Peptic Ulcer

What is Peptic Ulcer?

The word peptic refers to promoting digestion. Ulcer refers to an area of tissue erosion. Hence, peptic ulcer means tissue erosion in the digestive system.

What is Peptic Ulcer?

Peptic ulcer is a break in the inner lining of the esophagus, duodenum or stomach. If peptic ulcer forms in the stomach it is termed as gastric ulcer, similarly if it forms in the duodenum a duodenal ulcer, and esophageal ulcer if it forms in the esophagus.

Peptic ulcers are formed when the lining of any of these organs is corroded by the acidic digestive juices which are secreted by the stomach. A peptic ulcer is pretty different from erosion as it extends deeper into the lining of the esophagus, duodenum or stomach and triggers more of an inflammatory reaction from the tissues that are eroded.

Classification and Types of Peptic Ulcer

There are three different types of peptic ulcers.

  • Esophageal Ulcers: These are open sores or lesions, which form in the lining of the esophagus.
  • Gastric Ulcers: These are the ulcers, which form in the lining of the stomach.
  • Duodenal Ulcers: These ulcers form in the upper part of the small intestine, an area known as duodenum.

Epidemiology of Peptic Ulcer

H. pylori infection is very common affecting more than a billion people worldwide. Half of the United States population older than the age of 60 is estimated to be infected with H. pylori. Infection usually persists for years together leading to ulcer disease in 10% to 15% of infected individuals. H. pylori was found in more than 80% of the patients in the past with gastric and duodenal ulcers, however, the prevalence of infection with H. pylori as well as the proportion of ulcers caused by the bacterium has decreased with increased appreciation, diagnosis and treatment over a period of time. It is estimated that only 20% of ulcers are associated with the bacterium currently.

Pathophysiology of Peptic Ulcer

Peptic ulcers are defects or corrosions in the gastric or duodenal mucosa that extend through the muscularis mucosa. The epithelial cells of the stomach and duodenum secrete mucus as a result of cholinergic stimulation in response to irritation of the epithelial lining. The superficial portion of the gastric and duodenal mucosa is a form of a gel layer, which is resistant to pepsin and acid. In the event that pepsin and acid enters the epithelial cells, there are other additional mechanisms in place to reduce the injury.

Under normal conditions, a physiologic balance exists between gastroduodenal mucosal defense and gastric acid secretion. Peptic ulcer occurs when the balance between the aggressive factors and the defensive mechanisms is disrupted. Aggressive factors, such as H pylori infection, NSAIDs, alcohol, acid, pepsin and bile salts, can alter the mucosal defense by allowing back diffusion of hydrogen ions and subsequent epithelial cell injury. The defensive mechanisms include tight intercellular junctions, mucosal blood flow, mucus, epithelial renewal and cellular restitution.

Causes and Risk Factors of Peptic Ulcer

Peptic ulcers are usually caused by either Helicobacter pylori also known as H pylori bacteria or NSAIDs i.e., non-steroidal anti-inflammatory drugs. H Pylori bacteria are known to be responsible for about 4/5 of all gastric ulcers and about 95% of duodenal ulcers. NSAIDs are known to be responsible for about 20% of gastric ulcers and 5% duodenal ulcers.

  • H. Pylori: Over 25% of people in Western Europe and North America are carriers of H. pylori though it is uncertain why the bacteria do not cause ulcers in all people who carry H. pylori. The bacterium spreads through water and food. It can spread through mouth-to-mouth contact through saliva for instance with kissing. It resides in the mucus that coats the lining of the stomach and duodenum and produces an enzyme called urease that neutralizes the stomach acid by making it less acidic. In order to compensate for the loss, the stomach makes more acid, which irritates the lining of the stomach.
  • H. pylori also weakens the defense system of the stomach and causes inflammation. Patients with peptic ulcers caused by H. pylori need to be treated first to get rid of the bacterium in order to prevent recurrences.
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs are the medications generally used for period pains, headaches, and other minor pains. Aspirin and ibuprofen are the most common. Many NSAIDs can be obtained over the counter, while there are others such as naproxen, meloxicam and diclofenac that be acquired only on a doctor's prescription. Non-steroidal anti-inflammatory drugs decrease the stomach's ability to make a protective layer of mucus making it more prone to damage by acids produced by stomach.
  • Mental Stress: Mental stress has not been directly linked to the development of peptic ulcers, however, sustained mental stress in people who suffer with peptic ulcers tend to have symptom worsening.
  • Smoking: Regular smoking and tobacco use are more likely to cause peptic ulcers.
  • Alcohol Consumption: Regular heavy drinking of alcohol predisposes to a higher risk of developing peptic ulcers.
  • Genetics: Genetic factors may also be involved to some extent as studies have found that people suffering with peptic ulcer disease have some close relatives with the same problem.

Signs and Symptoms of Peptic Ulcer

The most common symptoms of peptic ulcer are indigestion-like pain. The pain can be felt anywhere in the area from the belly button to the breast bone. It can last from a couple of minutes to a number of hours. It can be more severe when the stomach is empty or can be worse during the night. It is relieved temporarily after eating certain foods and goes away and then returns for a few days or weeks.

Following Symptoms Indicate That an Individual may be Suffering from Peptic Ulcer Disease:

  • Difficulty swallowing food.
  • Regurgitation of food, or food coming back up from the stomach.
  • Retching after eating.
  • Feeling sick after eating.
  • Loss of appetite.
  • Weight loss.

Less Frequent or Uncommon Symptoms of Peptic Ulcers are:

  • Nausea and vomiting.
  • Vomiting blood.
  • Black and tarry stools.

These symptoms should be considered and treated as medical emergencies.

Tests to Diagnose Peptic Ulcer

  • Blood Test: General to confirm the presence of H pylori.
  • Breath Test: This uses a radioactive carbon atom to detect H pylori. The breath test is also useful in checking to see how effective treatment has been in eliminating H pylori.
  • Stool Antigen Test: This test is to determine whether H. pylori is present in the feces (stools). This test is also used to determine the affect of treatment of H. pylori.
  • Upper gastrointestinal X-ray (upper GI X-ray): Upper GI X-rays are only useful in detecting some ulcers.
  • Endoscopy: Endoscopy is performed to visualize the upper part of the digestive system and check for ulcers.
  • Biopsy: If an ulcer is detected on endoscopy, a biopsy or a small sample of tissue may be taken for examination to rule out cancer or test for H. pylori.

Treatment for Peptic Ulcer

Antacids: Antacids neutralize the acid present in the stomach. Antacids such as Mylanta and Maalox are safe and effective treatments, however the neutralizing action of these agents is short-lived, and continuous dosing is required. Antacids like Mylanta and Maalox which contain Magnesium can cause diarrhea, while aluminum containing agents like Amphojel can cause constipation. Ulcers return frequently when antacids are discontinued.

PPIs (Proton Pump Inhibitors)

PPIs reduce the amount of acid produced by the stomach and are given for individuals who tested negative for H pylori infection. Treatment generally runs from one to two months and if the ulcer is severe treatment can last longer.

Side effects, if they occur, are usually mild and go away as soon as the treatment stops. Some of them are:

  • Skin rashes.
  • Headaches.
  • Dizziness.
  • Nausea.
  • Stomach pain.
  • Constipation.
  • Diarrhea.

H2-receptor Antagonists

H2 blockers or histamine antagonists are drugs designed to block the action of histamine on gastric cells and reduce acid production in the stomach.

Side effects, if they occur, are usually mild and go away as soon as the treatment stops. Some of them are:

  • Skin rashes.
  • Headaches.
  • Dizziness.
  • Nausea.
  • Stomach pain.
  • Constipation.
  • Diarrhea.

H. Pylori Treatment: Elimination of this bacteria may decrease the risk of developing gastric cancer in the future.

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Individuals whose peptic ulcer was caused by taking NSAIDs will have to stop taking them or replace them with another painkiller such as Tylenol. In cases where it may not be possible to stop taking NSAIDs, the dosage has to be minimized and kept under continuous check. PPI or an H2-receptor antagonist may be added to counter the effects of NSAIDs in such cases.

Sucralfate and Misoprostol: These agents strengthen the gut lining against attacks by acidic digestive juices. Sucralfate provides protective coating to the ulcer surface and promotes healing. It has very minimal side effects. The most common side effect is constipation and the interference with the absorption of other medications. Misoprostol is commonly used to counteract the ulcerogenic effects of NSAIDs. Diarrhea is a common side effect. Misoprostol can cause miscarriages in pregnant women, and hence should be avoided in women of childbearing age.

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Last Modified On: May 13, 2016

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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