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Peptic Ulcers

Peptic Ulcers

In the digestive system, an ulcer is an area where tissue has been destroyed bygastric juices and stomach acid. Peptic ulcer disease is a general term for ulcers that occur in the stomach or duodenum (upper part of the small intestine).

 

  • A peptic ulcer is an erosion or sore in the wall of the gastrointestinal tract. 
  • The mucous membrane lining the digestive tract erodes and causes a gradual breakdown of tissue. 
  • This breakdown causes a gnawing or burning pain in the upper middle part of the belly (abdomen). 
  • Although most peptic ulcers are small, they can cause a considerable amount of discomfort.

 

Peptic ulcers are a very common condition in the United States and throughout the world.

 

  • In the United States, an estimated 25 million people will suffer an ulcer at some point. That's 1 in 10 people. 
  • About 4 million people are affected by ulcers at any given time. 
  • There are approximately 350,000-500,000 new cases and more than 1 million ulcer-related hospitalizations each year in this country alone. 
  • About 6000 people die each year of ulcer-related complications.

 

Ulcers can occur at any age, although they are rare in children and teenagers.

 

  • Duodenal ulcers usually first occur between the ages of 30-50 years and are twice as common in men as in women. 
  • Stomach (or gastric) ulcers usually occur in people older than 60 years and are more common in women.

 

The good news is that we have learned a lot about ulcers in the past 20 years and effective therapies are now available.

Symptoms

Ulcers do not always cause symptoms. Sometimes, a serious complication such as bleeding is the first sign of an ulcer.

 

The most common symptom of peptic ulcers by far is abdominal pain.

 

  • The pain is usually in the upper middle part of the abdomen, above the belly button (navel) and below the breastbone. 
  • The pain can feel like burning or gnawing, and it may go through to the back. 
  • Pain often comes several hours after a meal when the stomach is empty. 
  • The pain is often worse at night and early morning. 
  • It can last anywhere from a few minutes to several hours. 
  • The pain may be relieved by food, antacids, or vomiting.

 

Other symptoms of peptic ulcers include the following:

 

  • Nausea.
  • Vomiting.
  • Loss of appetite.
  • Loss of weight.

 

Very severe ulcers sometimes cause bleeding in the stomach or duodenum. Bleeding is sometimes the only symptom of an ulcer. This bleeding can be fast or slow.

 

Fast bleeding reveals itself in one of the following ways:

 

  • Vomiting of blood or dark material that looks something like coffee grounds: This is an emergency and warrants an immediate visit to an emergency department. 
  • Blood in the stool or black, tarry, sticky-looking stools.
  • Slow bleeding is often more difficult to detect, because it has no dramatic symptoms.
  • The usual result is low blood cell count (anemia). 
  • The symptoms of anemia are tiredness (fatigue), lack of energy (lethargy), weakness, and pallor.

Causes

When you eat, your stomach produces hydrochloric acid and an enzyme called pepsin to digest the food.

 

  • The food is partially digested in the stomach and then moves on to the duodenum to continue the process. 
  • Peptic ulcers occur when the acid and enzyme overcome the defense mechanisms of the gastrointestinal tract and cause an erosion in the mucosal wall.

 

The medical community long believed that ulcers were caused by lifestyle factors such as eating habits, cigarette smoking, and stress.

 

  • Gradually, researchers realized that people with ulcers had an imbalance between, on one hand, acid and pepsin, and on the other, the digestive tract's ability to protect itself from these harsh substances. 
  • Research done in the 1980s showed that ulcers are actually caused by infection with a bacterium named Helicobacter pylori, usually called H pylori. 
  • Not everyone who gets an ulcer is infected with H pylori. We now know that aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) can cause ulcers if taken regularly.

 

While we no longer believe that lifestyle factors cause ulcers, we do believe that they play a role. Some types of medical therapy also can contribute to ulcer formation. The following factors can weaken the protective mucosal barrier of the stomach. This increases the chances of getting an ulcer and slows healing of existing ulcers.

 

  • Aspirin, nonsteroidal anti-inflammatory drugs (such as ibuprofen andnaproxen), and newer anti-inflammatory medications (such as celecoxib[Celebrex]).
  • Alcohol.
  • Stress - Physical (severe injuries or burns, major surgery) or emotional.
  • Caffeine.
  • Cigarette smoking.
  • Radiation therapy - Used for diseases such as cancer.

 

People who take aspirin or other anti-inflammatory medication are at increased risk even if they do not have H pylori infection.

 

  • Elderly people with conditions such as arthritis are especially vulnerable. 
  • People who have had ulcers or intestinal bleeding before are also at higher-than-normal risk. 
  • If you take these medications regularly, you should talk to your health care provider about alternatives. This is especially true if you get an upset stomach or heartburn after taking one of these medications. H pylori bacteria spread through the stools (feces) of an infected person.
  • The stool contaminates food or water (usually through poor personal hygiene). 
  • The bacteria in the stool make their way into the digestive tracts of people who consume this food or water. 
  • This is called fecal-oral transmission and is a common way for infections to spread.

 

The bacteria are found in the stomach, where they are able to penetrate and damage the lining of the stomach and duodenum.

 

  • Many people who are exposed to the bacteria never develop ulcers. 
  • People who are newly infected usually develop symptoms within a few weeks. 
  • Researchers are trying to discover what is different about the people who develop ulcers.

 

Infection with H pylori occurs in all ages, races, and socioeconomic classes.

 

  • It is more common in older adults, although it is thought that many people are infected in childhood and carry the bacteria throughout their lifetimes. 
  • It is also more common in lower socioeconomic classes because these households tend to have more people living together, sharing bathrooms and kitchen facilities. 
  • African Americans and Hispanic Americans are more likely to have the bacteria than whites and Asian Americans.

 

It is important to distinguish between ulcers caused by H pylori and those caused by medications only, because the treatment is completely different.

 

Ulcers can be linked with other medical conditions.

 

  • People who worry excessively are usually thought to have a condition calledgeneralized anxiety disorder. This disorder has been linked with peptic ulcers. 
  • A rare condition called Zollinger-Ellison syndrome causes peptic ulcers as well as tumors in the pancreas and duodenum.

Treatment

The goal of ulcer treatment is to relieve pain and to prevent ulcer complications, such as bleeding, obstruction, and perforation. The first step in treatment involves the reduction of risk factors (NSAIDs and cigarettes). The next step is medications.

 

Antacids neutralize existing acid in the stomach. Antacids such as Maalox, Mylanta, and Amphojel are safe and effective treatments. However, the neutralizing action of these agents is short-lived, and frequent dosages are required. Magnesium containing antacids, such as Maalox and Mylanta, can cause diarrhea, while aluminum agents like Amphojel can cause constipation. Ulcers frequently return when antacids are discontinued.

 

Studies have shown that a protein in the stomach called histamine stimulates gastric acid secretion. Histamine antagonists (H2 blockers) are drugs designed to block the action of histamine on gastric cells, hence reducing acid output. Examples of H2 blockers are cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine (Pepcid). While H2 blockers are effective in ulcer healing, they have limited role in eradicating H. pylori without antibiotics. Therefore, ulcers frequently return when H2 blockers are stopped.

 

Generally, these drugs are well tolerated and have few side effects even with long term use. In rare instances, patients report headache,confusion, lethargy, or hallucinations. Chronic use of cimetidine may rarely cause impotence or breast swelling. Both cimetidine and ranitidine can interfere with body's ability to handle alcohol. Patients on these drugs who drink alcohol may have elevated blood alcohol levels. These drugs may also interfere with the liver's handling of other medications like Dilantin, Coumadin, and theophylline. Frequent monitoring and adjustments of the dosages of these medications may be needed.

 

Proton-pump inhibitors such as omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), esomeprazole (Nexium), andrabeprazole (Aciphex) are more potent than H2 blockers in suppressing acid secretion.

 

Different proton-pump inhibitors are very similar in action and there is no evidence that one is more effective than another in healing ulcers. While proton-pump inhibitors are comparable to H2 blockers in effectiveness in treating gastric and duodenal ulcers, it is superior to H2 blockers in treating esophageal ulcers.

 

Esophageal ulcers are more sensitive than gastric and duodenal ulcers to minute amounts of acid. Therefore, more complete acid suppression accomplished by proton-pump inhibitors are important for esophageal ulcer healing. Proton-pump inhibitors are well tolerated.

 

Side effects are uncommon; they include headache, diarrhea, constipation, nausea and rash. Interestingly, proton-pump inhibitors do not have any effect on a person's ability to digest and absorb nutrients. Proton-pump inhibitors have also been found to be safe when used long term, without serious adverse health effects reported.

 

Sucralfate (Carafate) and misoprostol (Cytotec) are agents that strengthen the gut lining against attacks by acid digestive juices. Carafate coats the ulcer surface and promotes healing. The medication has very few side effects. The most common side effect is constipation and the interference with the absorption of other medications. Cytotec is a prostaglandin-like substance commonly used to counteract the ulcer effects of NSAIDs.

 

Studies suggest that Cytotec may protect the stomach from ulceration in those who take NSAIDs on a chronic basis. Diarrhea is a common side effect. Cytotec can cause miscarriages when given to pregnant women, and should be avoided by women of childbearing age.

 

Many people harbor H. pylori in their stomachs without ever having pain or ulcers. It is not completely clear whether these patients should be treated with antibiotics. More studies are needed to answer this question. Patients with documented ulcer disease and H. pylori infection should be treated with antibiotic combinations. H. pylori can be very difficult to completely eradicate. Treatment requires a combination of several antibiotics, sometimes in combination with a proton-pump inhibitor, H2 blockers or Pepto-Bismol.

 

Commonly used antibiotics are tetracycline, amoxicillin, metronidazole (Flagyl), clarithromycin (Biaxin), and levofloxacin (Levaquin). Eradication of H. pylori prevents the return of ulcers (a major problem with all other ulcer treatment options). Elimination of this bacteria may also decrease the risk of developing gastric cancer in the future. Treatment with antibiotics carries the risk of allergic reactions, diarrhea, and sometimes severe antibiotic-induced colitis (inflammation of the colon).

 

There is no conclusive evidence that dietary restrictions and bland diets play a role in ulcer healing. No proven relationship exists between peptic ulcer disease and the intake of coffee and alcohol. However, since coffee stimulates gastric acid secretion, and alcohol can cause gastritis, moderation in alcohol and coffee consumption is often recommended.

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