What Is Peptic Ulcer Disease?

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Peptic ulcer disease is a common digestive disorder in which acid and pepsin (an important digestive enzyme) cause the lining of the stomach or the first part of the small intestine, known as the duodenum, to erode. This leads to sores known as peptic ulcers. More specifically, a peptic ulcer that's located in the stomach is called a gastric ulcer. If a sore is in the duodenum, it is called a duodenal ulcer.

Peptic ulcer disease can cause significant upper abdominal pain, but symptoms, on the whole, may vary somewhat between the two types of peptic ulcers, and your doctor may treat each a little differently. Managing your case is important, as serious consequences, such as bleeding and anemia, can occur.

The most common causes are now known to be infection by the Helicobacter pylori (H. pylori) bacterium and long-term use of certain pain relievers. This knowledge has revolutionized the care of peptic ulcer disease.

At any given time, up to 1% of people worldwide will have a peptic ulcer.

Peptic Ulcer Disease 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:

Gastric Ulcer Symptoms
  • Pain is often made worse by a meal

  • Weight loss (possible due to eating less to avoid discomfort)

Peptic Ulcer Symptoms
  • Pain between meals (when the stomach is empty) and that improves after eating

  • Possible weight gain

That said, 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.

Complications

People with peptic ulcers have a relatively high chance of developing gastroesophageal reflux disease (GERD) and the symptoms associated with it, especially heartburn.

While concerning, there are other possible complications that can be more serious and even life-threatening:

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 (GI) 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.

A perforation (when an ulcer completely burns through the stomach or intestinal lining) and a fistula (an abnormal connection in the GI tract) may also occur, allowing gastrointestinal fluids to leak out, potentially leading to issues such as infection.

Causes

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

  • H. pylori infection
  • 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 least 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 20-fold. NSAID users who also have H. pylori 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.

While H. pylori and NSAIDs account for most peptic ulcer disease, there are many other potential factors that can also play a role in your risk. These include:

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 doing so may only help you feel better, not prevent peptic ulcer disease.

Similarly, experts now discount the idea that ulcers are caused by either acute or chronic emotional stress unless the stress leads you to smoke, drink, use drugs, or overuse medications.

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. A biopsy is not performed, a urea breath test may be used to determine this (H. pylori secretes the enzyme urease, which results in excess urea that's detectable in 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. 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 and eliminating contributing factors.

If testing is positive for H. pylori, the infection must be eradicated with a course of antibiotics. Generally, two different antibiotics—most often clarithromycin, metronidazole, and/or amoxicillinare—used for seven to 14 days.

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 proton pump inhibitor (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, H. pylori has been eliminated, eight to 12 weeks of PPI therapy are completed, and offending agents like NSAIDs have been removed, the chances of completely healing a peptic ulcer are excellent—generally above 90% to 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.

Today, surgery is mainly needed or ulcers that prove utterly resistant to medical treatment or are suspected to harbor a malignancy. It may also be used to treat 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 your triggers are; keeping a food diary can help.

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 cause symptoms 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 to 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 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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