Relief may be on the way
Until recently, most people thought that the likelihood of developing an ulcer depended on their lifestyle. However, scientists have discovered the underlying cause of most ulcers: Helicobacter pylori. This bacteria exists in the digestive tracts of more than half the world's population, yet most of them will never develop an ulcer. Despite this discovery, though, lifestyle still plays a role in the development of ulcers. The likelihood of developing one increases if you smoke, have poor eating habits, consume an excessive amount of alcohol, and are experiencing stress. So if you feel a burning sensation in your digestive tract, it may indicate an ulcer.
Synonyms & Abbreviation of Condition
- Gastric ulcer
- Duodenal ulcer
- Helicobacter ulcer
- PUD (peptic ulcer disease)
Peptic ulcer disease involves the formation of small erosions along the digestive tract by stomach fluids, which contain hydrochloric acid and the enzyme pepsin (hence the name peptic ulcer).
Ulcers can occur anywhere from the stomach to the upper duodenal section of the small intestine. So peptic ulcers can be further classified as gastric ulcers, and duodenal ulcers, depending on their location.
The lining of the gastrointestinal (GI) tract is protected by a thick mucosal layer, which continually rebuilds itself as stomach acid destroys it. Ulcers start when an overproduction of acid or an underproduction of mucus degrades the mucosa, allowing erosion to occur and ulcers to form. The mechanisms of erosion are still not fully understood, but -- with the recent discovery of the Helicobacter pylori bacteria -- the cause is. Somehow, H. pylori is able to survive the acidic environment of the stomach and reproduce in the mucosa. Its reproduction causes damage to the tissue 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, ulcers have been shown to lead 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. The main reason treatments fail is noncompliance (i.e., not sticking to the medical treatment your doctor has suggested). Risk factors like alcohol, coffee, aspirin and even NSAIDs (nonsteroidal anti-inflammatory drugs, 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 Peptic Ulcers
An ulcer is a small erosion that forms along the digestive tract. Formations occurring in the upper segment of the small intestine are known as duodenal ulcers. These are the most common. Ulcerations in the stomach are known as gastric ulcers. Those found in the esophagus are known as esophageal ulcers; these are the least common. The ulcer is a sore or crater from one to two inches in diameter, depending on the progression of the erosion. The surrounding inflamed area is called the ulcer crater.
How Common Are Peptic Ulcers?
Approximately 20 million Americans suffer from ulcers, with duodenal ulcers accounting for more than 75% of all cases. Anyone can develop an ulcer, but they are rare in children and adolescents. Duodenal ulcers are more likely to form between ages 30 and 60, whereas gastric ulcers usually appear after age 60. Gastric ulcer cases are distributed equally between males and females, although men are twice as likely as women to develop duodenal ulcers.
What You Can Expect
Current medical treatments and medications make for a good prognosis if you are diagnosed with peptic ulcer disease. Duodenal ulcers are not as severe as gastric ulcers and in almost all cases are benign. Gastric ulcers may become malignant; therefore, a biopsy may be necessary. If peptic ulcer disease is diagnosed before complications or perforation occur, medication can be prescribed to eradicate the Helicobacter pylori bacteria, heal the ulcer, provide symptomatic relief, and in most cases, prevent recurrence.
The cause of peptic ulcers has not been fully established.
Ulcers seem to develop when acidic stomach fluid eats into the gastrointestinal lining. Normally, the lining is protected with a thick mucosal layer. Ulcers occur when digestive juices penetrate this lining. Currently, scientists cannot fully explain the mechanism of how this happens. Following are a few known causes:
- 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.
- 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.
- Genetic factors: Zollinger-Ellison syndrome is production of a tumor with a genetic component. It prompts excessive amounts of stomach acid to form, causing recurrent ulcer formations.
Risk factors include the following:
- Previous ulcers
- Excessive cigarette smoking
- Use of NSAIDs (such as aspirin, ibuprofen, or naproxen)
- Use of corticosteroids
- Improper diet (skipped meals or irregular eating patterns)
- Zollinger-Ellison syndrome
- Blood type O (duodenal)
- Physical stress (not emotional)
- Excess alcohol intake
- Certain chronic conditions (liver disease, rheumatoid arthritis) which 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.
- Indigestion (dyspepsia)
- Gnawing or burning pain in abdomen (typically after eating or late at night)
- Bloody stools or vomit
- Recurrent vomiting (especially if obstruction occurs)
Conditions That May Be Mistaken for Peptic Ulcers
Conditions with symptoms similar to those of a peptic ulcer include the following:
- Gastroesophageal reflux disease (GERD)
- Pancreatitis (inflammation of the pancreas)
- Gallbladder disease
- Crohn's disease
- Variant angina pectoris
- Gastric carcinoma
How Peptic 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.
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
- Testing the stool for H. pylori antibodies
- Your doctor may do an upper gastrointestinal (GI) series to look at the small intestine and stomach. This test involves swallowing barium, a chalky solution that coats the lining of the GI tract, and then having X-rays taken. This 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.
Goals of Treatment
Ulcers caused by Helicobacter pylori can be successfully treated and cured with antibacterial 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.
Peptic 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.
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:
- Flagyl (metronidazole)
- Biaxin (clarithromycin)
Histamine receptor antagonists (H2 blockers) to promote healing via slowing or stopping gastric acid production:
- Axid (nizatidine)
- Pepcid (famotidine)
- Tagamet (cimetidine)
- Zantac (ranitidine)
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 to 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 subsalicylate)
Nondrug treatments (if appropriate)
- Smoking and alcohol cessation programs
- Caffeine reduction
- Stress-reduction therapy
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 peptic ulcer, you might see any of the following doctors or healthcare professionals:
- Family physicians
- General surgeons
- Nurse practitioners
- Physician assistants
Activity & Diet Recommendations
For the most part, eat regularly and avoid alcohol, caffeine, and foods that might cause pain or indigestion. Talk to your doctor about discontinuing the use of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, as they can irritate the digestive tract.
Considerations for Women
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 metronidazole, 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.
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.
- 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.
- 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, 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. Be careful with alternative therapies if you have had a complicated ulcer.
1 Aldoori, W., et al. "Prospective Study of Diet and the Risk of Duodenal Ulcer in Men," American Journal of Epidemiology (1997) 145:42.
Self-Care & Prevention Measures
The following self-care measures may reduce an existing peptic ulcer, or prevent one from developing in the first place.
Websites & Organizations
American Digestive Disease Society
60 East 42nd Street, Room 411
New York, NY 10165
The Combined Health Information Datatbase:
Digestive Disease National Coalition
511 Capital Court, NE Ste. 300
Washington, DC 20002
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
Bethesda, MD 20892
National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD 20892-3570
National Ulcer Foundation
675 Main Street
Melrose, MA 02176
South Bank University
United Ostomy Association
36 Executive Park, Suite 120
Irvine, CA 92714
Phone: 800-826-0826 or 714-660-8624
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