Gastric Ulcers

Gastric Ulcer - That gnawing feeling in your gut

Have you ever felt like something was eating away at your stomach? Or have you experienced a burning sensation in your abdominal area? If you have, then you just might have an ulcer -- a small crater in your digestive tract created by your stomach's acidic gastric juices. These cause the pain and burning sensation you feel.

Ulcers are generally caused by a bacteria, Helicobacter pylori, that can live in your stomach. While antibiotics can eradicate these bacteria, the exact cause of infection is still unclear. However, risk factors include physical stress, smoking, improper diet, heavy alcohol consumption, and other lifestyle factors.

Pronunciation

GAS-trik UL-ser

Synonyms

  • Peptic ulcer disease

Detailed Description

A gastric ulcer develops once the formation of small erosions along the stomach lining form. Erosion is caused by the acidity of the stomach fluids, which contain hydrochloric acid and the enzyme pepsin (hence the name peptic ulcer). Usually, a thick mucosal layer protects the lining of the gastrointestinal (GI) tract. This layer is continually rebuilt as the acid continually destroys it. Overproduction of acid tips the equilibrium in favor of those forces favoring breakdown, and as the mucosa begins to degrade, erosion occurs and an ulcer begins to form. Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause or worsen this condition.

The mechanisms of erosion are still not fully understood, but somehow, Helicobacter pylori are able to survive stomach's acidic environment and reproduce in its mucosa. This infection causes tissue damage and leads to ulcer formation.

If you think you might have an ulcer, it's important to seek medical advice for diagnosis and treatment. If left untreated, an ulcer can further erode the mucosa until bleeding, obstruction, or perforation occurs. Follow-up is always recommended, as recurrence is likely if H. pylori is not completely eradicated. In some untreated cases, gastric ulcers have been shown to progress to malignancy, leading to a greater chance of developing stomach cancer.

A wide range of therapies exist to effectively treat symptoms and heal ulcers, so only in rare cases is surgery needed. So it's important to realize that treatment failure does not necessarily mean that your case is untreatable. The main reason treatments fail is noncompliance (i.e., not sticking to the medical treatment your doctor has suggested). Risk factors like alcohol, caffeine, aspirin and other NSAIDs, (such as ibuprofen) and especially cigarettes have been shown to aggravate existing ulcers, so it's important to follow your doctor's advice regarding diet and lifestyle modifications.

Characteristics of Gastric Ulcers

A gastric ulcer is one that forms within (or very near) the stomach. The ulcer is usually a crater anywhere from one to two inches in diameter. The surrounding area is typically inflamed.

How Common Are Gastric Ulcers?

Approximately 4 million Americans develop an ulcer or a recurrence due to a previous ulcer each year, with over 90,000 of those cases attributed to gastric ulcers. Anyone can develop an ulcer, but this is rarely the case in children and adolescents. Gastric ulcers usually appear after age 60 and are rare in people under age 40. Equal numbers of males and females are affected with gastric ulcers.

What You Can Expect

Current medications and dietary restrictions make for a good prognosis if you are diagnosed with a gastric ulcer. Gastric ulcers usually heal with treatment, but rarely they may become malignant. Thus, biopsies are sometimes necessary to determine if an ulcer is cancerous. If an ulcer is diagnosed before complications or perforation occur, medications can be prescribed to eradicate the Helicobacter pylori bacteria, heal the ulcer, provide symptom relief, and in most cases, prevent recurrence.


Established Causes

The cause of gastric ulcers has not been fully established.

Theoretical Causes

Ulcers seem to develop when the stomach acid eats into the gastrointestinal lining. Normally, the lining is protected by a thick mucosal layer. Gastric ulcers occur primarily when there is a defect in the layer of mucus that allows the digestive juices to penetrate it. Currently, scientists cannot fully explain the how this happens. A few known causes include:

  • NSAIDs: Nonsteroidal anti-inflammatory drugs like aspirin or ibuprofen have been shown to cause damage to the gastric lining and thus cause gastric ulcers. Studies show that NSAIDs are the primary cause in more than 30% of gastric ulcers.
  • Helicobacter pylori: Discovered only within the last 20 years, this resilient bacteria can survive in the acidic stomach environment. There, it burrows through the mucous lining into the tissue, where it reproduces, ultimately weakening the tissue and making it more susceptible to ulceration. This accounts for the majority of ulcer cases.
  • Genetic factors: Zollinger-Ellison syndrome is a genetic disease that prompts excessive amounts of stomach acid to form, causing recurrent ulcer formations.

Risk Factors

Risk factors include:

  • Excessive cigarette smoking
  • Use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, or naproxen)
  • Excess alcohol intake
  • Use of corticosteroids
  • Zollinger-Ellison syndrome
  • Physical stress (not emotional)
  • Certain chronic conditions (liver disease, rheumatoid arthritis) that increase GI tract vulnerability

Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.

Symptoms

  • Gnawing or burning pain in abdomen
  • Indigestion (dyspepsia)
  • Anemia
  • Blood stools or vomit
  • Recurrent vomiting (especially if obstruction occurs)

Conditions That May Be Mistaken for Gastric Ulcers

Conditions with symptoms similar to those of gastric ulcers include the following:

How Gastric Ulcers Are Diagnosed

Two imaging techniques, EGD (esophagogastroduodenoscopy) and the upper GI series, are the most reliable procedures to use when diagnosing an ulcer. Other useful diagnostic procedures can include a discussion of your medical history, laboratory breath and stool studies, blood tests, or a biopsy of the GI-tract mucosa. See Imaging, below, for more information on these tests.

Lab tests

Laboratory diagnostic procedures include the following:

  • Measurements of elevated blood gastrin levels (a hormone that stimulates stomach production of hydrochloric acid) to rule out Zollinger-Ellison syndrome
  • Testing the stool for blood
  • Measurement of blood pepsinogen (the precursor of pepsin) levels
  • Measurement of urea level in breath
  • Stool and serum tests for H. pylori antigens

Imaging

  • Your doctor may do an upper gastrointestinal (GI) series to look at the stomach. This test involves swallowing barium, a chalky solution that coats the lining of the GI tract, and then having X-rays taken. It helps to reveal inflammation or ulcers.
  • Your doctor may also perform an EGD (esophagogastroduodenoscopy), which involves inserting an endoscope into your mouth and threading it down the esophagus into the small intestine. Performed while you are under mild sedation, this procedure allows a doctor to see, photograph, and biopsy the ulcer. It offers the most reliable method of diagnosis, and allows for the treatment of bleeding, if present.

Goals of Treatment

Ulcers caused by Helicobacter pylori can be successfully treated and cured with antibiotic medication. Ulcers caused by certain drugs or substances can be cured by stopping their use and taking medications to protect the gastrointestinal tract lining. Your doctor can prescribe medication to provide symptom relief, promote ulcer healing, and prevent further complications. Surgery is rarely necessary.

Treatment Overview

Gastric ulcer treatment includes eliminating any H. pylori infection, controlling acute stomach acid to provide immediate pain relief and induce ulcer healing, controlling chronic stomach acid to prevent the ulcer from recurring, and preventing further complications. Antibiotics and antacids are typically prescribed, as are changes in lifestyle and diet, if necessary. Surgery, while rare, may be needed to repair a severe ulcer.

Drugs

Drug therapy is aimed at eradicating H. pylori, reducing acid production, and in some cases, enhancing mucosal protection.

Symptom-relieving drugs include the following:

Antibiotics To eliminate H. pylori bacteria:

Histamine receptor antagonists (H2 blockers) To promote healing via slowing or stopping gastric acid production:

Proton pump inhibitors to stop acid production:

  • Prilosec (Omeprazole) and Prevacid (Lansoprazole): reserved for more severe cases or when H2 blockers have failed. They completely shut down acid production.

Antacids To relieve acute excess acidity via neutralization:

  • Magnesium agents such as Mylanta and Maalox
  • Aluminum agents such as Amphojel
  • Calcium agents such as Tums and Rolaids

Mucosal protectants: directly protect the stomach and intestinal lining from damage:

  • Carafate (Sucralfate)
  • Cytotec (Misoprostol) (used specifically for NSAID-associated ulcers)

Drugs that provide symptom relief and antibacterial properties:

  • Pepto-Bismol (Bismuth subsalicyclate)

Nondrug treatments (if appropriate)

  • Smoking and alcohol cessation programs
  • Caffeine reduction
  • Stress-reduction therapy

Surgery

Surgery is usually a last resort. In rare cases, an ulcer might not respond to medication, gastric bleeding is serious enough to pose a danger, or there is danger of acute peritonitis. The latter cases (especially an ulcer that has perforated the lining or caused obstruction) are life-threatening conditions that require emergency surgery. Besides surgical repair of the ulcer, procedures have been developed that can reduce stomach acid production. If persistent obstruction occurs, surgery may be avoided via tube-suctioning the stomach contents for several days along with the IV administration of anti-ulcer medication.

Appropriate Healthcare Setting

Once you have been diagnosed, treatment is normally done on an outpatient basis under your doctor's supervision. You may need to be hospitalized if complications like bleeding, perforation, or obstruction develop. In this case, surgery may be necessary as a last resort.

Healthcare Professionals Who May Be Involved in Treatment

When being treated for a gastric ulcer, you might see any of the following doctors or healthcare professionals:

  • Internists
  • Gastroenterologists
  • General surgeons
  • Family physicians
  • Geriatricians
  • Nurse practitioners

Activity & Diet Recommendations

For the most part, eat regularly and avoid alcohol, coffee, tea, and foods that might cause pain or indigestion. Talk to your doctor about discontinuing the use of non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, as they can irritate the digestive tract.

Considerations for Women

Pregnancy

Pregnant women should not take the mucosal protective agent Cytotec (misoprostol), as it has been shown to cause miscarriages. Certain antibiotics, such as tetracycline and metranidazole, should also be avoided during pregnancy.

Considerations for Children and Adolescents

Children and adolescents are rarely diagnosed with ulcers.

Considerations for Older People

Special considerations should be taken if you are older because your immune system may be less efficient, leading to increased risk for other infections. Poor nutrition-- a problem with many elderly people-- may also have a greater impact on the course of an ulcer. Finally, ulcer symptoms may be more severe in older people.

Supplements

Vitamin A: can help prevent ulcers. Harvard researchers followed the diets of 48,000 middle-aged men for six years. Compared with men whose diets contained the least vitamin A, those who consumed more of it were only half as likely to develop ulcers. The safest way to take vitamin A is as beta-carotene.

Herbs

  • Licorice: Commission E, the panel of scientists that judges the safety and effectiveness of medicinal herbs for the German government, endorses licorice as an ulcer treatment -- 200 to 600 mg of glycyrrhizin a day. You can get this dose from a tea made with one teaspoon of powdered or crushed licorice root per cup of boiling water. Simmer for five minutes, strain, and drink one cup after each meal. Because of the risk of water retention, which can raise blood pressure, Commission E says this treatment should be used for no more than six weeks. [1]
  • Ginger: contains 11 compounds with scientifically verified anti-ulcer effects. It can be taken in capsule form or in a tea. To make your own tea, add one to two teaspoons of fresh grated ginger root per cup of boiling water and steep five to 10 minutes. Commercially prepared ginger teas are also available.[2]


Source

[1] Tyler, Varro. Herbs of Choice. Hawthorn Press, 1994.

[2] Duke, James. The Green Pharmacy. Emmaus, PA: Rodale Press, 1997.

Preventing Gastric Ulcers

If you do not have gastric ulcers, the best way to avoid them are:

  • Eradicate Helicobacter pylori bacteria through an antibiotic regimen
  • Discontinue nonsteroidal anti-inflammatory drug (NSAID) usage

Self-Care Measures

If you already have a gastric ulcer, the following lifestyle changes can help prevent you from getting more of them.

  • If you smoke, stop. Smoking increases the concentration of stomach acids in the duodenum, which boosts the risk of ulcers and interferes with their treatment.
  • Avoid NSAIDs (nonsteroidal anti-inflammatory drugs) including aspirin, ibuprofen (Motrin, Advil), and naproxen (Aleve). They can cause gastrointestinal bleeding and can cause and/or aggravate ulcers.
  • Limit or eliminate caffeine, and alcohol. They increase the secretion of stomach acids.
  • Eat more plant foods. In one study, Harvard researchers followed the diets of 48,000 middle-aged men for six years. Compared with those who did not develop ulcers during that time, those who did ate significantly fewer plant foods -- meaning they consumed less fiber. The most protective plant food was beans. Fruits and vegetables were also protective, but less so. Fiber slows the emptying of stomach contents into the duodenum, which reduces the concentration of stomach acids there.
  • Avoid stress as much as possible.

Websites & Organizations

American Digestive Disease Society
60 East 42nd Street, Room 411
New York, NY 10165

American Digestive Health Foundations
7910 Woodmont Avenue, 7th Floor
Bethesda, MD 20814-3015
Phone: 301-654-2635
Fax: 301-654-1140
Email: dlee@gastro.org

Digestive Disease National Coalition
511 Capital Court, NE Ste. 300
Washington, DC 20002
Phone: 202-665-6210

Health Answers

National Center for Infectious Diseases
Centers for Disease Control and Prevention
1600 Clifton Road, MS: C09
Atlanta, GA 30333
Phone: 888-MY-ULCER (888-698-5237)

National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD 20892-3570
Phone: 301-468-6344
Email: nddic@info.niddk.nih.gov

National Ulcer Foundation
675 Main Street
Melrose, MA 02176
Phone: 617-665-6210

South Bank University

United Ostomy Association
36 Executive Park, Suite 120
Irvine, CA 92714
Phone: 800-826-0826 or 714-660-8624
Email: uoa@deltanet.com

Sources for This Article

Books

Balch, James F. and Balch, Phyllis A. Prescription for Nutritional Healing. Garden City Park, NY: Avery Publishing, 1997.

Bennett, J. Claude and Plum, Fred. Cecil Textbook of Medicine, eds. Philadelphia: W. B. Saunders, 1996.

Duke, James. The Green Pharmacy. Emmaus, PA: Rodale Press, 1997.

Fauci, Anthony J., et. al. Harrison's Principles of Internal Medicine, eds. New York: McGraw-Hill, 1998.

Hardman, Joel G. and Limbird, Lee E. Goodman and Gilman's The Pharmacological Basis of Therapeutics eds. New York: McGraw-Hill, 1996.

Hurst, J. Willis. Medicine for the Practicing Physician eds. Stamford, CT: Appleton & Lange 1996.

Murray, Michael T. Encyclopedia of Natural Medicine. Prima, 1998.

Noble, John. Primary Care Medicine ed. St. Louis: Mosby, 1996.

Physicians' Desk Reference. Montvale, NJ: Medical Economics Co., 1998.

Rakel, Robert E. Conn's Current Therapy eds. Philadelphia: W.B. Saunders, 1998.

Taylor, Robert B. Family Medicine: Principles and Practice. New York: Springer-Verlag, 1998.

Tierney, L.M., McPhee, S.J., and Papadakis, M.A. Current Medical Diagnosis and Treatment eds. Stamford, CT: Appleton & Lange, 1998.

Tyler, Varro. Herbs of Choice. Hawthorn Press, 1994.


Articles

Aldoori, W. et al. "Prospective Study of Diet and the Risk of Duodenal Ulcer in Men," Am. J. Epidemiology (1997) 145:42.

Bayerdorffer, E, Miehlke, S, Lehn, N, Mannes, GA, Hochter, W; Weingart, J, Klann, H, Sommer, A, Heldwein, W, Hatz, R, Simon, T, Bolle, KH, Bastlein, E, Meining, A, Ruckdesche,l G, Stolte, M. "Cure of Gastric Ulcer Disease After Cure of Helicobacter Pylori Infection." Eur J Gastroenterol Hepatol. 8(4):343-9. Apr 1996.

Di Mario, F, Battaglia, G, Leandro, G, Grasso, G, Vianello, F, Vigneri, S. "Short-Term Treatment of Gastric Ulcer. A Meta-Analytical Evaluation of Blind Trials." Dig Dis Sci. 1108-31. Jun 1996.

Howden, CW, Hunt, RH. "The Relationship Between Suppression of Acidity and Gastric Ulcer Healing Rates." Aliment Pharmacol Ther. 25-33. Feb 1990.

Kang, JY. "Age of Onset of Symptoms in Duodenal and Gastric Ulcer." Gut. 854-7. Aug 1990.

Labenz, J, Borsch, G. "Evidence for the Essential Role of Helicobacter Pylori in Gastric Ulcer Disease." Gut. 19-22. Jan 1994.

Labenz, J, Ruhl GH, Bertrams, J; Borsch, G. "Medium- or High-Dose Omeprazole Plus Amoxicillin Eradicates Helicobacter Pylori in Gastric Ulcer Disease." Am J Gastroenterology. 726-30. May 1994.

Lamers, CB, Biemond, I, Masclee, AA, Veenendaal, RA. "Therapy and Prevention of Gastric Ulcer." Yale J Biol Med. 265-70. May-Jun 1996.

Leung, KM, Hu, PK, Chan, WY, Thomas, TM. "Helicobacter Pylori-Related Gastritis and Gastric Ulcer. A Continuum of Progressive Epithelial Degeneration." American Journal of Clinical Pathology. 569-74. Dec 1992.

Levi, S, Goodlad, RA, Lee, CY, Stamp, G, Walport, MJ, Wright, NA, Hodgson, HJ. "Inhibitory Effect of Non-Steroidal Anti-Inflammatory Drugs on Mucosal Cell Proliferation Associated With Gastric Ulcer Healing." Lancet. 840-3. Oct 6, 1990.

Saggioro, A, Chiozzini, G. "Pathogenesis of Gastric Ulcer." Ital J Gastroenterol. 3-9. Jan-Feb 1994.

 

 

 

 

 

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