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Peptic ulcers are small sores which develop in the acidic regions of the digestive tract. While you most often hear the term “stomach ulcers” in reference to peptic ulcers, ulcers can also develop in the esophagus, duodenum, and the Meckel's Diverticulum. These open sores can be extremely painful, leading to intense discomfort and sometimes medical complications for the people who suffer from them. This medical condition is also extremely common worldwide, with people in a wide range of environments, cultures, and societies suffering from peptic ulcers.
Historically, people believed that peptic ulcers were related to stress and diet. In fact, most peptic ulcers are actually caused by bacteria which weaken the mucus lining of the intestinal tract, allowing the harsh gastric acids in the stomach to damage the delicate underlying lining. Peptic ulcers can be exacerbated by things like aspirin, acidic foods, tobacco, and alcohol, but they can appear in people of any age and lifestyle, from a harried physicist to an elementary school student.
The discovery that bacteria were often responsible led to a major breakthrough in the treatment of peptic ulcers. Historically, people with ulcers simply had to suffer through them, after making significant dietary adjustments. Today, a round of antibiotics can be used to clear out the bacteria, and antacids can be used to reduce the amount of active acid in the digestive tract, giving the ulcerated lining of the digestive tract a chance to heal over.
People with peptic ulcers typically experience stomach pain, abdominal bloating, and nausea. In some cases, the ulcer may actually perforate the lining of the digestive tract, creating a medical emergency which must be addressed with prompt surgery. Peptic ulcers can be diagnosed with the assistance of a gastroscopy, in which a camera is inserted into the digestive tract to look for ulcers. Diagnosis is important, to rule out potential causes such as cancers, which are malignant and dangerous if untreated.
Many people neglect to seek treatment for peptic ulcers, rationalizing that the condition is bearable, if irritating, or operating under the assumption that there is no treatment. This is not a good idea, both because peptic ulcers are treatable, and because the symptoms associated with peptic ulcers are also linked with some dangerous medical conditions. There is no reason to suffer with the pain of peptic ulcers when treatment is possible, especially since treatment promotes good gastrointestinal health.
Symptoms of a peptic ulcer can be
abdominal pain, classically epigastric with severity relating to mealtimes, after around three hours of taking a meal (duodenal ulcers are classically relieved by food, while gastric ulcers are exacerbated by it);
bloating and abdominal fullness;
water brash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus - although this is more associated with gastroesophageal reflux disease);
nausea, and copious vomiting;
loss of appetite and weight loss;
hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or from damage to the esophagus from severe/continuing vomiting.
melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin);
rarely, an ulcer can lead to a gastric or duodenal perforation, which leads to acute peritonitis. This is extremely painful and requires immediate surgery.
A history of heartburn, gastroesophageal reflux disease (GERD) and use of certain forms of medication can raise the suspicion for peptic ulcer. Medicines associated with peptic ulcer include NSAID (non-steroid anti-inflammatory drugs) that inhibit cyclooxygenase, and most glucocorticoids (e.g. dexamethasone and prednisolone).
The timing of the symptoms in relation to the meal may differentiate between gastric and duodenal ulcers: A gastric ulcer would give epigastric pain during the meal, as gastric acid production is increased as food enters the stomach. Symptoms of duodenal ulcers would initially be relieved by a meal, as the pyloric sphincter closes to concentrate the stomach contents, therefore acid is not reaching the duodenum. Duodenal ulcer pain would manifest mostly 2–3 hours after the meal, when the stomach begins to release digested food and acid into the duodenum.
Also, the symptoms of peptic ulcers may vary with the location of the ulcer and the patient's age. Furthermore, typical ulcers tend to heal and recur and as a result the pain may occur for few days and weeks and then wane or disappear. Usually, children and the elderly do not develop any symptoms unless complications have arisen.
Burning or gnawing feeling in the stomach area lasting between 30 minutes and 3 hours commonly accompanies ulcers. This pain can be misinterpreted as hunger, indigestion or heartburn. Pain is usually caused by the ulcer but it may be aggravated by the stomach acid when it comes into contact with the ulcerated area. The pain caused by peptic ulcers can be felt anywhere from the navel up to the sternum, it may last from few minutes to several hours and it may be worse when the stomach is empty. Also, sometimes the pain may flare at night and it can commonly be temporarily relieved by eating foods that buffer stomach acid or by taking anti-acid medication. However, peptic ulcer disease symptoms may be different for every sufferer.
Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be life-threatening. It occurs when the ulcer erodes one of the blood vessels, such as the gastroduodenal artery.
Perforation (a hole in the wall) often leads to catastrophic consequences. Erosion of the gastro-intestinal wall by the ulcer leads to spillage of stomach or intestinal content into the abdominal cavity. Perforation at the anterior surface of the stomach leads to acute peritonitis, initially chemical and later bacterial peritonitis. The first sign is often sudden intense abdominal pain. Posterior wall perforation leads to bleeding due to involvement of gastroduodenal artery that lies posterior to the 1st part of duodenum.
Penetration is when the ulcer continues into adjacent organs such as the liver and pancreas.
Scarring and swelling due to ulcers causes narrowing in the duodenum and gastric outlet obstruction. Patient often presents with severe vomiting.
Cancer is included in the differential diagnosis (elucidated by biopsy), Helicobacter pylori as the etiological factor making it 3 to 6 times more likely to develop stomach cancer from the ulcer.
Your treatment plan will be determined by whether your peptic ulcer is due to a H. pylori infection or the use of non-steroidal anti-inflammatory drugs (NSAIDs) or, in some cases, by a combination of H. pylori infection and NSAIDs.
If your peptic ulcer is caused by a H. pylori infection, the recommended treatment plan is a course of antibiotics to kill the bacteria. This is known as eradication therapy.
If your peptic ulcer is caused by NSAIDs, and you do not have a H. pylori infection, your recommended treatment plan is a 1-2 month course of proton pump inhibitors (PPIs). Your use of NSAIDs will also need to be reviewed. For example, an alternative painkiller, such as paracetamol, may be recommended.
If it is thought that your peptic ulcer is caused by a combination of NSAID use and H. pylori infection, you will been given a two month dose of PPIs, followed by a course of eradication therapy.
An alternative medication called H2-receptor antagonists can be used in people who fail to respond to treatment with PPIs.
Eradication therapy involves taking a combination of three different antibiotics. A combination is used just in case the bacteria have evolved a resistance to one or more of the antibiotics. You will usually be asked to take each antibiotic twice a day for seven days. The antibiotics that are normally used in eradication therapy are:
amoxicillin,
clarithromycin, and
metronidazole.
The side effects of these antibiotic are usually mild and include:
nausea,
vomiting,
diarrhoea, and
a metallic taste in the mouth.
Some people who are taking metronidazole find that they experience unpleasant reactions if they drink alcohol such as:
hot and flushed skin, and
increased breathing and/or heart rate.
It is therefore usually recommended that you avoid drinking alcohol while taking metronidazole. You will be re-tested at least four weeks after eradication therapy has been completed to see whether there is any H. pylori bacteria left in your stomach and intestines. If there is, you will be given a further course of eradication therapy using a different mixture of antibiotics in combination with PPIs.
Proton pump inhibitors (PPIs) work by blocking the actions of proteins called proton pumps, which are partially responsible for producing stomach acid. Reducing the amount of stomach acid prevents any further damage to your peptic ulcer, allowing it to heal naturally. The two most commonly used PPIs in the treatment of peptic ulcers are lansoprazole and omeprazole.
Side effects of PPIs are generally mild and include:
headache,
diarrhoea,
nausea,
abdominal pain,
constipation,
dizziness, and
skin rashes.
The side effects should pass once treatment has been completed.
H2-receptor antagonists work by blocking the actions of a protein called histamine which is also responsible for stimulating the production of acid. Ranitidine is the most widely used H2-receptor antagonist for treating peptic ulcers.
Side effects of H2-receptor antagonists are uncommon but may include:
diarrhoea,
headaches,
dizziness,
skin rashes, and
tiredness.
All of the treatments discussed above can take several weeks to become effective, so it is likely that your GP will recommend some additional medication to help provide short-term relief from your symptoms.
Two types of medication that can be used are:
antacids - to neutralise stomach acid on a short-term basis, and
alginates - which produce a protective coating on the lining of your stomach.
Both antacids and alginates are over-the-counter (OTC) medications that are available from pharmacists. The pharmacist will be able to advise you about which particular types of antacid and alginate are most suitable for you.
Antacids are best taken when you experience symptoms, or when symptoms are expected, such as after meals, or at bedtime.
Alginates are best taken after meals.
If your peptic ulcer has been caused by taking NSAIDs, your GP will want to review your use of NSAIDs. You will usually be advised to use an alternative painkiller that is not linked to peptic ulcers, such as paracetamol, or a low-dose opiate-based painkiller. If you are taking aspirin to reduce your risk of blood clots, you have a number of possible options:
stop taking aspirin to allow the ulcer to heal, and then combine aspirin with a PPI, which will help counteract the negative effects of aspirin, or
switch to an alternative anti-clotting medication called clopodogrel.
If you (or your GP) feel that the continued used of NSAIDs is absolutely necessary, you will be prescribed a long-term dose of a PPI, or H2-receptor antagonist.
It is important to understand the potential drawbacks and risks that are associated with continued NSAID use. You are more likely to develop another peptic ulcer and the risks of experiencing serious complications, such as internal bleeding, are higher.