disease, intestinal ulcer, just ulcer disease; also see gastric ulcer |
- Peptic ulcers are areas of weakness or "depressions" that develop in the wall of the stomach or intestines, causing pain or discomfort. In a few cases they can bleed, tear open, or cause a blockage. Treatment is usually done with medicines, so surgery is very rarely needed.
- Peptic Ulcer Disease
is a broad description of any process that causes an
ulcer to form in the stomach or intestines. If the ulcer
is in the stomach, it is known as a gastric ulcer. If
it is in the first part of the intestines, then it is called
a duodenal ulcer. There are over half a million
new cases diagnosed each year and up to 4 million people have
a flare up of the disease each year. About 1 out
of every 10 people will at some time in life have an
ulcer. Ulcers are found in the intestines 5 times as
often as they are in the stomach. Ulcers occur more
often in men, in smokers, and in those using medications
that weaken the lining of the stomach and intestines.
- Duodenal ulcers usually occur in younger people, while gastric ulcers occur in older age groups. It is still not clear what, if any, role stress plays in the development of ulcers. Alcohol and diet are not felt to play a very important role in the formation of ulcers. Some ulcers are caused by an organism called Helicobacter pylori, some are due to medications, and a few are caused by stomach or intestinal cancer. Therefore, treatment and long-term outcome depends on the cause of the ulcer.
- Almost all people will have pain in
the upper, central part of the abdomen (just under the
breastbone). The pain can be a dull ache, throbbing,
sharp, burning, "gas-like," cramping, etc. However,
the pain can occur in almost any part of the abdomen.
- Often the pain associated with Peptic Ulcer Disease
comes and goes. Some people notice that the pain gets
worse after eating spicy foods. Also, many will notice
that over the counter antacids help relieve their
symptoms. Some people will feel better after eating,
while, in others, the pain may increase after meals.
- Many will complain of stomach pain
that wakes them up in the middle of the night -- usually
between 2 and 4 am.
- Nausea and vomiting
- Because of the stomach pain, some
lose their appetite and lose weight.
- In a few cases where the ulcers are
more severe, the pain may radiate or move to the back.
- Not all people with these symptoms have a true ulcer. In fact, of all the people who have upper abdominal pain, only a minority has real ulcers. Most have a condition known as Gastritis or
- Some will have chest pain or back
- If the ulcer causes a lot of
inflammation, a blockage may develop. Please see the
"Complications" section below.
- A few will have intestinal or stomach bleeding as their first symptom. There can be vomiting of blood or coffee-grounds like material. Others may complain of passing stools that are either red or black.
- In people with ulcers due to NSAIDs,
up to half may not have any symptoms at all.
- There are many things that can cause Peptic Ulcer Disease.
- The major causes of Peptic Ulcer Disease are Helicobacter pylori, NSAIDs, acid hypersecretion, and cancer.
- Stress, diet, and alcohol are not felt to directly cause ulcers.
- Helicobacter pylori -- this is a bacteria that is felt to cause many ulcers.
- H. pylori is a bacterium that
lives in the stomach
- H. pylori is involved in the development of the majority of duodenal and gastric ulcers not caused by NSAIDs.
- Destroying this bacterium with antibiotics leads to a much higher success rate in the treatment of ulcers.
- People who are treated for this infection also have much lower rates of the ulcer's returning.
- When the organism is not destroyed, up to 80% of people will have a recurrence of their ulcer. When the organism is treated and destroyed, only about 10-20% of people will have a recurrence of the ulcer.
- However, only one out of every
six people who have these bacteria in the stomach will ever
develop an ulcer.
- NSAIDs-this stands for nonsteroidal
- This is a group of medicines that includes things such as ibuprofen, naproxen, indomethacin, etc. These drugs are most often used to treat arthritis, headaches, back pain, and other conditions that cause pain and inflammation.
- It is felt that NSAIDs cause ulcers by decreasing the protective lining of the stomach and intestines.
- NSAIDs dramatically increase the risk of gastric ulcers.
- People who take NSAIDs for a prolonged period are 40 times more likely to develop gastric ulcers compared to those who do not take NSAIDS.
- People who take NSAIDs have a higher chance of developing complications such a bleeding or perforation.
- The risk of developing ulcers is higher in those over 70 years, those taking higher doses of NSAIDs, those with a previous history of ulcers, in those people who are on blood thinners or steroids, and in those with severe medical problems.
- Aspirin is the worst of all of the NSAIDs with respect to causing ulcers.
- There are newer NSAIDs that are
being used, such as etodolac and celecoxib, that have a
lower risk of developing ulcers. These medicines
help reduce pain and inflammation, but do not weaken the
stomach lining as much as other NSAIDs. Though they
are safer, there is still a risk of developing
- Zollinger-Ellison Syndrome is a condition that leads to excess acid production. This can overwhelm the protective layer in the stomach and intestines and lead to ulcers. Please look up the section on Zollinger-Ellison Syndrome for more information.
- In a few cases, the ulcer is
actually due to a cancer in the stomach or intestine.
- The best way to diagnose ulcers is
by an endoscopy. In this test, a camera is used to
look into the stomach. The doctor can look at the
lining of the stomach and intestines to see if an ulcer is
present. The doctor can also do a biopsy if needed
and, in some cases, stop any bleeding that may be present.
- All gastric ulcers must be
biopsied. This is because there is a high risk of
gastric ulcers' being caused by cancer.
- If there is any suspicion of
cancer, then people with gastric ulcers need to have a
repeat endoscopy within about 12 weeks after starting
treatment to make sure that the ulcer has completely healed.
- Duodenal ulcers are almost never
due to cancer. Therefore, they are usually not
biopsied for cancer testing purposes.
- However, biopsies are often done on
all ulcers in order to test for H. pylori. If H.
pylori is present then treatment is different.
Therefore, this is a very important diagnostic test.
- Another test that can be done to diagnose an ulcer is an upper GI series. In this test, the person is given barium and then X-Rays are taken to see if
there is an ulcer. This test is not as accurate as an
endoscopy, but it is less invasive. If a gastric ulcer
is detected, the patient is treated, and after about 12
weeks to make sure that the ulcer has healed, an endoscopy
All people with ulcers need to be tested for
H. pylori. There are many ways to test for this
- If an endoscopy is performed, then a biopsy is done, and the sample is tested for the presence of H. pylori.
- If the ulcer is detected by an upper GI, then a breath test can be done to see if the organism is present.
- Blood tests are also available
that detect the presence of antibodies to the
bacteria. This is a very convenient test, but it is
not the best option because it can be abnormal even if the
organism is not causing an active infection.
However, in some cases, antibody levels are followed over
a long period of time to see if the infection has been
- Blood tests are usually normal in
most cases of ulcer disease in which there is no
- If there is a complication, then
you may see abnormal blood tests. For example, if the
person develops a bleeding ulcer, they may be anemic.
If the ulcer tears a hole through the stomach, then the
person will be very ill with a high white blood count.
- X-Rays may show air in the
- In cases where Zollinger-Ellison Syndrome is suspected, a Gastrin level can be measured. In people with this disease, the Gastrin level will be
- Physical examination may only reveal some tenderness of the upper part of the abdomen. Testing of the stool may show the presence of blood if the ulcer is bleeding.
- Use of NSAIDs. The higher the dose, the higher the risk of developing ulcers. Also, some NSAIDs have a lower risk of ulcer formation.
- Infection with H. pylori.
- Diseases such as Zollinger-Ellison Syndrome that lead to increased production of acid.
- Increased stress may be a risk factor.
- Smoking increases the risk of ulcers and slows ulcer healing.
- In countries other than the U.S., lower socioeconomic status is a risk factor because those people have a higher rate of infection with H. pylori.
- There are several different medicines available to treat ulcers. The type of treatment and the medicines used depend on the cause of the ulcer.
- There are three main types of
medicines that can be used: 1) medicines that reduce the
amount of acid produced, 2) medicines that protect the
lining of the stomach and intestines, and 3) medicines that
destroy the bacterium, H. pylori.
Medicines that reduce acid
production are broken down into two categories. Generally, with
these medicines, duodenal ulcers heal within 4-6 weeks and gastric
ulcers heal within 6-8 weeks.
- Proton pump inhibitors -- Omeprazole and Lansoprazole are the most commonly used. Basically, they very effectively reduce acid production by the stomach. They are more potent than H2 receptor blockers but they are usually only used for short-term therapy. They can help cure up to 80-90% of ulcers. These medicines are usually taken 30 minutes before a meal. They help to relieve symptoms and allow healing to take place faster than H2 blockers, but the overall cure rate for ulcers is not much different between the two groups.
- H2 receptor blockers --
Cimetidine, Ranitidine, Famotidine, and Nizatidine are the
4 most commonly used medicines in this category.
These medicines also reduce acid production and they can
be used for longer periods of time. They are not as
potent as the proton pump inhibitors, but they can be just
as effective at curing ulcers. They also can cure about
80-90% of ulcers. Ulcer symptoms usually get better within
about 2 weeks, but treatment is usually continued for 6-8
- Certain medicines are available that
basically protect and preserve the lining of the stomach and
duodenum. These include:
- Sucralfate -- this is a medicine that basically coats ulcers and forms a protective layer. It is very good at treating duodenal ulcers. It is not as good for treatment of gastric ulcers.
- Bismuth -- this is a medicine that causes increased production of the substances that normally protect the stomach and intestines. It also helps destroy H. pylori.
- Misoprostol -- this is a medicine that increases the production of the substances that normally protect the stomach and intestines. It is not as effective as the other medicines in treating an active ulcer. It is used mainly to help prevent the formation of ulcers in people who are on long-term treatment with NSAIDs.
- Antacids -- these are available
over-the-counter. These medicines help protect the
wall of the stomach and intestines. They do not
reduce the formation of acid. They are no longer
used as initial treatment for ulcers because more
effective medicines are available. However, they do
work very quickly and can be use to rapidly control
- Treatment depends on the cause of the ulcer.
- For ulcers caused by H. pylori, there are several treatment options.
- Metronidazole (500 mg twice a day) and clarithromycin (500 mg twice a day) and a proton pump inhibitor (such as omeprazole 20 mg twice a day) for 14 days.
- Amoxicillin (1 gram twice a day) and clarithromycin (500 mg twice a day) and a proton pump inhibitor (such as omeprazole 20 mg twice a day) for 14 days.
- Amoxicillin (1 gram twice a day) and metronidazole (500 mg twice a day) and a proton pump inhibitor (such as omeprazole 20 mg twice a day) for 14 days.
- Bismuth subsalicylate (2 tablets 4 times a day) and tetracycline (500 mg 4 times a day) and either metronidazole (250 mg 4 times a day) or clarithromycin (500 mg 3 times a day) for 14 days. Some are now recommending using ranitidine along with this regimen.
- After the person has completed one of the above regimens, they need to be continued on a proton pump inhibitor, an H2 antagonist, or sucralfate for an additional 4-6 weeks. This will help allow the ulcer to heal completely.
- This course of therapy should destroy the bacterium in more than 85% of people.
- Newer combinations are constantly being tested. Therefore, it is best to discuss treatment options with your doctor.
- There are increasing reports of H. pylori being resistant to metronidazole. Therefore, in areas where there is a lot of resistance to this antibiotic, the other treatment options are being used first.
- In the past, most people with ulcers used to be continued on some sort of ulcer treatment for very long periods of time. However, now that we have found out that many of these ulcers are due to an infection, most people no longer need prolonged anti-ulcer treatment if their infection is cured. Therefore, only those who have recurrent ulcers, those in whom the infection could not be cured, and people with H. pylori infections who keep getting ulcers even though the infection was treated will need to be on long-term anti-ulcer treatment.
- If the person is treated for H.
pylori and the ulcer does not come back, no further
evaluation or treatment is needed. If the ulcer does
come back, then they need testing to see if the H. pylori
has truly been destroyed.
- For ulcers caused by NSAIDs,
treatment is a little different.
- The first step is to stop using the NSAIDs.
- Proton pump inhibitors (such as omeprazole, lansoprazole) should be started as soon as possible. These are the most effective medicines.
- You can also use H2 receptor antagonists or sucralfate, but these are not as effective.
- If the person is on NSAIDs but tests also show the presence of H. pylori, then the best option is to stop the NSAIDs but also to go ahead and treat the H. pylori infection.
- In people with ulcers, NSAIDs can
be continued along with one of the above medicines if
there is absolutely no other alternative. However,
healing of the ulcer will be delayed.
- Recurrent ulcers or ulcers that do
not heal with normal treatments are fairly rare these
days. If this is truly the case, then other diagnoses
must be considered. The most common cause of ulcers
not healing is because people do not take all the medicines
as prescribed by the doctor or they resume use of
NSAIDs. Another common cause is H. pylori infections
that are not adequately treated.
- Another cause is a missed cancer,
especially with stomach ulcers that do not heal despite
adequate therapy. Therefore, all gastric ulcers need
to be followed by repeat endoscopy to confirm that they have
healed. If they have not, then repeat biopsies should
be done after 2-3 months of treatment. Repeat
endoscopies should be done periodically until the ulcer has
- A much rarer cause of non-healing or recurrent ulcers is Zollinger-Ellison Syndrome. Therefore, all people with
continued ulcers should be checked for this condition.
- If all else fails and the person continues to
have recurrent ulcers, then he or she may need
surgery. This is the last treatment option that should only
be considered after all other options are exhausted.
- Stomach or intestinal bleeding
- Stomach or intestinal rupture
- Bowel obstruction or blockage
- Inflammation of the Pancreas, liver, or bile ducts
- Seek medical attention. Some
people will first try over-the-counter medications as listed
above. However, if this does not help or if the
symptoms persist, then you must seek medical attention.
- Also, if you have severe abdominal pain, if you vomit up blood or coffee-grounds looking material, have fever or chills, or if you have red or black stools, this is a medical emergency and you must go to the hospital immediately.
- Avoid prolonged NSAID use if possible.
- There are newer drugs such as
celecoxib, salsalate, and nabumetone that are associated
with fewer ulcers. If possible, one of these
medications can be used.
- Using misoprostol (200 micrograms
3-4 times a day) in people on chronic NSAID treatment may
help reduce the formation of ulcers. Proton pump
inhibitors may also be effective in preventing ulcers caused
by NSAIDs. At the present time, it is not felt that
using H2 blockers help much.
- Those individuals who are at
increased risk of developing NSAID associated ulcers should
be given either misoprostol or a proton pump inhibitor while
taking NSAIDs. There are now combination drugs
available that combine the NSAID with misoprostol.
- Smokers should stop smoking.
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