Peptic Ulcers

What is a peptic ulcer?

A peptic ulcer —peptic is defined as pertaining to, or associated with, digestion— is a break in the surface lining of the stomach or duodenum which is deep enough to produce a shallow crater (ulcer) in its wall.

An illustration showing examples of peptic ulcers.

Peptic ulcers are found approximately four times as often in the duodenum than in the stomach, and can also be found, albeit rarely, in the lower esophagus or beyond the duodenum in the small intestine.

Some other facts include:

  • duodenal ulcers are more common in men, whereas gastric ulcers affect men and women more or less equally
  • ulcers are found at all ages but are more common with increasing age
  • ulcers may appear acutely or develop slowly and chronically
  • close to 10% of all adults may suffer from peptic ulcer disease at some time in their lives

What causes peptic ulcers?

It is now known that over 90% of duodenal ulcers are the result of infection with helicobacter pylori (HP). It is not known for certain how this bacteria is transmitted but infection is more common in areas of poverty, poor sanitation and overcrowding.

The vast majority of infected people remain healthy and without symptoms … but for unknown reasons, a small percentage develop peptic ulcer disease. After infection, the bacteria lives close to the surface lining of the stomach, underneath the layer of mucus, where it is protected from acid.

As a result, acid secretion, in response to a meal, increases. It is thought that this excessive amount of acid causes further damage to the stomach and/or duodenum, thus leading to ulcer development.

H Pylori is also thought to be responsible for 60–70% of gastric ulcers. Other gastric ulcers usually occur in patients taking aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs).

Aspirin and NSAIDs

Aspirin and other NSAIDs (nonsteroidal anti-inflammatory drugs) damage the lining of the stomach and make it more susceptible to damage from acid and enzymes. These drugs, however, only play a small role in causing ulcers but may flare up existing ulcers. Not everybody is at risk of the side effects of NSAIDs. People at higher risk of complications include those over the age of sixty, those taking high doses, and those with a past history of peptic ulcer or complications from these drugs. Some NSAIDs are safer than others and if prescribed one of these medications, you should check with your doctor that it is safe to take it.

Family history and peptic ulcers

There is often a family history of peptic ulcer disease but reasons for this are unclear and peptic ulcers are not strictly a genetic disease.

Smoking also carries an increased risk of ulcers. Complications of ulcers, including delayed healing, are more common in smokers than in non-smokers. Lastly, ulcers may very rarely be the result of a hormone-producing tumor (gastrinoma) which leads to massive acid production. Ulcers in this condition are often multiple, aggressive and resistant to therapy. This condition is rare and accounts for only approximately 1% of all ulcers.

An internal image of a duodenal ulcer.
An internal image of a duodenal ulcer.

Can peptic ulcers be prevented?

At present there is no good evidence that widespread antibiotic therapy to eradicate helicobacter pylori in the population will prevent ulcer disease. This is the subject on ongoing debate by specialists and may change in the future. Careful use of aspirin and other NSAIDs, as well as avoidance by people at high risk of complications, is also recommended. Stopping smoking may also reduce the chances of developing and ulcer.

What are the symptoms and signs of an ulcer?

Peptic ulcers are usually chronic and may come and go over a period of many years, even without treatment. The most common symptoms are:

  • abdominal pain, usually located in the upper central abdomen
  • pain which may also be felt in the back
  • pain which may be worse when the stomach is empty; although not always the case, this pain can sometimes be relieved by eating
  • pain which wakes a patient from sleep
  • indigestion or heartburn,
  • vomiting and anemia.

In a few patients, an ulcer may be silent until it erodes completely through the gut wall causing perforation, or erodes into a blood vessel causing bleeding. These complications are serious and usually present as an emergency.

How are peptic ulcers diagnosed?

In most cases the diagnosis is made by endoscopy, at which time the ulcer is usually seen and can be biopsied if it appears suspicious for malignancy. Biopsies of the stomach can also be taken to look for the presence of HP organisms.

A further advantage of endoscopy is that treatment can be carried out at the same time if the ulcer is bleeding. The majority of ulcers can also be diagnosed by careful barium meal examination and this is an alternative for patients who cannot or do not wish to have endoscopy. Because of the ability to take biopsies and perform endoscopic treatment, endoscopy is the perferred method of investigation.

Although biopsies of the stomach are the "gold standard" for diagnosing HP infection, it is possible to diagnose the infection by using a simple breath test. A number of blood tests for the infection are also available but these are less accurate.

Routine blood tests are usually normal in patients with ulcers apart from those where bleeding has resulted in anemia.

An internal image of a gastric ulcer.
An internal image of a gastric ulcer.

How are peptic ulcers treated?

The goals of treatment for peptic ulcers are:

  • relieve symptoms quickly
  • heal the ulcer
  • prevent it from recurring in the future

Treatment of a helicobacter pylori infection is now recognized as the most important aspect of treatment. All ulcer patients who are infected with bacteria should be offered antibiotic therapy. Usually this requires a combination of drugs for which many different combinations are available. Usually an acid-suppressing drug is necessary to relieve symptoms and induce ulcer healing, but also to boost the effects of the antibiotics. At the same time, two antibiotics are usually necessary to ensure successful eradication of the infection.

This "triple therapy" (an acid-suppressing medication plus two antibiotics) is usually taken for one to two weeks and is 80–90% successful in getting rid of the infection. Symptoms may take longer to disappear completely, but when they do there is little need to perform further tests to ensure that treatment has worked.

Patients who have had serious complications from their ulcer (such as bleeding or perforation) should undergo repeat testing to ensure that the treatment is successful. For patients whose infection persists after antibiotic therapy, "second line" therapy (using a different combination of medicines) is usually given and is successful most of the time. A few patients fail this therapy and require long term acid-suppression therapy to prevent ulcer recurrence.

Managing ulcers

Important steps in management of peptic ulcers include:

  • stopping smoking;
  • curtailing excessive alcohol intake; and,
  • avoiding aspirin and other NSAIDs, if possible.

No specific dietary measures are required. Long-term treatment with acid-suppressing drugs is not usually necessary after successful helicobacter pylori therapy.