Peptic Ulcer Disease

(Stomach Ulcers, Ulcers, Gastric Ulcers, Duodenal Ulcers)

The Facts

A peptic ulcer is an erosion or sore in the lining of the stomach or intestine that occurs when the protective mucus layer wears away in certain areas, allowing damage to occur from the natural acids of the stomach.

Around 10% of people will have peptic ulcer disease (PUD) at some point in their life. The majority of peptic ulcers are caused by bacteria called Helicobacter pylori (H. pylori) or by taking ASA (acetylsalicylic acid) or nonsteroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen*, ketoprofen, naproxen).

The 2 most common types of peptic ulcers:

Gastric ulcers are sores in the lining of the stomach.
Duodenal ulcers are those in the first part of the small intestine, called the duodenum. This is an area where food is digested after passing through the stomach.

The Causes

Although stress and spicy foods might make the symptoms of peptic ulcer worse, they aren't the cause of the condition as was once thought.

A bacterium called H. pylori causes the majority of ulcers. The bacteria can spread into the mucus lining that usually protects the stomach and small intestine from digestive acids, damaging it in the process. By 60 years of age, up to 50% of people are infected with this bacteria, but only 10% to 20% of these people will actually develop stomach problems.

The other major cause of PUD is the use of ASA (acetylsalicylic acid) and other NSAIDs such as ibuprofen or naproxen. NSAIDs can penetrate the lining of the stomach and release substances that damage cells. NSAIDs also block natural chemicals called prostaglandins that can help to protect and repair those cells. People more at risk of ulcers caused by NSAIDs include those who:

are seniors
have a history of a peptic ulcer
have a family history of peptic ulcer disease
are also taking glucocorticoids (e.g., prednisone, dexamethasone)
are taking high doses of NSAIDs or ASA
have several medical conditions
are taking more than one NSAID or ASA
are smokers

Excessive alcohol can affect the stomach and cause it to produce more stomach acid, but it doesn’t seem to cause ulcers.

Symptoms And Complications

The most common symptom of peptic ulcers (both duodenal and gastric) is a gnawing or burning pain in the abdomen between the breastbone and the navel, sometimes passed off as "heartburn." An ulcer can also feel like a dull ache or strong hunger pangs. Yet some people, especially the elderly and children whose ulcers were caused by NSAIDs, may not feel any pain at all from an ulcer. Ulcer pain can come or go and can be aggravated by eating or an empty stomach. Ulcers can also cause belching and bloating.

The most common complication of stomach and duodenal ulcers is bleeding. Although the blood loss is usually too slow to be noticed, it might be enough to make you tired, pale, and weak.

If bleeding from the peptic ulcer is heavier, blood may show up in the stool or vomit. Stools that have blood in them may look tarry, black, or red. If you notice any of these signs, see a doctor right away. If a bleeding ulcer is severe, it can be fatal if left untreated. Keep in mind also that, since NSAIDs are such strong painkillers, they can mask the pain of bleeding ulcers.

Very rarely, ulcers can make a hole, called a perforation, in the stomach or intestine. This can cause sudden and severe pain. Sometimes an ulcer can create a blockage out of the stomach or in the duodenum. This may cause bloating, feeling full after eating, vomiting, and weight loss.

If an ulcer causes scarring, spasm, or inflammation, it is considered a gastric outlet obstruction and may lead to weight loss and dehydration. It may cause loss of appetite with fullness after eating, or it may cause large-volume vomiting up to 6 hours after a meal.

Making A Diagnosis

If you have the typical symptoms of PUD, your doctor will perform a physical exam and may order one or more of the following tests:

A breath test (drinking a fluid and exhaling into a tube), blood test, or stool test may be used to check for H. pylori infection. If you have H. pylori, treatment may be given to cure the infection without the need for more invasive tests.

A series of GI (gastrointestinal) X-rays may be done. These are X-rays of your stomach, duodenum, and esophagus (the swallowing tube). To make the ulcer easier for the doctor to see, you'll first need to swallow a chalky liquid called barium.

Endoscopy is another test used to detect ulcers. After numbing the throat, the doctor carefully guides a thin tube with a tiny camera on its end into the mouth and down the throat to get close-up pictures of the esophagus, stomach, and duodenum. A doctor can do a biopsy during the endoscopy to confirm the presence of H. pylori and whether the ulcer is cancerous.

If ulcers are detected by these tests, then appropriate treatment will be prescribed.

Finally, all people older than 55 years who, for the first time, show symptoms suggestive of a stomach acid-related disorder, and anyone of any age with "alarm" features such as vomiting, bleeding, anemia, an abdominal mass, unexplained weight loss, or trouble swallowing should have an endoscopy to identify the cause quickly and to rule out cancer.

Treatment And Prevention

Medical treatment focuses on eliminating the H. pylori bacteria in people where it has been detected. The majority of peptic ulcers caused by H. pylori can be cured with a combination of antibiotics, antacids (bismuth subsalicylate), and proton pump inhibitors (PPIs; e.g., omeprazole, lansoprazole, esomeprazole, pantoprazole, rabeprazole).

Other combinations may also be used (e.g., 2 antibiotics and a PPI without bismuth subsalicylate) to treat H. pylori induced ulcers. There are several different combinations, but most of them require taking medications for 14 days. For some people, several courses of treatment may be needed to get rid of H. pylori. In this case, at least one of the antibiotics will be different from the initial combination used.. Follow-up testing to make sure H. pylori is cleared can be done through the breath test or checking the stool.

When an ulcer is not associated with *H. pylori *or is caused by NSAIDs, treatment with a PPI is prescribed for 4 to 8 weeks. Some people may need to continue treatment for longer periods of time. Another type of acid reducer, H2-antagonists (e.g., ranitidine, nizatidine), may also be used.

If the peptic ulcer was caused by NSAIDs, such as ASA, your doctor will most often recommend that you stop taking them if possible. Some people are more susceptible to peptic ulcers caused by NSAIDs, including those who:

are seniors
are smokers
have a history of a peptic ulcer
are also taking glucocorticoids (e.g., prednisone, dexamethasone)
are taking high doses of NSAIDs or ASA
have several medical conditions
are taking more than one NSAID or ASA

If you're taking a NSAID and have one of these risk factors, your doctor may prescribe a protective medication to take along with it. Acid-suppressing medications (e.g., PPIs) or misoprostol may be used for this. Misoprostol encourages the stomach to produce its protective mucus coating and improves blood flow.

It's important for people with PUD to quit smoking. Smoking can delay healing and can cause ulcers to return.

Very rarely, surgical treatment may be needed for PUD and its complications.

*All medications have both common (generic) and brand names. The brand name is what a specific manufacturer calls the product (e.g., Tylenol®). The common name is the medical name for the medication (e.g., acetaminophen). A medication may have many brand names, but only one common name. This article lists medications by their common names. For information on a given medication, check our Drug Information database. For more information on brand names, speak with your doctor or pharmacist.