Peptic Ulcer

Overview

Peptic ulcers are open sores that develop on the inside lining of your stomach and the upper portion of your small intestine. The most common symptom of a peptic ulcer is stomach pain.

Peptic ulcers include:

• Gastric ulcers that occur on the inside of the stomach
• Duodenal ulcers that occur on the inside of the upper portion of your small intestine (duodenum)

The most common causes of peptic ulcers are infection with the bacterium Helicobacter pylori (H. pylori) and long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve). Stress and spicy foods do not cause peptic ulcers. However, they can make your symptoms worse.

Symptoms

• Burning stomach pain
• Feeling of fullness, bloating or belching
• Intolerance to fatty foods
• Heartburn
• Nausea

The most common peptic ulcer symptom is burning stomach pain. Stomach acid makes the pain worse, as does having an empty stomach. The pain can often be relieved by eating certain foods that buffer stomach acid or by taking an acid-reducing medication, but then it may come back. The pain may be worse between meals and at night.

Many people with peptic ulcers don't even have symptoms.

Less often, ulcers may cause severe signs or symptoms such as:

• Vomiting or vomiting blood — which may appear red or black
• Dark blood in stools, or stools that are black or tarry
• Trouble breathing
• Feeling faint
• Nausea or vomiting
• Unexplained weight loss
• Appetite changes

When to see a doctor

See your doctor if you have the severe signs or symptoms listed above. Also see your doctor if over-the-counter antacids and acid blockers relieve your pain but the pain returns.

Causes

Peptic ulcers occur when acid in the digestive tract eats away at the inner surface of the stomach or small intestine. The acid can create a painful open sore that may bleed.

Your digestive tract is coated with a mucous layer that normally protects against acid. But if the amount of acid is increased or the amount of mucus is decreased, you could develop an ulcer.

Common causes include:

• A bacterium. Helicobacter pylori bacteria commonly live in the mucous layer that covers and protects tissues that line the stomach and small intestine. Often, the H. pylori bacterium causes no problems, but it can cause inflammation of the stomach's inner layer, producing an ulcer.

  It's not clear how H. pylori infection spreads. It may be transmitted from person to person by close contact, such as kissing. People may also contract H. pylori through food and water.

• Regular use of certain pain relievers. Taking aspirin, as well as certain over-the-counter and prescription pain medications called nonsteroidal anti-inflammatory drugs (NSAIDs) , can irritate or inflame the lining of your stomach and small intestine. These medications include ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve, Anaprox DS, others), ketoprofen and others. They do not include acetaminophen (Tylenol, others).
• Other medications. Taking certain other medications along with NSAIDs, such as steroids, anticoagulants, low-dose aspirin, selective serotonin reuptake inhibitors (SSRIs), alendronate (Fosamax) and risedronate (Actonel), can greatly increase the chance of developing ulcers.

Risk factors

In addition to having risks related to taking NSAIDs, you may have an increased risk of peptic ulcers if you:

• Smoke. Smoking may increase the risk of peptic ulcers in people who are infected with H. pylori.
• Drink alcohol. Alcohol can irritate and erode the mucous lining of your stomach, and it increases the amount of stomach acid that's produced.
• Have untreated stress.
• Eat spicy foods.

Alone, these factors do not cause ulcers, but they can make ulcers worse and more difficult to heal.

Complications

Left untreated, peptic ulcers can result in:

• Internal bleeding. Bleeding can occur as slow blood loss that leads to anemia or as severe blood loss that may require hospitalization or a blood transfusion. Severe blood loss may cause black or bloody vomit or black or bloody stools.
• A hole (perforation) in your stomach wall. Peptic ulcers can eat a hole through (perforate) the wall of your stomach or small intestine, putting you at risk of serious infection of your abdominal cavity (peritonitis).
• Obstruction. Peptic ulcers can block passage of food through the digestive tract, causing you to become full easily, to vomit and to lose weight either through swelling from inflammation or through scarring.
• Gastric cancer. Studies have shown that people infected with H. pylori have an increased risk of gastric cancer.

Prevention

You may reduce your risk of peptic ulcer if you follow the same strategies recommended as home remedies to treat ulcers. It also may be helpful to:

• Protect yourself from infections. It's not clear just how H. pylori spreads, but there's some evidence that it could be transmitted from person to person or through food and water.

  You can take steps to protect yourself from infections, such as H. pylori, by frequently washing your hands with soap and water and by eating foods that have been cooked completely.

• Use caution with pain relievers. If you regularly use pain relievers that increase your risk of peptic ulcer, take steps to reduce your risk of stomach problems. For instance, take your medication with meals.

  Work with your doctor to find the lowest dose possible that still gives you pain relief. Avoid drinking alcohol when taking your medication, since the two can combine to increase your risk of stomach upset.

  If you need an NSAID, you may need to also take additional medications such as an antacid, a proton pump inhibitor, an acid blocker or cytoprotective agent. A class of NSAIDs called COX-2 inhibitors may be less likely to cause peptic ulcers, but may increase the risk of heart attack.

Diagnosis

To detect an ulcer, your doctor may first take a medical history and perform a physical exam. You then may need to undergo diagnostic tests, such as:

• Laboratory tests for H. pylori. Your doctor may recommend tests to determine whether the bacterium H. pylori is present in your body. He or she may look for H. pylori using a blood, stool or breath test. The breath test is the most accurate.

  For the breath test, you drink or eat something that contains radioactive carbon. H. pylori breaks down the substance in your stomach. Later, you blow into a bag, which is then sealed. If you're infected with H. pylori, your breath sample will contain the radioactive carbon in the form of carbon dioxide.

  If you are taking an antacid prior to the testing for H. pylori, make sure to let your doctor know. Depending on which test is used, you may need to discontinue the medication for a period of time because antacids can lead to false-negative results.

• Endoscopy. Your doctor may use a scope to examine your upper digestive system (endoscopy). During endoscopy, your doctor passes a hollow tube equipped with a lens (endoscope) down your throat and into your esophagus, stomach and small intestine. Using the endoscope, your doctor looks for ulcers.

  If your doctor detects an ulcer, a small tissue sample (biopsy) may be removed for examination in a lab. A biopsy can also identify whether H. pylori is in your stomach lining.

  Your doctor is more likely to recommend endoscopy if you are older, have signs of bleeding, or have experienced recent weight loss or difficulty eating and swallowing. If the endoscopy shows an ulcer in your stomach, a follow-up endoscopy should be performed after treatment to show that it has healed, even if your symptoms improve.

• Upper gastrointestinal series. Sometimes called a barium swallow, this series of X-rays of your upper digestive system creates images of your esophagus, stomach and small intestine. During the X-ray, you swallow a white liquid (containing barium) that coats your digestive tract and makes an ulcer more visible.

Treatment

Treatment for peptic ulcers depends on the cause. Usually treatment will involve killing the H. pylori bacterium if present, eliminating or reducing use of NSAIDs if possible, and helping your ulcer to heal with medication.

Medications can include:

• Antibiotic medications to kill H. pylori. If H. pylori is found in your digestive tract, your doctor may recommend a combination of antibiotics to kill the bacterium. These may include amoxicillin (Amoxil), clarithromycin (Biaxin), metronidazole (Flagyl), tinidazole (Tindamax), tetracycline and levofloxacin.

  The antibiotics used will be determined by where you live and current antibiotic resistance rates. You'll likely need to take antibiotics for two weeks, as well as additional medications to reduce stomach acid, including a proton pump inhibitor and possibly bismuth subsalicylate (Pepto-Bismol).

• Medications that block acid production and promote healing. Proton pump inhibitors — also called PPIs — reduce stomach acid by blocking the action of the parts of cells that produce acid. These drugs include the prescription and over-the-counter medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium) and pantoprazole (Protonix).

  Long-term use of proton pump inhibitors, particularly at high doses, may increase your risk of hip, wrist and spine fracture. Ask your doctor whether a calcium supplement may reduce this risk.

• Medications to reduce acid production. Acid blockers — also called histamine (H-2) blockers — reduce the amount of stomach acid released into your digestive tract, which relieves ulcer pain and encourages healing.

  Available by prescription or over the counter, acid blockers include the medications famotidine (Pepcid AC), cimetidine (Tagamet HB) and nizatidine (Axid AR).

• Antacids that neutralize stomach acid. Your doctor may include an antacid in your drug regimen. Antacids neutralize existing stomach acid and can provide rapid pain relief. Side effects can include constipation or diarrhea, depending on the main ingredients.

  Antacids can provide symptom relief but generally aren't used to heal your ulcer.

• Medications that protect the lining of your stomach and small intestine. In some cases, your doctor may prescribe medications called cytoprotective agents that help protect the tissues that line your stomach and small intestine.

  Options include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec).

Follow-up after initial treatment

Treatment for peptic ulcers is often successful, leading to ulcer healing. But if your symptoms are severe or if they continue despite treatment, your doctor may recommend endoscopy to rule out other possible causes for your symptoms.

If an ulcer is detected during endoscopy, your doctor may recommend another endoscopy after your treatment to make sure your ulcer has healed. Ask your doctor whether you should undergo follow-up tests after your treatment.

Ulcers that fail to heal

Peptic ulcers that don't heal with treatment are called refractory ulcers. There are many reasons why an ulcer may fail to heal, including:

• Not taking medications according to directions
• The fact that some types of H. pylori are resistant to antibiotics
• Regular use of tobacco
• Regular use of pain relievers — such as NSAIDs — that increase the risk of ulcers

Less often, refractory ulcers may be a result of:

• Extreme overproduction of stomach acid, such as occurs in Zollinger-Ellison syndrome
• An infection other than H. pylori
• Stomach cancer
• Other diseases that may cause ulcerlike sores in the stomach and small intestine, such as Crohn's disease

Treatment for refractory ulcers generally involves eliminating factors that may interfere with healing, along with using different antibiotics.

If you have a serious complication from an ulcer, such as acute bleeding or a perforation, you may require surgery. However, surgery is needed far less often now than previously because of the many effective medications available.

Lifestyle and home remedies

You may find relief from the pain of a stomach ulcer if you:

• Consider switching pain relievers. If you use pain relievers regularly, ask your doctor whether acetaminophen (Tylenol, others) may be an option for you.
• Control stress. Stress may worsen the signs and symptoms of a peptic ulcer. Consider the sources of your stress and do what you can to address the causes. Some stress is unavoidable, but you can learn to cope with stress with exercise, spending time with friends or writing in a journal.
• Don't smoke. Smoking may interfere with the protective lining of the stomach, making your stomach more susceptible to the development of an ulcer. Smoking also increases stomach acid.
• Limit or avoid alcohol. Excessive use of alcohol can irritate and erode the mucous lining in your stomach and intestines, causing inflammation and bleeding.

Alternative medicine

Products containing bismuth may help with symptoms of a peptic ulcer. There is also some evidence that zinc can help heal ulcers. Mastic powder, the product of a type of evergreen shrub, may also help improve symptoms and speed healing of peptic ulcers.

While certain over-the-counter and alternative medications may be helpful, evidence on effectiveness is lacking. Therefore they are not recommended as the primary treatment for peptic ulcers.

Preparing for your appointment

Make an appointment with your regular doctor if you have signs or symptoms that worry you. Your doctor may refer you to a specialist in the digestive system (gastroenterologist).

It's a good idea to be well prepared for your appointment. Here's some information to help you get ready, and what you can expect from your doctor.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet. Certain medications can affect peptic ulcer tests, so your doctor may want you to stop taking them. He or she may be able to suggest alternatives to these drugs.
• Write down any symptoms you're experiencing, as well as the food you're eating. People with peptic ulcers often experience more symptoms when their stomachs are empty.
• Write down key personal information, including any other medical problems, major stresses or recent life changes.
• Make a list of all medications, including over-the-counter medications, vitamins or supplements that you're taking. It's especially important to note any pain reliever use and the usual dose that you take.
• Write down questions to ask your doctor.

For peptic ulcers, some questions you might want to ask your doctor include:

• What's the most likely cause of my symptoms?
• What kinds of tests do I need, and how do I need to prepare for them?
• Is my condition likely temporary or chronic?
• Am I at risk of complications related to this condition?
• What treatment do you recommend?
• If the initial treatment doesn't work, what will you recommend next?
• Are there any dietary restrictions that I need to follow?
• I have other medical problems. How can I manage these along with ulcers?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to cover. Your doctor may ask:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous or intermittent?
• How severe are your symptoms?
• Are your symptoms worse when you're hungry?
• What, if anything, have you been taking to relieve your symptoms?
• Does anything seem to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Do you take pain relievers or aspirin? If yes, how often?
• Do you feel nauseated or have you been vomiting?
• Have you ever vomited blood or black material?
• Have you noticed blood in your stool or black stools?

What you can do in the meantime

While you're waiting to see your doctor, avoiding tobacco, alcohol, spicy foods and stress may help lessen your discomfort.