Peptic Ulcer

A peptic ulcer is a round or oval sore where the lining of the stomach or duodenum has been eaten away by stomach acid and digestive juices.

Ulcers penetrate into the lining of the stomach or duodenum (the first part of the small intestine). Gastritis may develop into ulcers.

The names given to specific ulcers identify their anatomic locations or the circumstances under which they developed. Duodenal ulcers, the most common type of peptic ulcer, occur in the duodenum, the first few inches of the small intestine just below the stomach. Gastric ulcers, which are less common, usually occur along the upper curve of the stomach. Marginal ulcers can develop when part of the stomach has been removed surgically, at the point where the remaining stomach has been reconnected to the intestine. As with acute stress gastritis, stress ulcers can occur under the stress of severe illness, skin burns, or trauma. Stress ulcers occur in the stomach and the duodenum.

Causes

Ulcers develop when the lining of the stomach or duodenum is chronically inflamed or exposed to irritants, such as excess stomach acid, and digestive enzymes, such as pepsin.

Almost everyone produces stomach acid, but only 1 of 10 people develops ulcers at some point during his or her lifetime. Different people generate different amounts of stomach acid, and a person's pattern of acid secretion tends to persist throughout life. People who normally secrete more acid (high secretors) have a greater tendency to develop peptic ulcers than those who secrete less acid (low secretors). However, other factors besides acid secretion are involved, because most people who are high secretors never develop ulcers, and some people who are low secretors do develop them. In addition, ulcers are common among older people, even though less acid is produced with age.

By far, the two most common causes of peptic ulcer are infection with Helicobacter pylori bacteria and use of certain drugs. Many drugs, especially aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids, irritate the stomach lining and can cause ulcers. However, most people who take NSAIDs or corticosteroids do not develop peptic ulcers. Regardless, some experts suggest that people at high risk of developing peptic ulcers should use a new type of NSAID called a coxib (COX-2 inhibitor) rather than one of the older types of NSAIDs, because coxibs are less likely to irritate the stomach (see Section 6, Chapter 78).

People who smoke are more likely to develop a peptic ulcer than people who do not smoke, and their ulcers heal more slowly. Although psychologic stress can increase acid production, no link has been found between psychologic stress and peptic ulcers.

A rare cause of ulcers is cancer. The symptoms of cancerous ulcers are very similar to those of noncancerous ulcers. However, cancerous ulcers usually do not respond to the treatments used for noncancerous ulcers.

Symptoms

The typical ulcer tends to heal and recur; thus, pain may occur for days or weeks and then wane or disappear. Symptoms can vary with the location of the ulcer and the person's age. For example, children and older people may not have the usual symptoms or may have no symptoms at all. In these instances, ulcers are discovered only when complications develop.

Only about half of the people with duodenal ulcers have the typical symptoms of gnawing, burning, aching, soreness, an empty feeling, and hunger. The pain is steady and mild or moderately severe, and it is usually located just below the breastbone. For many people with a duodenal ulcer, pain is usually absent on awakening but appears by midmorning. Drinking milk or eating (which buffers stomach acid) or taking antacids generally relieves the pain, but it usually returns 2 or 3 hours later. Pain that awakens the person during the night is common. Frequently, the pain erupts once or more a day over a period of one to several weeks and then may disappear without treatment. However, pain usually recurs, often within the first 2 years and occasionally after several years. People generally develop patterns and often learn by experience when a recurrence is likely (commonly in spring and fall and during periods of stress).

The symptoms of gastric, marginal, and stress ulcers, unlike those of duodenal ulcers, do not follow any pattern. Eating may relieve pain temporarily or may cause pain rather than relieve it. Gastric ulcers sometimes cause swelling of the tissues (edema) that lead into the small intestine, which may prevent food from easily passing out of the stomach. This blockage may cause bloating, nausea, or vomiting after eating.

Complications of peptic ulcers, such as bleeding or rupture, are accompanied by symptoms of low blood pressure, such as dizziness and fainting.

See the sidebar What Are the Complications of Peptic Ulcers?

Diagnosis

A doctor suspects an ulcer when a person has characteristic stomach pain. Sometimes the doctor simply treats the person for an ulcer to see if the symptoms resolve, which suggests that the person had an ulcer that has healed.

Tests may be needed to confirm the diagnosis, especially when symptoms do not resolve after a few weeks of treatment, because stomach cancer can cause similar symptoms. Also, when severe ulcers resist treatment, particularly if a person has several ulcers or the ulcers are in unusual places, a doctor may suspect an underlying condition that causes the stomach to overproduce acid.

To help diagnose ulcers and determine their cause, the doctor may use endoscopy (a procedure performed using a flexible viewing tube) or barium contrast x-rays (x-rays taken after a substance that outlines the digestive tract has been swallowed).

Endoscopy is usually the first diagnostic procedure ordered by a doctor. Endoscopy is more reliable than barium contrast x-rays for detecting ulcers in the duodenum and on the back wall of the stomach; endoscopy is also more reliable if the person has had stomach surgery. However, even a highly skilled endoscopist may miss a small number of gastric and duodenal ulcers. With an endoscope, a doctor can perform a biopsy (removal of a tissue sample for examination under a microscope) to determine if a gastric ulcer is cancerous and to help identify the presence of Helicobacter pylori bacteria. An endoscope also can be used to stop active bleeding and decrease the likelihood of recurring bleeding from an ulcer.

Barium contrast x-rays of the stomach and duodenum (also called a barium swallow or an upper gastrointestinal series) can help determine the severity and size of an ulcer, which sometimes cannot be completely seen on endoscopy.

Treatment

Because infection with H. pylori bacteria is a major cause of ulcers, antibiotics are often used. Sometimes bismuth subsalicylate is used in combination with antibiotics. Neutralizing or reducing stomach acid by using drugs that directly inhibit the stomach's production of acid promotes healing of peptic ulcers regardless of the cause. In most people, treatment is continued for 4 to 8 weeks. Although bland diets may help reduce acid, no evidence supports the belief that such diets speed healing or keep ulcers from recurring. Nevertheless, it makes sense for people to avoid foods that seem to make pain and bloating worse. Eliminating possible stomach irritants, such as NSAIDs, alcohol, and nicotine, is also important.

Antacids: Antacids relieve symptoms of ulcers by neutralizing stomach acid. Their effectiveness varies with the amount of antacid taken and the amount of acid a person produces. Almost all antacids can be purchased without a doctor's prescription and are available in tablet or liquid form. Generally, antacids are not effective in healing ulcers.

Sodium bicarbonate and calcium carbonate, the strongest antacids, may be taken occasionally for short-term relief. However, because they are absorbed by the bloodstream, continual use of these drugs may make the blood too alkaline (alkalosis (see Section 12, Chapter 159)), resulting in nausea, headache, and weakness. Therefore, these antacids generally should not be used in large amounts for more than a few days. These products also contain a lot of salt and should not be used by people who need to follow a low-sodium diet.

Aluminum hydroxide is a relatively safe, commonly used antacid. However, aluminum may bind with phosphate in the digestive tract, reducing phosphate levels in the blood and causing weakness and a loss of appetite. The risk of these side effects is greater in alcoholics and in people with kidney disease, including those receiving dialysis. Aluminum hydroxide may also cause constipation.

Magnesium hydroxide is a more effective antacid than aluminum hydroxide. Bowel movements usually remain regular if only four doses of 1 to 2 tablespoons a day are taken; more than four doses a day may cause diarrhea. Because small amounts of magnesium are absorbed into the bloodstream, people with kidney damage should take magnesium hydroxide only in small doses. Many antacids contain both magnesium hydroxide and aluminum hydroxide.

Acid-reducing Drugs: Histamine-2 (H₂) blockers, such as cimetidine, famotidine, nizatidine, and ranitidine, relieve symptoms and promote ulcer healing by reducing the production of stomach acid. These highly effective drugs are taken once or twice a day. H₂ blockers usually do not cause serious side effects. However, cimetidine is more likely to cause side effects, particularly in older people, in whom the drug may cause confusion. In addition, cimetidine may interfere with the body's elimination of certain drugs--such as theophylline for asthma, warfarin for excessive blood clotting, and phenytoin for seizures.

Proton pump inhibitors are the most potent of the drugs that reduce acid production. Proton pump inhibitors promote healing of ulcers in a greater percentage of people in a shorter period of time than do H₂ blockers. They are also very useful in treating conditions that cause excessive stomach acid secretion, such as Zollinger-Ellison syndrome.

See the sidebar Zollinger-Ellison Syndrome: An Acid-Generating Cancer.

Miscellaneous Drugs: Sucralfate may work by forming a protective coating in the base of an ulcer to promote healing. It works well on peptic ulcers and is a reasonable alternative to antacids. Sucralfate is taken 2 to 4 times a day and is not absorbed into the bloodstream, so it causes few side effects. It may, however, cause constipation, and in some cases it reduces the effectiveness of other drugs.

Misoprostol may be used to reduce the likelihood of developing stomach and duodenal ulcers caused by NSAIDs. Misoprostol may work by reducing production of stomach acid and by making the stomach lining more resistant to acid. People who are at higher risk of developing an ulcer caused by NSAIDs for other reasons, including older people, people taking corticosteroids, and people who have a history of ulcers, may also be potential candidates for misoprostol. However, misoprostol causes diarrhea and other digestive problems in more than 30% of people who take it. In addition, this drug can cause spontaneous abortions in pregnant women. Alternatives to misoprostol are available for people taking aspirin, NSAIDs, or corticosteroids. These alternatives, such as proton pump inhibitors, are just as effective for reducing the likelihood of developing an ulcer and cause fewer side effects.

See the drug table Drugs Used to Treat Peptic Disorders.

Surgery: Surgery for ulcers is now seldom needed because drugs so effectively heal peptic ulcers and endoscopy so effectively stops active bleeding. Surgery is used primarily to deal with complications of a peptic ulcer, such as a perforation, an obstruction that fails to respond to drug therapy or that recurs, two or more major episodes of bleeding ulcers, a gastric ulcer suspected of being cancerous, or severe and frequent recurrences of peptic ulcers. A number of different operations may be performed to treat these problems. However, ulcers may recur after surgery, and each procedure may cause problems of its own, such as weight loss, poor digestion, and anemia.