Peptic ulcer is the term used to describe a defect or injury that occurs in the inner lining (mucosa) of the stomach and small intestine. Peptic comes from the Greek term peptikos, meaning related to digestion. Ulcers occurring in the stomach and small intestine were initially believed to be due entirely to acid and the digestive enzyme pepsin, both produced by the stomach. However, research has revealed that peptic ulcer disease can have a variety of causes other than increased production of stomach acid and pepsin, although some stomach acid is necessary for the development of ulcers. Most ulcers of the small intestine occur in the duodenum, the first portion of the small intestine.
The most common cause of ulcers is H. pylori, a bacteria that colonizes (lives in) the stomach of nearly half the world’s population. H. pylori is acquired early in childhood and colonization can be lifelong. H. pylori is transmitted from person to person through saliva, vomitus, or feces. Although millions of people are colonized with H. pylori, only a small percentage will develop a peptic ulcer. Factors such as the strain (type) of H. pylori, genetic differences among individuals, and NSAID or tobacco use may influence ulcer development. H. pylori creates ulcers by causing inflammation of the stomach and small intestinal mucosa as well as increasing stomach acid production.
NSAIDs cause peptic ulcers in two ways. First, when NSAIDs come in direct contact with the mucosa of the stomach or small intestine, they cause irritation and literally eat away at the mucosa. In addition, a chemical reaction caused by NSAIDs can dissolve the protective mucus layer that overlies the mucosa of the stomach and protects the stomach lining from damage by acid and pepsin.
While NSAIDs and H. pylori are the two most common causes of peptic ulcer, other causes exist. For example, medications such as corticosteroids (an immune suppressant), potassium chloride, and bisphosphonates (used to treat osteoporosis) can cause ulcers. In addition, Crohn’s disease, a disorder that typically causes inflammation in the distal small intestine and colon, as well as infection caused by cytomegalovirus or herpes simplex virus, can lead to ulcers in the stomach and small intestine.
A common belief is that stress can cause ulcers, but this is not generally the case. However, ulcers can develop in patients who are critically ill and hospitalized in an intensive care unit; such ulcers are often referred to as “stress” ulcers. These ulcers are likely the result of reduced blood flow to the stomach and small intestine. When blood flow to the GI tract is inadequate the tissue is not supplied with necessary oxygen and nutrients. When this occurs tissue damage and death can occur, leading to ulceration.
A rare cause of peptic ulcer is Zollinger-Ellison syndrome, which results from tumors (gastrinomas) that produce the hormone gastrin, which stimulates production of excess stomach acid.
Peptic ulcers in the stomach must be distinguished from gastric cancer and other types of stomach tumors that can sometimes look like benign ulcers and cause similar symptoms.
To determine if NSAIDs are the cause of an ulcer, the patient’s medications, both prescribed and over the counter, should be carefully reviewed. If a person is taking an NSAID, it is important to determine the daily dose consumed. Daily use of moderate to high doses of NSAIDs points toward the medication as the cause of an ulcer. If a patient has no history of recent NSAID use, an investigation for other causes of the ulcer must be continued.
Upper endoscopy is the procedure of choice for confirming the presence of an ulcer by direct visualization of the stomach and duodenum. (Figure 1) During an upper endoscopy, while the patient is under sedation, a scope with a camera attached to the end is inserted into the patient’s mouth and passed through the esophagus to the stomach and duodenum. The camera can identify ulcers, and the scope can obtain biopsies (tissue samples) to test for H. pylori and to make sure that any ulcer in the stomach is not cancerous. If an ulcer is bleeding, treatment to stop the bleeding, such as electrocautery, can be administered.
An upper gastrointestinal series is a radiologic test that can be used to detect ulcers. Barium sulfate is swallowed by the patient, and a series of x-rays is taken to demonstrate ulcers. The test is used less commonly than in the past because upper endoscopy is generally more accurate and permits biopsy and other interventions.
For some patients who present with dyspepsia, it may be appropriate to treat the symptoms without performing an endoscopy or upper gastrointestinal series. For patients under the age of 55 years without “alarm” symptoms (such as anemia, severe weight loss, gastrointestinal bleeding, or vomiting) that raise the possibility of gastric cancer or an ulcer complication, treatment of H. pylori, if detected by blood testing, can be prescribed. If symptoms do not resolve after H. pylori treatment or if a test for H. pylori is negative, treatment with a proton pump inhibitor (see below) to suppress gastric acid production can be tried. Further investigation with upper endoscopy should be undertaken if symptoms persist.
If NSAIDs are believed to be the culprit, the NSAID should be stopped, if possible, and treatment with a PPI started. If the patient must continue to take the NSAID (as for arthritis), then the PPI should be continued indefinitely.
Several important lifestyle changes can aid in ulcer healing. Both alcohol and smoking hinder ulcer healing and should be stopped. Caffeine can increase production of stomach acid, thereby worsening pain from ulcers and slowing the rate of healing. Therefore, coffee, tea, soda, and chocolate should be avoided. Fatty foods and spicy foods may also increase gastric acid production and should be avoided. Many patients find symptomatic improvement in a diet that emphasizes bland foods or small, frequent meals during the period of ulcer treatment.
Surgery is rarely required nowadays for the treatment of ulcers. It was commonly undertaken in the past before the advent of effective medical therapy. Surgery, including resection (removal) of part of the stomach, cutting the vagus nerve (which stimulates gastric acid secretion), or sewing an ulcer closed, is now reserved for ulcers that do not respond to medical therapy or are associated with a complication (see below).(4)
Perforation is another serious complication that occurs when an ulcer penetrates the wall of the stomach or small intestine. Perforation is a surgical emergency and requires repair with either a patch closure of the hole or resection of the perforated section of stomach or small intestine.
Gastric outlet obstruction occurs when recurrent ulcers develop at the end of the stomach or in the canal (pyloric channel) between the stomach and the duodenum and lead to scarring and narrowing. Patients develop recurrent vomiting associated with weight loss and abdominal pain. Treatment includes a PPI, eradication of H. pylori if present, and decompression of the stomach with a tube passed via the nose (“nasogastric tube”). Occasionally, surgical resection is necessary.
Fortunately, the prognosis for PUD is very good. The majority of peptic ulcers resolve with antibiotic therapy for H. pylori, withdrawal of NSAIDs, and/or use of PPIs. Fewer than 10% of patients who undergo these measures will have recurrent PUD, and most will respond to repeated treatment.
Causes
The two most common causes of peptic ulcer by far are the bacteria Helicobacter pylori (H. pylori) and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen. (1, 2)
The most common cause of ulcers is H. pylori, a bacteria that colonizes (lives in) the stomach of nearly half the world’s population. H. pylori is acquired early in childhood and colonization can be lifelong. H. pylori is transmitted from person to person through saliva, vomitus, or feces. Although millions of people are colonized with H. pylori, only a small percentage will develop a peptic ulcer. Factors such as the strain (type) of H. pylori, genetic differences among individuals, and NSAID or tobacco use may influence ulcer development. H. pylori creates ulcers by causing inflammation of the stomach and small intestinal mucosa as well as increasing stomach acid production.
NSAIDs cause peptic ulcers in two ways. First, when NSAIDs come in direct contact with the mucosa of the stomach or small intestine, they cause irritation and literally eat away at the mucosa. In addition, a chemical reaction caused by NSAIDs can dissolve the protective mucus layer that overlies the mucosa of the stomach and protects the stomach lining from damage by acid and pepsin.
While NSAIDs and H. pylori are the two most common causes of peptic ulcer, other causes exist. For example, medications such as corticosteroids (an immune suppressant), potassium chloride, and bisphosphonates (used to treat osteoporosis) can cause ulcers. In addition, Crohn’s disease, a disorder that typically causes inflammation in the distal small intestine and colon, as well as infection caused by cytomegalovirus or herpes simplex virus, can lead to ulcers in the stomach and small intestine.
A common belief is that stress can cause ulcers, but this is not generally the case. However, ulcers can develop in patients who are critically ill and hospitalized in an intensive care unit; such ulcers are often referred to as “stress” ulcers. These ulcers are likely the result of reduced blood flow to the stomach and small intestine. When blood flow to the GI tract is inadequate the tissue is not supplied with necessary oxygen and nutrients. When this occurs tissue damage and death can occur, leading to ulceration.
A rare cause of peptic ulcer is Zollinger-Ellison syndrome, which results from tumors (gastrinomas) that produce the hormone gastrin, which stimulates production of excess stomach acid.
Peptic ulcers in the stomach must be distinguished from gastric cancer and other types of stomach tumors that can sometimes look like benign ulcers and cause similar symptoms.
Symptoms
The most common symptom of a peptic ulcer is dyspepsia, defined as pain or discomfort that is located in the mid, upper abdomen and may radiate to the back. Dyspepsia associated with duodenal ulcer characteristically improves with eating and worsens with fasting and at night. In contrast, the discomfort or pain of gastric (stomach) ulcer often worsens with eating and may be accompanied by poor appetite and weight loss. Additional symptoms such as gastrointestinal bleeding (which can lead to shock and damage to the heart, kidneys, and brain), severe weight loss, and persistent vomiting or the presence of anemia (low blood count) raise concern that the ulcer is bleeding or is cancerous. These signs and symptoms are concerning and warrant evaluation by a healthcare professional.Diagnosis
The diagnosis of peptic ulcer is typically confirmed by endoscopy or a radiologic study. The physical examination in a patient with a peptic ulcer is usually normal, although abdominal tenderness may be detected in some patients. Laboratory testing can reveal anemia and iron deficiency in some cases. Blood tests for H. pylori can determine if a person has been exposed to the bacteria. However, a positive blood test result may signify evidence of previous exposure to H. pylori and does not prove that H. pylori is the cause of an ulcer. A positive test for the presence of H. pylori antigen in the stool indicates that a person is currently infected with the organism and is stronger evidence that H. pylori is the cause of an ulcer. Another method for confirming infection is a test for the presence of urea in a person’s breath; breath urea is only positive when H. pylori is in the stomach.To determine if NSAIDs are the cause of an ulcer, the patient’s medications, both prescribed and over the counter, should be carefully reviewed. If a person is taking an NSAID, it is important to determine the daily dose consumed. Daily use of moderate to high doses of NSAIDs points toward the medication as the cause of an ulcer. If a patient has no history of recent NSAID use, an investigation for other causes of the ulcer must be continued.
Upper endoscopy is the procedure of choice for confirming the presence of an ulcer by direct visualization of the stomach and duodenum. (Figure 1) During an upper endoscopy, while the patient is under sedation, a scope with a camera attached to the end is inserted into the patient’s mouth and passed through the esophagus to the stomach and duodenum. The camera can identify ulcers, and the scope can obtain biopsies (tissue samples) to test for H. pylori and to make sure that any ulcer in the stomach is not cancerous. If an ulcer is bleeding, treatment to stop the bleeding, such as electrocautery, can be administered.
An upper gastrointestinal series is a radiologic test that can be used to detect ulcers. Barium sulfate is swallowed by the patient, and a series of x-rays is taken to demonstrate ulcers. The test is used less commonly than in the past because upper endoscopy is generally more accurate and permits biopsy and other interventions.
For some patients who present with dyspepsia, it may be appropriate to treat the symptoms without performing an endoscopy or upper gastrointestinal series. For patients under the age of 55 years without “alarm” symptoms (such as anemia, severe weight loss, gastrointestinal bleeding, or vomiting) that raise the possibility of gastric cancer or an ulcer complication, treatment of H. pylori, if detected by blood testing, can be prescribed. If symptoms do not resolve after H. pylori treatment or if a test for H. pylori is negative, treatment with a proton pump inhibitor (see below) to suppress gastric acid production can be tried. Further investigation with upper endoscopy should be undertaken if symptoms persist.
Treatment
Treatment of a peptic ulcer is based on the cause. If an ulcer is believed to be caused by H. pylori infection, the patient is often treated with two antibiotics and a proton pump inhibitor (PPI), a medication that suppresses gastric acid secretion, for one to two weeks, after which the PPI is continued alone for another four to six weeks. (3) If symptoms persist after completion of a course of therapy and a test for H. pylori remains positive, the H. pylori is considered resistant to the antibiotics prescribed. In that case, a different combination of antibiotics and ulcer medications (up to a total of four different medications) may be prescribed. Once H. pylori infection is cured, it is rare for the organism to recur.If NSAIDs are believed to be the culprit, the NSAID should be stopped, if possible, and treatment with a PPI started. If the patient must continue to take the NSAID (as for arthritis), then the PPI should be continued indefinitely.
Several important lifestyle changes can aid in ulcer healing. Both alcohol and smoking hinder ulcer healing and should be stopped. Caffeine can increase production of stomach acid, thereby worsening pain from ulcers and slowing the rate of healing. Therefore, coffee, tea, soda, and chocolate should be avoided. Fatty foods and spicy foods may also increase gastric acid production and should be avoided. Many patients find symptomatic improvement in a diet that emphasizes bland foods or small, frequent meals during the period of ulcer treatment.
Surgery is rarely required nowadays for the treatment of ulcers. It was commonly undertaken in the past before the advent of effective medical therapy. Surgery, including resection (removal) of part of the stomach, cutting the vagus nerve (which stimulates gastric acid secretion), or sewing an ulcer closed, is now reserved for ulcers that do not respond to medical therapy or are associated with a complication (see below).(4)
Follow-Up
Most peptic ulcers heal with appropriate therapy. However, approximately 2% of ulcers in the stomach actually turn out to be cancers and not benign ulcers. Therefore, it is important that all patients with a gastric ulcer found on endoscopy undergo a repeat endoscopy four to eight weeks later to ensure that the ulcer has healed (or is healing) on therapy. (3) If the ulcer fails to heal, additional studies, including biopsy, are needed to exclude cancer. Endoscopy need not be repeated after treatment of duodenal ulcers, because they are always benign.Complications
One of the more common and alarming complications of peptic ulcer disease is gastrointestinal (GI) bleeding. Gl bleeding occurs when an ulcer erodes into an underlying blood vessel. Patients may present with vomiting blood (hematemesis), black tarry stools (as a result of the interaction between stomach acid and blood in the intestine), or anemia. Severe bleeding can lead to shock and damage to the heart, kidneys, and brain. Urgent therapy consists of administration of fluid and blood to restore the patient’s blood pressure and interventions via an endoscope to arrest bleeding and prevent recurrent bleeding. Endoscopic methods to arrest bleeding include the injection of agents that constrict blood vessels (such as epinephrine), electrocautery, and application of clips that seal the bleeding vessel. In occasional instances when these measures are ineffective at stopping the bleeding, radiologic measures such as angiography or surgery is required. (See Knol on Upper Gastrointestinal Bleeding)Perforation is another serious complication that occurs when an ulcer penetrates the wall of the stomach or small intestine. Perforation is a surgical emergency and requires repair with either a patch closure of the hole or resection of the perforated section of stomach or small intestine.
Gastric outlet obstruction occurs when recurrent ulcers develop at the end of the stomach or in the canal (pyloric channel) between the stomach and the duodenum and lead to scarring and narrowing. Patients develop recurrent vomiting associated with weight loss and abdominal pain. Treatment includes a PPI, eradication of H. pylori if present, and decompression of the stomach with a tube passed via the nose (“nasogastric tube”). Occasionally, surgical resection is necessary.
Fortunately, the prognosis for PUD is very good. The majority of peptic ulcers resolve with antibiotic therapy for H. pylori, withdrawal of NSAIDs, and/or use of PPIs. Fewer than 10% of patients who undergo these measures will have recurrent PUD, and most will respond to repeated treatment.
Figure 1: Photograph of an ulcer in the stomach as seen on upper endoscopy
References
1. Ramakrishnan K, Salinas RC. Peptic ulcer disease. Am Fam Physician. 2007;76(7):1005-12.
2. Makola D, Peura DA, Crowe SE. Helicobacter pylori infection and related gastrointestinal diseases. J Clin Gastroenterol. 2007;41(6):548-58.
3. Shah R. Dyspepsia and Helicobacter pylori. BMJ. 2007;334(7583):41-3.
4. Behrman SW. Management of complicated peptic ulcer disease. Arch Surg. 2005;140(2):201-8.
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