Peptic ulcer disease,
gastric ulcer, duodenal ulcer, or intestinal 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 their 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 stomach (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 dyspepsia.
- Some will have chest pain or back pain
- 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 bacterium that is felt to cause many ulcers.
- H. pylori is a bacterium that lives in the stomach and has been shown to be the cause of many ulcers.
- 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 ulcers coming back.
- 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 their ulcer.
- However, only one out of every six people who have this bacterium in their stomach will ever develop an ulcer.
- NSAIDs -- this stands for nonsteroidal anti-inflammatory drugs.
- 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 ulcers.
- 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
- 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 done.
- All people with ulcers need to be tested for H. pylori. There are many ways to test for this infection.
- 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 fully treated.
- Blood tests are usually normal in most cases of ulcer disease in which there is no complication.
- 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 abdominal cavity.
- In cases where Zollinger-Ellison Syndrome is suspected, a Gastrin level can be measured. In people with this disease, the Gastrin level will be elevated.
- Physical examination may only
reveal some tenderness of the upper part of the stomach.
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.
- 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.
- 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 weeks.
- 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 symptoms.
- 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 completely healed.
- A much more rare 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 they 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
- 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
- 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
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