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Stomach Ulcer (Peptic Ulcer) |
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Definition
A
peptic ulcer is erosion in the lining of the stomach
or duodenum (the first part of the small intestine).
The word “peptic” refers to pepsin, a stomach enzyme
that breaks down proteins. If a peptic ulcer is
located in the stomach it is called a gastric ulcer.
Causes
Ulcer Disease.
The major causes of peptic
Ulcer Disease are
Helicobacter pylori, NSAIDs, acid hypersecretion,
and cancer.
Stress, diet, and alcohol are not
felt to directly cause ulcers.
Helicobacter pylori --
this is a bacterium that is felt to cause many
ulcers.
-
H. pylori is a
bacterium that lives in the stomach and has been
shown to be the cause of many ulcers.
-
H. pylori is involved
in the development of the majority of duodenal and
Gastric Ulcers not
caused by NSAIDs.
Destroying this bacterium with
antibiotics leads to a much higher success rate in
the treatment of ulcers.
People who are treated for this
infection also have much lower rates of the ulcers
coming back.
When the organism is not
destroyed, up to 80% of people will have a
recurrence of their ulcer. When the organism is
treated and destroyed, only about 10-20% of people
will have a recurrence of their ulcer.
However, only one out of every
six people who have this bacterium in their
stomach will ever develop an ulcer.
-
This is a group of medicines
that includes things such as ibuprofen, naproxen,
indomethacin, etc. These drugs are most often
used to treat arthritis, headaches, back pain, and
other conditions that cause pain and inflammation.
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It is felt that NSAIDs cause
ulcers by decreasing the protective lining of the
stomach and intestines.
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NSAIDs dramatically increases
the risk of
Gastric Ulcers.
People who take NSAIDs for a
prolonged period are 40 times more likely to
develop
Gastric Ulcers
compared to those who do not take NSAIDS.
People who take NSAIDs have a
higher chance of developing complications such as
bleeding or perforation.
The risk of developing ulcers
is higher in those over 70 years, those taking
higher doses of NSAIDs, those with a previous
history of ulcers, in those people who are on
blood thinners or steroids, and in those with
severe medical problems.
Aspirin is the worst of all of
the NSAIDs with respect to causing ulcers.
There are newer NSAIDs that are
being used, such as etodolac and celecoxib, that
have a lower risk of developing ulcers. These
medicines help reduce pain and inflammation, but
do not weaken the stomach lining as much as other
NSAIDs. Though they are safer, there is still a
risk of developing ulcers.
is a condition that leads to excess acid
production. This can overwhelm the protective layer
in the stomach and intestines and lead to ulcers.
Please look up the section on
Zollinger-Ellison
Syndrome for more information.
In a few cases, the ulcer is
actually due to a cancer in the stomach or
intestine.
Risk Factors
-
Use of NSAIDs. The higher the
dose, the higher the risk of developing ulcers.
Also, some NSAIDs have a lower risk of ulcer
formation.
-
Infection with H. pylori.
-
Diseases such as
Zollinger-Ellison
Syndrome that lead to increased production of acid.
Increased stress may be a risk
factor.
Smoking increases the risk of
ulcers and slows ulcer healing.
In countries other than the U.S.,
lower socioeconomic status is a risk factor because
those people have a higher rate of infection with
H. pylori.
Symptoms
-
Almost all people will have pain
in the upper, central part of the stomach (just
under the breastbone). The pain can be a dull ache,
throbbing, sharp, burning, "gas-like", cramping,
etc. However, the pain can occur in almost any part
of the abdomen.
-
Often the pain associated with
peptic Ulcer
Disease comes and goes. Some people notice that the
pain gets worse after eating spicy foods. Also,
many will notice that over the counter antacids help
relieve their symptoms. Some people will feel
better after eating, while, in others, the pain may
increase after meals.
-
Many will complain of stomach
pain that wakes them up in the middle of the night
-- usually between 2 and 4 am.
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Nausea and vomiting
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Because of the stomach pain, some
lose their appetite and lose weight.
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In a few cases where the ulcers
are more severe, the pain may radiate or move to the
back.
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Not all people with these
symptoms have a true ulcer. In fact, of all the
people who have upper abdominal pain, only a
minority has real ulcers. Most have a condition
known as
Gastritis or dyspepsia.
Some will have chest pain or back
pain
If the ulcer causes a lot of
inflammation, a blockage may develop. Please see
the "Complications" section below.
A few will have intestinal or
stomach bleeding as their first symptom. There can
be vomiting of blood or coffee-grounds like
material. Others may complain of passing stools
that are either red or black.
In people with ulcers due to
NSAIDs, up to half may not have any symptoms at all.
Screening and
Diagnostics
-
The best way to diagnose ulcers
is by an endoscopy. In this test, a camera is used
to look into the stomach. The doctor can look at
the lining of the stomach and intestines to see if
an ulcer is present. The doctor can also do a
biopsy if needed and, in some cases, stop any
bleeding that may be present.
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All
Gastric Ulcers must be
biopsied. This is because there is a high risk of
Gastric Ulcers
being caused by cancer.
If there is any suspicion of
cancer, then people with
Gastric Ulcers need to
have a repeat endoscopy within about 12 weeks after
starting treatment to make sure that the ulcer has
completely healed.
Duodenal Ulcer s
are almost never due to cancer. Therefore, they are
usually not biopsied for cancer testing purposes.
However, biopsies are often done
on all ulcers in order to test for H. pylori.
If H. pylori is present then treatment is
different. Therefore, this is a very important
diagnostic test.
Another test that can be done to
diagnose an ulcer is an upper GI series. In this
test, the person is given barium and then
X-Rays are taken to see
if there is an ulcer. This test is not as accurate
as an endoscopy, but it is less invasive. If a
Gastric Ulcer is
detected, the patient is treated, and after about 12
weeks to make sure that the ulcer has healed, an
endoscopy done.
All people with ulcers need to be
tested for H. pylori. There are many ways
to test for this infection.
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If an endoscopy is performed,
then a biopsy is done, and the sample is tested
for the presence of H. pylori.
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If the ulcer is detected by an
upper GI, then a breath test can be done to see if
the organism is present.
-
Blood tests are also available
that detect the presence of antibodies to the
bacteria. This is a very convenient test, but it
is not the best option because it can be abnormal
even if the organism is not causing an active
infection. However, in some cases, antibody
levels are followed over a long period of time to
see if the infection has been fully treated.
Ulcer Disease in which
there is no complication.
If there is a complication, then
you may see abnormal blood tests. For example, if
the person develops a bleeding ulcer, they may be
anemic. If the ulcer tears a hole through the
stomach, then the person will be very ill with a
high white blood count.
X-Ray s
may show air in the abdominal cavity.
In cases where
Zollinger-Ellison
Syndrome is suspected, a
Gastrin level can be
measured. In people with this disease, the
Gastrin level will be
elevated.
Physical examination may only
reveal some tenderness of the upper part of the
stomach. Testing of the stool may show the presence
of blood if the ulcer is bleeding.
Treatment
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There are several different
medicines available to treat ulcers. The type of
treatment and the medicines used depend on the cause
of the ulcer.
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There are three main types of
medicines that can be used: 1) medicines that reduce
the amount of acid produced, 2) medicines that
protect the lining of the stomach and intestines,
and 3) medicines that destroy the bacterium H.
pylori.
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Medicines that reduce acid
production are broken down into two categories.
Generally, with these medicines, Duodenal Ulcers
heal within 4-6 weeks and
Gastric Ulcers heal
within 6-8 weeks.
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Proton pump inhibitors --
Omeprazole and Lansoprazole are the most commonly
used. Basically, they very effectively reduce
acid production by the stomach. They are more
potent than H2 receptor blockers but they are
usually only used for short-term therapy. They
can help cure up to 80-90% of ulcers. These
medicines are usually taken 30 minutes before a
meal. They help to relieve symptoms and allow
healing to take place faster than H2 blockers, but
the overall cure rate for ulcers is not much
different between the two groups.
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H2 receptor blockers --
Cimetidine, Ranitidine, Famotidine, and Nizatidine
are the 4 most commonly used medicines in this
category. These medicines also reduce acid
production and they can be used for longer periods
of time. They are not as potent as the proton
pump inhibitors, but they can be just as effective
at curing ulcers. They also can cure about 80-90%
of ulcers. Ulcer symptoms usually get better
within about 2 weeks, but treatment is usually
continued for 6-8 weeks.
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Sucralfate -- this is a
medicine that basically coats ulcers and forms a
protective layer. It is very good at treating
Duodenal Ulcers. It
is not as good for treatment of
Gastric Ulcers.
Bismuth -- this is a medicine
that causes increased production of the substances
that normally protect the stomach and intestines.
It also helps destroy H. pylori.
Misoprostol -- this is a
medicine that increases the production of the
substances that normally protect the stomach and
intestines. It is not as effective as the other
medicines in treating an active ulcer. It is used
mainly to help prevent the formation of ulcers in
people who are on long-term treatment with NSAIDs.
Antacids -- these are available
over-the-counter. These medicines help protect
the wall of the stomach and intestines. They do
not reduce the formation of acid. They are no
longer used as initial treatment for ulcers
because more effective medicines are available.
However, they do work very quickly and can be use
to rapidly control symptoms.
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Treatment depends on the cause of
the ulcer.
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For ulcers caused by H.
pylori, there are several treatment options.
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Metronidazole (500 mg twice a
day) and clarithromycin (500 mg twice a day) and a
proton pump inhibitor (such as omeprazole 20 mg
twice a day) for 14 days.
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Amoxicillin (1 gram twice a
day) and clarithromycin (500 mg twice a day) and a
proton pump inhibitor (such as omeprazole 20 mg
twice a day) for 14 days.
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Amoxicillin (1 gram twice a
day) and metronidazole (500 mg twice a day) and a
proton pump inhibitor (such as omeprazole 20 mg
twice a day) for 14 days.
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Bismuth subsalicylate (2
tablets 4 times a day) and tetracycline (500 mg 4
times a day) and either metronidazole (250 mg 4
times a day) or clarithromycin (500 mg 3 times a
day) for 14 days. Some are now recommending using
ranitidine along with this regimen.
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After the person has completed
one of the above regimens, they need to be
continued on a proton pump inhibitor, an H2
antagonist, or sucralfate for an additional 4-6
weeks. This will help allow the ulcer to heal
completely.
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This course of therapy should
destroy the bacterium in more than 85% of people.
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Newer combinations are
constantly being tested. Therefore, it is best to
discuss treatment options with your doctor.
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There are increasing reports of
H. pylori being resistant to
metronidazole. Therefore, in areas where there is
a lot of resistance to this antibiotic, the other
treatment options are being used first.
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In the past, most people with
ulcers used to be continued on some sort of ulcer
treatment for very long periods of time. However,
now that we have found out that many of these
ulcers are due to an infection, most people no
longer need prolonged anti-ulcer treatment if
their infection is cured. Therefore, only those
who have recurrent ulcers, those in whom the
infection could not be cured, and people with
H. pylori infections who keep getting ulcers
even though the infection was treated will need to
be on long-term anti-ulcer treatment.
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If the person is treated for
H. pylori and the ulcer does not come
back, no further evaluation or treatment is
needed. If the ulcer does come back, then they
need testing to see if the H. pylori has
truly been destroyed.
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The first step is to stop using
the NSAIDs.
-
Proton pump inhibitors (such as
omeprazole, lansoprazole) should be started as
soon as possible. These are the most effective
medicines.
-
You can also use H2 receptor
antagonists or sucralfate, but these are not as
effective.
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If the person is on NSAIDs but
tests also show the presence of H. pylori,
then the best option is to stop the NSAIDs but
also to go ahead and treat the H. pylori
infection.
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In people with ulcers, NSAIDs
can be continued along with one of the above
medicines if there is absolutely no other
alternative. However, healing of the ulcer will
be delayed.
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Recurrent ulcers or ulcers that
do not heal with normal treatments are fairly rare
these days. If this is truly the case, then other
diagnoses must be considered. The most common cause
of ulcers not healing is because people do not take
all the medicines as prescribed by the doctor or
they resume use of NSAIDs. Another common cause is
H. pylori infections that are not
adequately treated.
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Another cause is a missed cancer,
especially with stomach ulcers that do not heal
despite adequate therapy. Therefore, all
Gastric Ulcers need to
be followed by repeat endoscopy to confirm that they
have healed. If they have not, then repeat biopsies
should be done after 2-3 months of treatment.
Repeat endoscopies should be done periodically until
the ulcer has completely healed.
A much more rare cause of
non-healing or recurrent ulcers is
Zollinger-Ellison
Syndrome. Therefore, all people with continued
ulcers should be checked for this condition.
If all else fails and the person
continues to have recurrent ulcers, then they may
need surgery. This is the last treatment option
that should only be considered after all other
options are exhausted.
Complications
Prevention
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Don't
smoke or chew tobacco.
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Limit
alcohol.
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Avoid
aspirin, ibuprofen, and naproxen. Try acetaminophen
instead.
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