An Overview of Peptic Ulcer Disease

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Peptic ulcer disease is a common digestive disorder in which painful sores develop in the stomach lining or the first part of the small intestine. It not only can make life very uncomfortable with upper abdominal pain, but can also have serious consequences in bleeding or anemia. The most common causes are now known to be infection by the Helicobacter pylori bacterium or long-term use of pain relievers. This new knowledge about its causes and treatments has revolutionized the care of peptic ulcer disease.

What Is a Peptic Ulcer?

A peptic ulcer is an erosion of the lining of the stomach or duodenum (the first part of the small intestine). These ulcers are called “peptic” ulcers because they are related to the activity of acid and pepsin (an important digestive enzyme) on the cells that line the stomach and duodenum. A peptic ulcer located in the stomach is called a gastric ulcer. If it is in the duodenum it is called a duodenal ulcer. Symptoms may vary somewhat between these two types of peptic ulcers and your doctor may treat them a little differently. Doctors see people with peptic ulcers very frequently. At any given time, up to 1% of people worldwide will have a peptic ulcer.

Symptoms

The chief symptom of a peptic ulcer is abdominal pain. Most people will describe a gnawing or burning pain usually located in the pit of the stomach or just below the ribs on either the right or left side.

The pattern of abdominal pain may depend on the location of the ulcer. With gastric ulcers, the pain is often made worse by a meal and, occasionally, a person with a gastric ulcer may (possibly subconsciously) cut back on eating and even lose some weight.

In contrast, duodenal ulcers tend to produce pain in between meals when the stomach is empty—the pain is often relieved by eating something. People with a duodenal ulcer seldom lose weight and may actually gain weight.

While a peptic ulcer obviously creates a potential for many different symptoms, a surprising proportion of people with peptic ulcers (perhaps up to 50%) may not notice any particular symptoms. Unfortunately, even peptic ulcers that do not directly produce symptoms may ultimately cause significant complications.

If a peptic ulcer becomes large enough, it may erode into a blood vessel and produce bleeding. Doctors call this an “upper GI bleed” since the site of bleeding is in the upper part of the gastrointestinal system. The symptoms of an upper GI bleed may be quite dramatic and impossible to ignore, such as vomiting bright red blood.

On the other hand, if the bleeding is slow, symptoms may be much more subtle and may include the gradual onset of weakness (from anemia), dizziness, palpitations (from a rapid heart rate), abdominal cramping (caused by blood moving through, and irritating, the intestines), and melena or tarry stool (caused by the digestive process acting on blood in the intestinal tract).

A peptic ulcer located at the junction of the stomach and the duodenum (a location called the pyloric channel) may cause enough swelling in the stomach lining to produce a partial obstruction. If so, symptoms may include bloating, severe indigestion, nausea, vomiting, and weight loss. People with peptic ulcers also have a relatively high chance of developing gastroesophageal reflux disease (GERD) and the symptoms associated with it, especially heartburn.

If the only thing peptic ulcers did was to cause abdominal pain, they might not be considered such a significant problem. But, as we have already seen, they can do much more than that. The major complications of peptic ulcer disease include bleeding, gastric outlet obstruction, perforation, and fistula. These all can be life-threatening medical emergencies, often requiring surgery to correct them.

Causes

In the large majority of cases, peptic ulcers are caused by one of two things:

  1. An infection with a bacterium called Helicobacter pylori (H. pylori)
  2. The chronic use of non-steroidal anti-inflammatory drugs (NSAIDS)

The realization that H. pylori infections are responsible for much if not most peptic ulcer disease is one of the greatest medical advances of the last few decades. At 50% of all humans have H. pylori in their upper gastrointestinal tracts, and about 75% of peptic ulcers in the U.S. are associated with this infection.

Research indicates that H. pylori may predispose people to peptic ulcers by several different mechanisms, including:

  • Increasing the secretion of stomach acid
  • Causing inflammation
  • Diminishing the defense mechanisms of the stomach lining
  • Causing gastric cells (which secrete acid and pepsin) to grow in the lining of the duodenum

The chronic use of NSAIDs, including aspirin, increases the risk of peptic ulcers by 20-fold. NSAID users who also have H. pylori (a group that, again, includes more than half of all people) have a 60-fold increase in peptic ulcer disease.

NSAIDs are thought to increase the risk of peptic ulcers by inhibiting the COX-1 receptor in the upper gastrointestinal tract. Inhibition of COX-1 reduces the production of various prostaglandins that function to protect the lining of the stomach and duodenum.

People without H. pylori can develop peptic ulcers, especially if they use NSAIDs. People who do not use NSAIDs can develop peptic ulcers, especially if they have H. pylori. But people who have both of these factors have an especially high risk of peptic ulcer disease.

While H. pylori and NSAIDs account for most peptic ulcer disease, there are many other potential causes or risk factor as well. These include:

Despite what you may have heard all your life, there is really no evidence that eating any kind of specific foods, like spicy dishes, causes peptic ulcer disease. You may find that, in your own case, eating particular foods can bring on heartburn, indigestion, or other gastrointestinal symptoms—and if so, you should avoid them. But you’re avoiding them in order to feel better, not to prevent peptic ulcer disease.

Similarly, experts now discount the idea that ulcers are caused by either acute or chronic emotional stress, like dealing with an annoying boss, unless the stress leads you to smoke, drink, or pop lots of Advil.

Diagnosis

Diagnostic testing for peptic ulcer disease has two distinct goals:

  1. Establishing the presence or absence of a peptic ulcer
  2. Assessing the cause of an ulcer, if present

If your symptoms are mild, your doctor may simply put you on a course of therapy to block stomach acid. If your symptoms go away and do not return after this simple measure, that may be all there is to it. However, if your symptoms are moderately severe, or if your symptoms return after a short course of therapy, it is usually a good idea to make a definitive diagnosis. Today, this is done most efficiently and most accurately with an endoscopy procedure.

With endoscopy, a flexible tube containing a fiberoptic system is passed down the esophagus and into the stomach—and the lining of the stomach and duodenum is directly visualized. Endoscopy is quick and accurate. In addition, if an ulcer is present, its general severity can be assessed and it can be examined for any signs of malignancy—in which case a biopsy can be taken. A biopsy is also very helpful in detecting whether H. pylori is present. Endoscopy has largely replaced upper GI X-ray studies using swallowed barium.

If a peptic ulcer is diagnosed, it is important to assess whether an infection with H. pylori is present and whether NSAIDs may be a factor. This information is very important in deciding on appropriate treatment. The best way to detect H. pylori is with a biopsy obtained during endoscopy. Alternatively, a urea breath test may be used. H. pylori secretes the enzyme urease that results in excess urea—which can be detected in the breath. Blood testing and stool testing may also be used to detect H. pylori.

Because NSAIDs (and sometimes other medications) often play a prominent role in the development of peptic ulcers, it is important to give your doctor a full account of all the medications you have been using, prescription or over-the-counter.

If you have a peptic ulcer and do not have either an H. pylori infection or NSAID usage, your doctor may need to perform further medical evaluation, looking for other potential underlying causes. In the large majority of people with peptic ulcer disease, however, this is not necessary.

Treatment

In most cases, peptic ulcers can be successfully treated with medical therapy. In general, medical therapy consists of three things: 

  1. Eradicating H. pylori 
  2. Giving a course of proton pump inhibitor (PPI) therapy
  3. Withdrawing factors that contribute to peptic ulcers

If testing is positive for H. pylori, the key to successfully treating peptic ulcer disease is to get rid of the infection with a course of antibiotics. Generally, two different antibiotics are used for seven to 14 days—most often clarithromycin, metronidazole, and/or amoxicillin. It is important to repeat testing for H. pylori after the course of antibiotics to document that the infection is gone. If it is not, another treatment course, using different drugs or different dosages, will be needed.

Ulcer healing can also be promoted by inhibiting the secretion of stomach acid. When a peptic ulcer is present, this is best accomplished by using a PPI, such as Nexium (esomeprazole), Prevacid (pantoprazole), Prilosec (omeprazole), or AcipHex (rabeprazole). Reducing the acid in the stomach not only helps the ulcer to heal but also makes antibiotics more effective against H. pylori. PPI therapy is usually continued for eight to 12 weeks in people with peptic ulcer disease.

In addition to avoiding all NSAIDs, anyone with a peptic ulcer should stop smoking and limit alcohol to no more than one drink per day (if that). After antibiotics have been taken, the H. pylori eradicated, eight to 12 weeks of PPI therapy, and eliminating offending agents like NSAIDs, the chances of completely healing a peptic ulcer are excellent—generally above 90-95%. Furthermore, the risk of a recurrent ulcer is quite low.

In the past, surgical treatment for peptic ulcer disease was quite common. However, since H. pylori was discovered to be an important and frequent underlying cause—and since powerful PPI drugs were developed—surgery has become only rarely necessary. Surgery is now needed mainly for ulcers that prove utterly refractory to medical treatment, are suspected to harbor a malignancy, or as treatment of the complications of peptic ulcer disease, like severe bleeding, obstruction, perforation, or fistula formation.

Coping

Much has changed in the treatment and management of peptic ulcer disease. You no longer need to follow a bland diet, for example. That said, while your digestive tract is healing you may experience symptoms when eating or drinking certain foods. This will be individual and you will need to note what triggers it for you. Eating smaller meals, having no food or drink for at least two hours before going to bed, avoiding alcohol, and limiting the food and drink you know are your triggers are suggested tactics.

While emotional stress is no longer considered a cause of ulcers, some people have more symptoms when under stress. It could be that stress leads you drink, smoke, or indulge in foods that are triggers for your symptoms. While healing, it can be good to reduce your emotional stress through physical exercise, meditation, yoga, or breathing exercises.

A Word From Verywell

While a peptic ulcer is a significant medical problem that can have dire consequences, advances in medical care over the past few decades have utterly changed the treatment of this condition and the prognosis of the people who have it.

If you are diagnosed with peptic ulcer disease, as long as you work with your doctor to establish an underlying cause, faithfully follow the two to three month regimen of medical therapy that likely will be prescribed, and avoid the medications—and habits—you are supposed to avoid, there is an excellent chance that your ulcer will heal completely and will never come back.

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Article Sources

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Additional Reading

  • Li LF, Chan RL, Lu L, et al. Cigarette Smoking and Gastrointestinal Diseases: the Causal Relationship and Underlying Molecular Mechanisms (Review). Int J Mol Med 2014; 34:372.

  • Malfertheiner P, Megraud F, O'Morain CA, et al. Management of Helicobacter Pylori Infection--the Maastricht IV/ Florence Consensus Report. Gut 2012; 61:646.

  • Lau JY, Sung J, Hill C, et al. Systematic Review of the Epidemiology of Complicated Peptic Ulcer Disease: Incidence, Recurrence, Risk Factors and Mortality. Digestion 2011; 84:102.