Peptic Ulcer

Definition
Too much stress, too much spicy food, and you may be headed for an ulcer — that
was the way the thinking used to go.

Peptic ulcers are open sores that develop on the inside lining of your stomach, upper
small intestine or esophagus. The most common symptom of a peptic ulcer is pain.

Not long ago, the common belief was that peptic ulcers were a result of lifestyle.
Doctors now know that a bacterial infection or some medications — not stress or diet
— cause most ulcers of the stomach and upper part of the small intestine (duodenum).
Esophageal ulcers also may occur and are typically associated with the reflux of
stomach acid.

Peptic ulcers are common, and oftentimes successful treatment of peptic ulcers takes
just a few weeks.

Symptoms
Burning pain is the most common peptic ulcer symptom. The pain is caused by the
ulcer and is aggravated by stomach acid coming in contact with the ulcerated area.
The pain typically may:

 Be felt anywhere from your navel to your breastbone

 Last from a few minutes to many hours
 Be worse when your stomach is empty
 Flare at night
 Often be temporarily relieved by eating certain foods that buffer stomach acid
or by taking an acid-reducing medication
 Come and go for a few days or weeks

Less often, ulcers may cause severe signs or symptoms such as:

 The vomiting of blood — which may appear red or black

 Dark blood in stools or stools that are black or tarry
 Nausea or vomiting
 Unexplained weight loss
 Chest pain
Causes

Ulcers

Depending on their location, peptic ulcers have different names:

 Gastric ulcer. This is a peptic ulcer that occurs in your stomach.

 Duodenal ulcer. This type of peptic ulcer develops in the first part of the small intestine
(duodenum).
 Esophageal ulcer. An esophageal ulcer is usually located in the lower section of your
esophagus. It's often associated with chronic gastroesophageal reflux disease (GERD).

The culprit in most cases

Although stress and spicy foods were once thought to be the main causes of peptic
ulcers, doctors now know that the cause of most ulcers is the corkscrew-shaped
bacterium Helicobacter pylori (H. pylori).

H. pylori lives and multiplies within the mucous layer that covers and protects tissues
that line the stomach and small intestine. Often, H. pylori causes no problems. But
sometimes it can disrupt the mucous layer and inflame the lining of the stomach or
duodenum, producing an ulcer. One reason may be that people who develop peptic
ulcers already have damage to the lining of the stomach or small intestine, making it
easier for bacteria to invade and inflame tissues.

H. pylori is a common gastrointestinal infection around the world. In the United

States, one in five people younger than 30 and half the people older than 60 are
infected. Although it's not clear exactly how H. pylori spreads, it may be transmitted
from person to person by close contact, such as kissing. People may also contract H.
pylori through food and water.

H. pylori is the most common, but not the only, cause of peptic ulcers. Besides H.
pylori, other causes of peptic ulcers, or factors that may aggravate them, include:
  Regular use of pain relievers. Nonsteroidal anti-inflammatory drugs
(NSAIDs) can irritate or inflame the lining of your stomach and small
intestine. The medications are available both by prescription and over-the-
counter. Nonprescription NSAIDs include aspirin, ibuprofen (Advil, Motrin,
others), naproxen (Aleve) and ketoprofen (Orudis KT). To help avoid
digestive upset, take NSAIDs with meals.

NSAIDs inhibit production of an enzyme (cyclooxygenase) that produces

prostaglandins. These hormone-like substances help protect your stomach
lining from chemical and physical injury. Without this protection, stomach
acid can erode the lining, causing bleeding and ulcers.

 Smoking. Nicotine in tobacco increases the volume and concentration of stomach acid,
increasing your risk of an ulcer. Smoking may also slow healing during ulcer treatment.
 Excessive alcohol consumption. Alcohol can irritate and erode the mucous lining of your
stomach and increases the amount of stomach acid that's produced. It's uncertain, however,
whether this alone can progress into an ulcer or whether other contributing factors must be
present, such as H. pylori bacteria or ulcer-causing medications, such as NSAIDs.
 Stress. Although stress per se isn't a cause of peptic ulcers, it's a contributing factor. Stress
may aggravate symptoms of peptic ulcers and, in some cases, delay healing. You may
undergo stress for a number of reasons — an emotionally disturbing circumstance or event,
surgery, or a physical trauma, such as a burn or other severe injury.

When to seek medical advice

An ulcer isn't something that you should treat on your own, without a doctor's help.
Over-the-counter antacids and acid blockers may relieve the gnawing pain, but the
relief is short-lived. If you have signs or symptoms of an ulcer, see your doctor. With
a doctor's help, you can find prompt relief of ulcer pain as well as a complete healing
of the ulcer.

Tests and diagnosis

In order to detect an ulcer, your doctor may have you undergo the following
diagnostic tests:

 Upper gastrointestinal (upper GI) X-ray. Your doctor may begin with this
test, which outlines your esophagus, stomach and duodenum. During the X-
ray, you swallow a white, metallic liquid (containing barium) that coats your
digestive tract and makes an ulcer more visible. An upper GI X-ray can detect
some ulcers, but not all.
 Endoscopy. This procedure may follow an upper GI X-ray if the X-ray
suggests a possible ulcer, or your doctor may perform endoscopy first. In this
more sensitive procedure, a long, narrow tube with an attached camera is
threaded down your throat and esophagus into your stomach and duodenum.
With this instrument, your doctor can view your upper digestive tract and
identify an ulcer.

If your doctor detects an ulcer, he or she may remove small tissue samples (biopsy)
near the ulcer. These samples are examined under a microscope to rule out cancer. A
biopsy can also identify the presence of H. pylori in your stomach lining. Depending
on where the ulcer is found, your doctor may recommend a repeat endoscopy after
two to three months to confirm that the ulcer is healing.

Additional tests
In addition to a biopsy, these other tests can determine if the cause of your ulcer is H.
pylori infection:

 Blood test. This test checks for the presence of H. pylori antibodies. A
disadvantage of this test is that it sometimes can't differentiate between past
exposure and current infection. After H. pylori bacteria have been eradicated,
you may still have a positive result for many months.
 Breath test. This procedure uses a radioactive carbon atom to detect H. pylori.
First, you blow into a small plastic bag, which is then sealed. Then, you drink
a small glass of clear, tasteless liquid. The liquid contains radioactive carbon
as part of a substance (urea) that will be broken down by H. pylori. Thirty
minutes later, you blow into a second bag, which also is sealed. If you're
infected with H. pylori, your second breath sample will contain the radioactive
carbon in the form of carbon dioxide.

The advantage of the breath test is that it can monitor the effectiveness of
treatment used to eradicate H. pylori, detecting when the bacteria have been
killed or eradicated. With the blood test, H. pylori antibodies may sometimes
still be present a year or more after the infection is gone.

 Stool antigen test. This test checks for H. pylori in stool samples. It's useful
both in helping to diagnose H. pylori infection and in monitoring the success
of treatment.

Complications
Left untreated, peptic ulcers can cause internal bleeding and can eat a hole through the
wall of your stomach or small intestine, putting you at risk of serious infection of your
abdominal cavity (peritonitis). Peptic ulcers can also produce scar tissue that can
obstruct passage of food through the digestive tract, causing you to become full
easily, to vomit and to lose weight.

Treatments and drugs

Because many ulcers stem from H. pylori bacteria, doctors use a two-pronged
approach to peptic ulcer treatment:

 Kill the bacteria.

 Reduce the level of acid in your digestive system to relieve pain and
encourage healing.

Accomplishing these two goals requires the use of at least two, and sometimes three
or four, of the following medications:
  Antibiotic medications. Doctors use combinations of antibiotics to treat H.
pylori because one antibiotic alone isn't sufficient to kill the organism. For the
treatment to work, it's essential that you follow your doctor's instructions
precisely. Antibiotics commonly prescribed for treatment of H. pylori include
amoxicillin (Amoxil), clarithromycin (Biaxin) and metronidazole (Flagyl).
Some companies package a combination of two antibiotics together, with an
acid suppressor or cytoprotective agent specifically for treatment of H. pylori
infection. These combination treatments are sold under the names Prevpac and
Helidac. You'll likely need to take antibiotics for two weeks, depending on
their type and number. Other medications prescribed in conjunction with
antibiotics generally are taken for a longer period.
 Acid blockers. Acid blockers — also called histamine (H-2) blockers —
reduce the amount of hydrochloric acid released into your digestive tract,
which relieves ulcer pain and encourages healing. Acid blockers work by
keeping histamine from reaching histamine receptors. Histamine is a substance
normally present in your body. When it reacts with histamine receptors, the
receptors signal acid-secreting cells in your stomach to release hydrochloric
acid. Available by prescription or over-the-counter (OTC), acid blockers
include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine
(Tagamet) and nizatidine (Axid).
 Antacids. Your doctor may include an antacid in your drug regimen. An
antacid may be taken in addition to an acid blocker or in place of one. Instead
of reducing acid secretion, antacids neutralize existing stomach acid and can
provide rapid pain relief.
 Proton pump inhibitors. Another way to reduce stomach acid is to shut down
the "pumps" within acid-secreting cells. Proton pump inhibitors reduce acid by
blocking the action of these tiny pumps. These drugs include the prescription
medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole
(Aciphex) and esomeprazole (Nexium). The drug pantoprozole (Protonix) can
be taken orally or administered intravenously in the hospital. Proton pump
inhibitors are frequently prescribed to promote the healing of peptic ulcers. If
you are admitted to the hospital with a bleeding ulcer, taking intravenous
proton pump inhibitors decreases the chance that bleeding will recur. Proton
pump inhibitors also appear to inhibit H. pylori. However, long-term use of
proton pump inhibitors, particularly at high doses, may increase your risk of
hip fracture.
 Cytoprotective agents. In some cases, your doctor may prescribe these
medications that help protect the tissues that line your stomach and small
intestine. They include the prescription medications sucralfate (Carafate) and
misoprostol (Cytotec). Another nonprescription cytoprotective agent is
bismuth subsalicylate (Pepto-Bismol). In addition to protecting the lining of
your stomach and intestines, bismuth preparations appear to inhibit H. pylori
activity.

If H. pylori isn't identified in your system, then it's likely that your ulcer is due to
NSAIDs — which you should quit using, if possible — or acid reflux, which can
cause esophageal ulcers. In both cases, your doctor will try to reduce acid levels —
through use of acid blockers, antacids or proton pump inhibitors — and may also have
you use cytoprotective drugs.
Ulcers that fail to heal
Peptic ulcers that don't heal with treatment are called refractory ulcers. There are
many reasons why an ulcer may fail to heal. Not taking medications according to
directions is one reason. Another is that some types of H. pylori are resistant to
antibiotics. Other factors that can interfere with the healing process include regular
use of tobacco, alcohol or nonsteroidal anti-inflammatory drugs (NSAIDs).
Sometimes the problem is accidental: People are unaware that a medication they're
taking contains an NSAID.

In rare cases, refractory ulcers may be a result of:

 Extreme overproduction of stomach acid, such as occurs in Zollinger-Ellison

syndrome
 An infection other than H. pylori
 Stomach cancer
 Other digestive diseases, including Crohn's disease or cancer

Treatment for refractory ulcers generally involves eliminating factors that may
interfere with healing, along with stronger doses of ulcer medications. Sometimes,
additional medications may be included. Surgery to help heal an ulcer is necessary
only when the ulcer doesn't respond to aggressive drug treatment.

Lifestyle and home remedies

Before the discovery of H. pylori, doctors often advised people with ulcers to eat a
restricted diet and reduce the amount of stress in their lives. Now that food and stress
have been eliminated as direct causes of ulcers, these factors are no longer of as much
importance. However, while an ulcer is healing, it's still advisable to watch what you
eat and to control stress. Acidic or spicy foods may increase ulcer pain. The same is
true for stress. Stress may increase acid and slow digestion, allowing food and
digestive acid to remain in your stomach and intestines for a longer period. If stress is
severe, it may delay the healing of an ulcer.

Your doctor may also give you this advice:

 Don't smoke. Smoking may interfere with the protective lining of the
stomach, making your stomach more susceptible to the development of an
ulcer. Smoking also increases stomach acid.
 Limit or avoid alcohol. Excessive use of alcohol can irritate and erode the
mucous lining in your stomach and intestines, causing inflammation and
bleeding.
 Avoid nonsteroidal anti-inflammatory drugs (NSAIDs). If you use pain
relievers regularly, use acetaminophen (Tylenol, others).
 Control acid reflux. If you have an esophageal ulcer — usually associated
with acid reflux — you can take several steps to help manage acid reflux.
These include avoiding spicy and fatty foods, avoiding reclining after meals
for at least three hours, raising the head of your bed and reducing your weight.
Avoiding smoking, alcohol and NSAIDs also may help to control acid reflux.