Peptic Ulcer

Definition

A peptic ulcer is a sore in the protective lining (mucosal lining) of the gastrointestinal (digestive) tract and develops when the lining is damaged. The acid and enzymes (pepsin) secreted by the stomach cells eat away at the wall of the stomach or upper small intestine, forming an ulcer.

Cause

Until the middle of the 1980s it was believed that the major causes of ulcers were stress, the genetically linked secretion of excessive stomach acid, eating too much fatty, rich and spicy foods, and drinking too much alcohol, coffee and colas. It was also believed that certain personality types were more susceptible to peptic ulcers. The viewpoint was that all these factors contributed to an excessive production of stomach acids, which eroded the protective lining of the stomach, duodenum or oesophagus.

A relatively recent theory holds that the primary cause of peptic ulcers is a bacterium in the stomach called Helicobacter pylori (H. pylori). Research conducted in the mid-1980s revealed the presence of this bacterium in almost 92 percent of cases of duodenal ulcers and 73% of cases of gastric ulcers. This bacterium causes ulcers either by stimulating increased acid production or by damaging the lining of the stomach or duodenum.

Factors that have been shown to increase the risk of peptic ulcers include smoking and the regular use of non-steroidal anti-inflammatory drugs such as aspirin, ibuprofen, indomethacin and naproxen.

Who gets peptic ulcers?

More than 90% of duodenal ulcers are caused by the bacterium Helicobacter pylori and about two-thirds of the world’s population are infected with this. However, most of those infected do not show symptoms.

The absolute incidence of duodenal ulcers is not known, but the most recent estimates suggest that around 10 percent of a population will have evidence of this type of ulcer at some time in their lives.

The peak incidence of gastric ulcer is in the 60s, around 10 years later than for duodenal ulcer. They are slightly more common in men.

Risk factors

• People who take over-the-counter painkillers in large quantities are more susceptible to gastric ulcers.
• Research findings also indicate that heavy smokers are more likely to develop duodenal ulcers (ulcers in the lining of the duodenum) than non-smokers. Smoking increases the risk of complications arising from ulcers, such as bleeding, obstruction and perforation of the stomach. Smoking is also the main obstacle to effective medication for ulcers.
• Stress may also increase the risk of ulcers.
• Studies on the incidence of gastric ulcers in elderly people have shown that they are more likely to develop this condition. Many elderly people have arthritis and therefore take aspirin and ibuprofen frequently for pain relief.

Symptoms

Symptoms of peptic ulcers vary widely. Though many patients do not have indigestion or discomfort, others suffer from a severe burning or hunger pain in the upper abdomen (between the navel and the lower end of the breastbone) one to three hours before, after a meal and often at night. This pain may also occur after drinking orange juice, coffee or alcohol, or after taking aspirin. Eating something or taking an antacid usually relieves the discomfort (often indication of duodenal ulcer).

Other symptoms may include a bloated or full feeling during or after meals; nausea and vomiting; tar-like, black or bloody stools; weight loss; and fatigue.

A duodenal ulcer may cause heartburn.

Diagnosis

Your doctor may suspect a peptic ulcer when he or she notes your symptoms, but because the symptoms of the different ulcers are much alike, several tests may be ordered to make a specific diagnosis.

For diagnosing a stomach ulcer, your doctor may request a barium X-ray of your upper gastrointestinal tract. This is not at all uncomfortable and involves no risk. You swallow barium, a white chalky substance that is visible on X-ray (it is sometimes called a “barium milkshake”) and are asked to lie down on a tilted examining table. The tilting distributes the barium evenly around your upper digestive tract and the X-ray can capture images at different angles. This allows the doctor to locate the ulcer, and to determine its type and severity. This is not a very accurate procedure: in almost 20 percent of cases these X-rays do not detect ulcers.

A more accurate procedure is an upper endoscopy or gastroscopy. You are sedated and a slim, flexible lighted tube is inserted through your mouth to examine the stomach, oesophagus and duodenum. During the procedure the doctor can also take a biopsy of the lining of the stomach tissue to test for H. pylori infection. Biopsies, especially of stomach or gastric ulcers that may be cancerous, can be examined under a microscope to determine if cancer is present.

The doctor may also order a blood test to check for anaemia (indicative of internal bleeding), an analysis of a stool sample to check for blood (indicating a bleeding ulcer) or other blood tests to check for the presence of H. pylori bacteria. H.pylori can also be diagnosed by a breath test. Recently urine and stools test have also been developed.

Outcome

Because the severity of the symptoms varies so widely, symptoms alone are usually not a good indication of the presence or severity of an ulcer. Ulcers often come and go unnoticed by sufferers; they might only become aware of the condition when a serious complication such as bleeding or perforation occurs.

Complications

People who have peptic ulcers generally continue to function quite comfortably and some ulcers heal spontaneously without medication. Therefore the main problems due to ulcers are their complications, which include bleeding, perforation and obstruction of the gastric system.

1. Bleeding: If you have a bleeding ulcer, you have black (resembling tar) stools (called melaena) and feel weak. You may feel as if you are going to faint when standing and you may vomit blood. The blood in the stomach is usually changed by gastric acid so that has a grainy, black appearance (looking like coffee grains) – referred to as haematemesis. The initial treatment consists of rapidly replacing lost body fluids. If bleeding is severe or persists, you may need a blood transfusion.
2. Perforation: In the case of a perforated ulcer (when an ulcer makes a hole right through the stomach wall), the gastric contents leak into the abdominal cavity. This causes acute peritonitis (inflammation of the abdominal cavity). You have sudden and severe abdominal pain, which worsens whenever you move. The abdominal muscles become rigid and board-like. Surgery is usually urgently required.
3. Gastric obstruction: The obstruction usually occurs at or near the pyloric canal. The pyloric canal is the naturally narrow part of the stomach where it joins the upper part of the small intestine, the duodenum. People with obstruction have increasing abdominal pain and they usually vomit undigested or partially digested food because it cannot pass into the rest of the digestive tract. They also report weight loss and a diminished appetite. The doctor usually does an upper endoscopy to exclude the possibility that gastric cancer may be causing the obstruction.

When to call a doctor

Contact your doctor if:

• You have an ulcer and develop sudden, severe abdominal pain that your usual home treatment does not relieve
• You suspect that you may have an ulcer but your symptoms do not improve within two weeks of home treatment
• You have been diagnosed with a stomach ulcer and suddenly get symptoms of anaemia, such as pallor, dizziness, weakness and fatigue – your ulcer may be bleeding and need medical attention.
• You have stomach ulcer symptoms and you have severe back pain – your ulcer may be perforating the wall of the stomach. You may need urgent surgery.
• You have stomach ulcer symptoms and vomit blood, which gastric acid may have changed to look like ground coffee – you may have internal bleeding. It is important to call a health professional urgently.
• You have an ulcer and become cold and clammy, feel faint or actually faint – these are symptoms of shock, usually due to massive blood loss. You’ll require immediate medical attention.You feel the kind of pain associated with a peptic ulcer and shortness of breath or other symptoms that might be related to heart problems. See a doctor urgently.

Note: two to three percent of stomach ulcers become stomach cancer – report all continuing or recurrent symptoms to your doctor.

Visit preparation

If your doctor has requested a barium X-ray of your upper gastrointestinal tract, you may be required to eat only bland, easily digestible food two to three days before the test.

Treatment

Peptic ulcers tend to respond well to treatment but often recur in many people. The goal of treating an ulcer is to relieve pain and prevent complications. The first step in such a treatment plan aims at reducing risk factors (smoking and use of anti-inflammatory medication). As a second step medication can be taken. Surgery may be necessary in severe cases.

Home treatment

• Stop smoking.
• Take paracetamol, instead of aspirin, ibuprofen or naproxen, to relieve pain.
• Try to eat smaller and more frequent meals, but if this does not help, return to your regular eating pattern.
• Avoid foodstuffs such as alcohol, caffeine and spicy foods that seem to bring on symptoms.
• If a particular food does not cause any problems, there is no need to eliminate it from your diet.
• If you need an antacid to neutralise stomach acid, speak to your doctor about the best one, especially if you are on a low-salt diet, as many of the antacids have a high sodium content.
• Keep emotional stress under control by using relaxation techniques such as muscle relaxation exercises, positive mental imagery and breathing exercises.
• Change your lifestyle to help you cope with stress by exercising, eating balanced meals and getting enough rest.
• Get professional assistance to help you to change stressful life circumstances and to develop positive coping mechanisms.
• Nurture positive relationships.

Medication

Antacids: This kind of medication neutralises the acid present in the stomach. Frequent dosages are needed, because the neutralising action of the medication is short-lived. Peptic ulcers often return when the use of antacids is discontinued. Antacids that contain magnesium may cause diarrhoea and those containing aluminium may cause constipation.

H2 blockers: Studies have shown that a protein in the stomach, histamine, stimulates the secretion of gastric acid. Histamine antagonists (H2 blockers such as ranitidine, cimetidine and famotidine) can block this action of histamine on gastric cells and thereby reduce the amount of acid produced. This kind of medication is quite effective in healing peptic ulcers, but unless antibiotics are administered simultaneously, H2 blockers have limited success with eradicating the H. pylori bacteria. Although H2 blockers have few side effects and are well tolerated even when used continuously for a long time, ulcers often return when people stop taking this medication.

Proton pump inhibitors: These drugs are the most potent suppressors of gastric acid secretion. There are five main drugs available – omeprazole, lansoprazole, pantoprazole esomeprazole and rabeprazole. All five are used as part of a regime to eliminate H. pylori and are highly effective. The most frequent side effects are nausea, headaches diarrhoea, flatulence and constipation.

Antibiotics for H. pylori infection: H. pylori bacteria can infect the stomach lining, but this may or may not cause a peptic ulcer. Although H. pylori can be difficult to eradicate completely, treatment with several antibiotics, sometimes in combination with other medications such as H2 blockers or proton pump inhibitors, can be effective. Commonly used antibiotics are amoxycillin clarithromycin or metromedazole. If the bacteria are eliminated completely, this can prevent ulcers from recurring; it may also decrease the risk of developing stomach cancer. It is important for patients to note that treatment with antibiotics does have a risk of causing allergic reactions, diarrhoea and sometimes inflammation of the colon. It can take two to three weeks for infection with H. pylori to clear and may require two to three antibiotics in combination. Some patients find that this regime is difficult to adhere to.

For gastric ulcers a follow-up gastroscope is needed six to eight weeks later to ensure that the ulcer has healed. Further biopsies are needed if healing is not occurring as fast as expected.

Surgery: Surgery may be necessary if all the medications for treating peptic ulcers are unsuccessful or if serious complications develop. In the case of a bleeding ulcer, the doctor will repair the source of the bleeding. If the ulcer has perforated the stomach or duodenal wall, an emergency operation is required to close the perforation.

In some cases the doctor may perform an operation to decrease the secretion of stomach acid. The surgery usually involves either removing part of the stomach (partial gastrectomy) or a section of the vagus nerve (vagotomy), as this autonomic nerve stimulates secretion of gastric acid.

Peptic ulcer surgery is performed only in emergencies because of the associated risk of complications. These include recurrence of the ulcer(s); the formation of fistulae (connections between the small intestine and colon); vomiting of bile; diarrhoea; haematological complications (anaemia); and dumping syndrome. Dumping syndrome occurs when the stomach empties rapidly (“dumps”) into the small intestine. This may lead to reactive hypoglycaemia (low blood sugar). Symptoms include colic-like abdominal pain, diarrhoea, vomiting and/or sweating an hour after eating. Dumping syndrome may be lessened by a regimen of small meals at frequent intervals.

Prevention

The most important way to prevent any disease – including peptic ulcer disease – is to maintain a generally healthy lifestyle, which includes the following:

• Exercise the way your doctor or health professional has advised you to.
• Eat three to six small but balanced meals daily.
• Get plenty of rest and decrease your consumption of caffeine, nicotine, alcohol and anti-inflammatory medicines. In certain cases it may be advisable to eliminate these substances completely.
• Stop smoking. Heavy smokers are more likely to develop duodenal ulcers, primarily because nicotine is thought to prevent the pancreas from secreting enzymes that neutralise acid. Smoking also slows healing.
• Avoid eating foods that irritate your stomach, especially fatty and spicy foods, and rather choose foods with a high fibre content. High-fibre foods not only play an important role in the prevention of cancer, but can also greatly reduce your risk of developing a duodenal ulcer: fibre is believed to enhance the secretion of mucin, which protects the duodenal lining.

Previously reviewed by Dr Ganief Adams, Gastroenterologist, MBChB (UCT), FCP (SA)

Reviewed by Prof Jan van Zyl, Department of Gastroenterology, University of the Free State, July 2011

The information provided in this article was correct at the time of publishing. At Mediclinic we endeavour to provide our patients and readers with accurate and reliable information, which is why we continually review and update our content. However, due to the dynamic nature of clinical information and medicine, some information may from time to time become outdated prior to revision.