Peptic Ulcer

What Is It?

A peptic ulcer is a sore or hole that forms in the lining of the stomach or intestine.  

The word "peptic" refers to the digestive tract. An ulcer in the lining of the stomach is a gastric ulcer. An ulcer in the first part of the small intestine is a duodenal ulcer.

The lining of the stomach is a layer of special cells and mucous. Mucous prevents the stomach and duodenum from being damaged by acid and digestive enzymes.  

If there is a break in the lining (such as an ulcer), the tissue under the lining can be damaged by the enzymes and corrosive acid. If the ulcer is small, there may be few symptoms. The wound can heal on its own.  

If the ulcer is deep, it can cause serious pain or bleeding. Rarely, acids in the digestive juices may eat completely through the stomach or duodenum wall. 

Peptic ulcers are very common. They become more common as people age.  

The bacterium Helicobacter pylori is believed to cause most peptic ulcers. This bacteria causes inflammation in the stomach lining. This probably makes the lining vulnerable. But only a minority of people infected with H. pylori develop ulcers.

Another common cause of ulcers is the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Examples of NSAIDs include aspirin, ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn).  

NSAIDs block the formation of some prostaglandins. Prostaglandins are chemicals that normally help protect against ulcers. With less prostaglandins, ulcers are more likely to form.  

Several factors can increase your risk of developing a peptic ulcer. Risk factors include: 

• Family history 
• Smoking (particularly if you are infected with H. pylori) 
• Excessive alcohol use  

However, contrary to popular belief, stress and spicy foods do not seem to increase the risk of ulcers.

Symptoms

Most people with ulcers complain of a burning or gnawing pain in the upper abdomen. This typically occurs when the stomach is empty. These symptoms may be worse at night or upon waking. However, some people's pain may worsen when they eat.

Other symptoms include:

• Nausea 

• Vomiting 

• Loss of appetite 

• Bloating 

• Burping  

• Weight loss

Some of these symptoms may be relieved by taking over-the-counter antacids or avoiding spicy or acidic foods.  

In general, symptoms worsen as an ulcer grows, or if more than one ulcer develops. Some people with mild disease don't have any symptoms. 

In more severe cases, ulcers may bleed or extend deep into the wall of the stomach or intestine. Bleeding from large ulcers can be life threatening. Blood may appear in the vomit. It may appear either red or black, or resemble coffee grounds. Blood also may appear in the stools, which would look tarry-black or maroon.  

Peritonitis is a very serious abdominal infection. It may develop if the ulcer eats completely through the wall of the stomach or intestine

Diagnosis

If your health care professional suspects that you have a peptic ulcer, he or she may recommend one of the following tests:

• A blood antibody test for evidence of H. pylori infection. This test is widely available and simple to do. If the test is positive, treatment might be given without more invasive tests.

However, the H. pylori blood test is not always accurate. The test results may remain positive for years after an H. pylori infection has been treated. Also, the test cannot tell whether an H. pylori infection has caused an ulcer.

• A stool test for the presence of H. pylori antigen. This test is more specific than the blood antibody test.

• An esophagogastroduodenoscopy (EGD or endoscopy). A flexible, lighted tube with a tiny camera on the end is passed through your throat into your stomach and intestines. This allows your doctor to examine the walls of the stomach and duodenum.

The doctor may snip off a small piece of the lining of the stomach for a biopsy. A biopsy is a close examination of the tissue in a laboratory. A biopsy can show whether there is an ongoing infection with H. pylori. It can also check to make sure an ulcer did not form because of cancer.

• An upper-gastrointestinal (GI) series. This test is rarely done today because endoscopy is generally a better test. It involves a series of X-rays. They are taken after you drink a chalky liquid that coats the esophagus, stomach and upper part of the intestine.

• Other tests for H. pylori. Another test to detect the bacteria is called a urea breath test. You swallow a substance containing carbon (in many cases, a small amount of radioactivity is present). If H. pylori are present in your stomach, you will have a positive breath test.

Stool samples can be tested for proteins that are associated with the bacteria.

Sometimes, more than one test is needed to diagnose your condition.

Expected Duration

Ulcers caused by a medication should begin healing shortly after you stop taking the drug. Anti-acid medicine may be used for two to six weeks to help healing and relieve pain.  

Ulcers caused by H. pylori can heal after the bacteria are killed. Typically, you will take antibiotics along with acid-suppressing medicine for two weeks. Then you may take acid-suppressing medication for another four to eight weeks.  

Gastric ulcers tend to heal more slowly than duodenal ulcers. Uncomplicated gastric ulcers take up to two or three months to heal completely. Duodenal ulcers take about six weeks to heal.  

An ulcer can temporarily heal without antibiotics. But it is common for an ulcer to recur or for another ulcer to form nearby, if the bacteria are not killed. 

Prevention

Peptic ulcers are not usually preventable the first time around.  

Infection with H. pylori is extremely common. It is probably spread from person to person. Crowded living space appears to be a risk factor. 

Good hygiene may limit the spread of H. pylori somewhat. This includes washing your hands thoroughly before eating and after using the bathroom.  

Recurrent ulcers from H. pylori can usually be prevented if you get appropriate treatment for your first ulcer. This should include antibiotics that kill the bacteria.  

You may help to prevent peptic ulcers by: 

• Avoiding smoking 
• Avoiding excessive alcohol use 
• Limiting the use of NSAIDs for pain 

Treatment

For ulcers caused by H. pylori, treatment requires a combination of medications. The goals of treatment are to: 

• Kill H. pylori bacteria in the body 
• Reduce the amount of acid in the stomach 
• Protect the lining of the stomach and intestines 

Most patients are treated with "triple therapy." This requires taking two antibiotics and one acid-suppressing medication for one to two weeks. Your doctor will prescribe a specific regimen based on convenience, cost and any allergies you have.  

If your ulcer occurred while you were using a non-steroidal anti-inflammatory drug (NSAID), you will need to stop taking it. Healing will begin almost immediately. Your doctor also will recommend medications to reduce acid damage during healing. These may include antacids to neutralize gastric acids. Medications that decrease the amount of acid produced by the stomach may also be used. Examples include H2 blockers or proton pump inhibitors.  

Emergency treatment may be needed if an ulcer causes serious bleeding. Usually, this treatment is done through an endoscope. Acid-blocking medications may be given intravenously (injected into a vein). Blood transfusions may be necessary if the bleeding is severe.  

In rare circumstances, surgery may be needed to treat a perforated or bleeding peptic ulcer. Surgery for peptic ulcer disease may involve closing a bleeding artery.  

Surgery is rarely needed for peptic ulcer treatment these days. That is because treatments for H. pylori infections and other causes of peptic ulcer disease are so successful. 

When To Call a Professional

Call for medical advice if you have continuing abdominal pain or indigestion. Also call if you need to take antacids frequently to prevent these symptoms.  

• Seek emergency care if you experience: 
• A sudden sharp pain in your abdomen 
• Bloody or black vomit 
• Maroon or black stools

Prognosis

With proper treatment, the outlook for peptic ulcers is excellent.  

To prevent another ulcer, people who have had a peptic ulcer should avoid: 

• Aspirin (unless a low dose is needed to prevent a heart attack or stroke) 
• NSAIDs 
• Excessive alcohol  
• Smoking

Additional Info

National Institute of Diabetes & Digestive & Kidney Disorders
https://www.niddk.nih.gov/

American College of Gastroenterology (ACG)
https://www.acg.gi.org/

American Gastroenterological Association
https://www.gastro.org/