurs in Zollinger-Ellison syndrome An infection other than H. pylori Stomach cancer Other digestive diseases, including Crohn's disease or cancer

Treatment for refractory ulcers generally involves eliminating factors that may interfere with healing, along with stronger doses of ulcer medications. Sometimes, additional medications may be included. Surgery to help heal an ulcer is necessary only when the ulcer doesn't respond to aggressive drug treatment.

Lifestyle and home remedies Before the discovery of H. pylori, doctors often advised people with ulcers to eat a restricted diet and reduce the amount of stress in their lives. Now that food and stress have been eliminated as direct causes of ulcers, these factors are no longer of as much importance. However, while an ulcer is healing, it's still advisable to watch what you eat and to control stress. Acidic or spicy foods may increase ulcer pain. The same is true for stress. Stress may increase acid and slow digestion, allowing food and digestive acid to remain in your stomach and intestines for a longer period. If stress is severe, it may delay the healing of an ulcer. Your doctor may also give you this advice: 

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Don't smoke. Smoking may interfere with the protective lining of the stomach, making your stomach more susceptible to the development of an ulcer. Smoking also increases stomach acid. Limit or avoid alcohol. Excessive use of alcohol can irritate and erode the mucous lining in your stomach and intestines, causing inflammation and bleeding. Avoid nonsteroidal anti-inflammatory drugs (NSAIDs). If you use pain relievers regularly, use acetaminophen (Tylenol, others). Control acid reflux. If you have an esophageal ulcer — usually associated with acid reflux — you can take several steps to help manage acid reflux. These include avoiding spicy and fatty foods, avoiding reclining after meals for at least three hours, raising the head of your bed and reducing your weight. Avoiding smoking, alcohol and NSAIDs also may help to control acid reflux.