Ulcers

PEPTIC ULCER OVERVIEW

Peptic ulcers are sores that form in the lining of the digestive (gastrointestinal) tract. They usually occur in the stomach (gastric ulcer) or in the duodenum (duodenal ulcer), which is the upper region of the small intestine. The two primary causes of peptic ulcers are infection with a specific bacteria called Helicobacter pylori and the use of aspirin and nonsteroidal anti-inflammatory medications. Ulcers also occur in other areas such as the esophagus and colon but are due to different mechanisms and are not considered peptic ulcers.

HOW ULCERS DEVELOP

The stomach and duodenal lining have several ways to protect from the injurious affect of stomach acid and thus prevent ulcers from developing.  A coating of mucus (mucous layer) protects the stomach lining from the effects of acidic digestive juices. Food and other substances in the stomach neutralize acid.  There are proteins called prostaglandins produced by the stomach that protect the lining cells.

If these protective barriers are altered, digestive juices and stomach acid can cause irritation and breakdown of the stomach or duodenal lining, allowing an ulcer sore to form.

PEPTIC ULCER SYMPTOMS

Peptic ulcers can cause no symptoms or mild to severe symptoms. It is not possible to reliably differentiate between gastric (stomach) and duodenal (small intestine) ulcers based on symptoms.

Pain is a typical ulcer symptom. It is usually located in the upper mid abdomen “in the pit of the stomach”.  It can be burning or gnawing and can be made better or worse by eating.  The pain can wake one up during sleep when there is a peak of gastric acid production (typically around 3AM).  Ulcers can also cause nausea and vomiting and loss of appetite.

Bleeding from ulcers is usually not preceded by abdominal pain.  Bleeding can manifest with vomiting of red blood or of partially digested blood, which looks like coffee grounds.  Usually the stools turn smelly and tarry black or bloody.

Ulcers can perforate (bore a hole all the way through the wall) which presents as acute severe abdominal pain. Urgent medical and surgical attention is then needed.

PEPTIC ULCER CAUSES

Helicobacter pylori is a bacteria that can cause ulcers. This bacteria does not cause the symptoms usually associated with infection (fever, fatigue etc) and for many years was thought to be an innocent bystander.  It took Nobel prize winning work by Dr Barry Marshall who himself ingested the bacteria to prove the relationship between this infection and ulcers.  H. pylori reduces the protective barrier and allows stomach acid to have a caustic effect, producing inflammation and ulcers.

Aspirin and Nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen and naproxen (and many others) cause ulcers by direct chemical effect.

Smoking has an adverse effect on the stomach lining and its protective barrier and can predispose to ulcers.

Stress, of the psychological kind and dietary factors were once thought to cause of ulcers, they do not.

Physiological stress, such as severe burns or severe illness in the hospital intensive care unit can predispose to ulcers.

PEPTIC ULCER DIAGNOSIS

There are many causes of abdominal “ulcer-like” pain. Many who have ulcer symptoms do not actually have an ulcer. Similar symptoms can be caused by a wide variety of conditions such as functional dyspepsia (the presence of ulcer-symptoms without a visible cause), abnormal emptying of the stomach (gastroparesis), acid reflux, gallbladder problems, irritable bowel, rarely stomach cancer, and more. Testing for the cause of symptoms will usually lead to specific treatment.

H. pylori can be tested for with blood, stool, breath testing, and endoscopy.  Endoscopy often provides not only accurate H. pylori testing but also directly visualizes the upper GI tract for specific abnormalities and diagnosis. Those who test positive for H. pylori are treated for the infection with a combination of acid blockers and antibiotics.   (See article on H pylori on our web site in the Diseases section).

Upper endoscopy is performed in a sedated patient by passing a thin flexible scope via the mouth into the upper GI tract.  Ulcers and other abnormalities can be directly visualized. Endoscopy is especially performed when there are “alarm” symptoms such as weight loss, difficulty swallowing, or anemia, and if the person is older (higher risk for complications and cancer).

  Stomach ulcer as seen during endoscopy

UGI barium X-ray studies are performed by drinking a white barium solution and taking X-rays of the area as it passes through. It is a non-invasive way to diagnose most ulcers but lacks the ability to see more subtle abnormalities and can not biopsy or test for H pylori.

PEPTIC ULCER COMPLICATIONS

Peptic ulcers can heal spontaneously and may come and go. They can also be associated with serious, potentially life-threatening complications, sometimes without warning signs. This is most common in elderly patients and those who take NSAIDs but can occur in others. The most common complications of ulcers are bleeding and perforation.

Bleeding from ulcers can be gradual or abrupt. Blood can be vomited (red blood or digested coffee grouds appearance), seen in the stool (black tarry or red bloody stools) or cause anemia detected on blood work.  Bleeding is evaluated with endoscopy during which cautery and clipping and injection techniques can be used to control the bleeding, if needed. Severe or recurrent bleeding can require surgery to control. Only about 2 to 5 percent of people with a peptic ulcer require surgery.

Bleeding ulcer seen during endoscopy

Perforation is the term for a puncture of the stomach lining or duodenum caused by the ulcer boring a hole through the intestinal wall. Perforation usually causes sudden severe abdominal pain and usually requires urgernt surgery.

Scarring can develop from chronic ulcers.  This can lead to narrowing and obstruction of the stomach or duodenum.  Balloon dilation during endoscopy can sometimes be used otherwise surgery is necessary to correct this complication of ulcers.

PEPTIC ULCER TREATMENT

Most ulcers can be healed with medications. Surgery is rarely needed, except when significant complications have developed.

The initial step in treating an ulcer is to identify that an ulcer exists as the cause of symptoms. To treat, acid blocking medications are begun. There are two classes of acid blockers: H2 blockers (ranitidine, cimetidine, famotidine) and proton pump inhibitors (PPI’s).  PPI medications include lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), dexlansoprazole (Dexilant), rabeprazole (AcipHex), Zegerid, and esomeprazole (Nexium and are usually preferred as they are more potent and more effective.

The cause of the ulcer then needs to be determined. NSAIDs (ibuprofen, naproxen etc) should be stopped. Aspirin should be stopped, if possible.  If aspirin is being used for pain or for prevention of heart attack or stroke with no prior history of these, it can usually be discontinued.  When aspirin is used because of preexisting heart disease or stroke, the decision to stop or continue is individualized.

If H. pylori is found, treatment is given with acid blockers plus a combination of antibiotics.   No single antibiotic effectively rids H. pylori infection. Treatment involves taking several medications for 7 to 14 days.  Commonly used antibiotics are amoxicillin, metronidazole (Flagyl), claritromycin (Biaxin), and tetracycline plus a PPI acid blocker – all given twice daily.

ULCER HEALING AND ULCER PREVENTION

  • Stop smoking.
  • Avoid NSAIDs and aspirin, if possible.  If these medications are needed, use in the lowest dose possible and for the shortest duration needed.
  • Complicated ulcers (bleeding or perforation) that were associated with H. pylori are often retested for H. pylori after treatment to make sure that antibiotic therapy was successful.
  • Gastric ulcers are often reevaluated with endoscopy 1-3 months after initial diagnosis to assure ulcer healing and to obtain a biopsy specimen if the ulcer has not yet healed.
  • Stress (emotional or psychological stress) does not cause ulcers but can accentuate the symptoms of an underlying ulcer.