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Peptic Ulcer

by Sidney Cohen, MD

A peptic ulcer is a round or oval sore where the lining of the stomach or duodenum has been eaten away by stomach acid and digestive juices.

  • Peptic ulcers can result from an infection with Helicobacter pylori or from drugs that weaken the lining of the stomach or duodenum.

  • Discomfort caused by ulcers tends to come and go.

  • The diagnosis is based on symptoms of stomach pain and on the results of an examination of the stomach by using a flexible viewing tube (endoscopy).

  • Antacids and other drugs are given to reduce acid in the stomach, and antibiotics are given to eliminate Helicobacter pylori.

Ulcers penetrate into the lining of the stomach or duodenum (the first part of the small intestine). Gastritis may develop into ulcers.

The names given to specific ulcers identify their anatomic locations or the circumstances under which they developed. Duodenal ulcers, the most common type of peptic ulcer, occur in the first few inches of the duodenum. Gastric ulcers, which are less common, usually occur along the upper curve of the stomach. Marginal ulcers can develop when part of the stomach has been removed surgically, at the point where the remaining stomach has been reconnected to the intestine. Stress ulcers, like acute stress gastritis, can occur as a result of the stress of severe illness, skin burns, or trauma. Stress ulcers occur in the stomach and the duodenum.

Causes

Ulcers develop when the normal defense and repair mechanisms of the lining of the stomach or duodenum are weakened, making the lining more likely to be damaged by stomach acid.

By far, the two most common causes of peptic ulcer are infection of the stomach with Helicobacter pylori bacteria and use of certain drugs.

Before current treatments for Helicobacter pylori infection were used, these bacteria were present in nearly 90% of people with duodenal ulcers and in 75% of people with stomach ulcers. Currently, the percentage is lower, about 50 to 75%.

Many drugs, especially aspirin , other nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids, irritate the stomach lining and can cause ulcers. However, most people who take NSAIDs or corticosteroids do not develop peptic ulcers. Regardless, some experts suggest that people at high risk of developing peptic ulcers should use a type of NSAID called a coxib (COX-2 inhibitor), rather than one of the older types of NSAIDs, because coxibs are less likely to irritate the stomach (see Pain:Coxibs (COX-2 Inhibitors)). However, studies have shown that coxibs appear to increase the risk of heart attack and stroke with long-term use and, therefore, caution should be taken with their use. Because of these complications, most doctors now use a standard NSAID plus a strong acid inhibitor (such as a proton pump inhibitor) for people at high risk of developing peptic ulcers.

People who smoke are more likely to develop a peptic ulcer than people who do not smoke, and their ulcers heal more slowly. Although psychologic stress can increase acid production, no link has been found between psychologic stress and peptic ulcers.

A rare cause of peptic ulcers is a type of cancer that causes excess acid production (Zollinger-Ellison syndrome—see see Zollinger-Ellison Syndrome: An Acid-Stimulating Cancer). The symptoms of cancerous ulcers are very similar to those of noncancerous ulcers. However, cancerous ulcers usually do not respond to the treatments used for noncancerous ulcers.

Symptoms

The typical ulcer tends to heal and recur. Thus, pain may occur for days or weeks and then wane or disappear. Symptoms can vary with the location of the ulcer and the person's age. For example, children and older people may not have the usual symptoms or may have no symptoms at all. In these instances, ulcers are discovered only when complications develop.

Only about half of the people with duodenal ulcers have the typical symptoms of gnawing, burning, aching, soreness, an empty feeling, and hunger. The pain is steady and mild or moderately severe and usually located just below the breastbone. For many people with a duodenal ulcer, pain is usually absent on awakening but appears by midmorning. Drinking milk or eating (which buffers stomach acid) or taking antacids generally relieves the pain, but it usually returns 2 or 3 hours later. Pain that awakens the person during the night is common. Frequently, the pain erupts once or more a day over a period of one to several weeks and then may disappear without treatment. However, pain usually recurs, often within the first 2 years and occasionally after several years. People generally develop patterns and often learn by experience when a recurrence is likely (commonly in spring and fall and during periods of stress).

The symptoms of gastric, marginal, and stress ulcers, unlike those of duodenal ulcers, do not follow any pattern. Eating may relieve pain temporarily or may cause pain rather than relieve it. Gastric ulcers sometimes cause swelling of the tissues (edema) that lead into the small intestine, which may prevent food from easily passing out of the stomach. This blockage may cause bloating, nausea, or vomiting after eating.

Complications of peptic ulcers, such as bleeding or rupture, are accompanied by symptoms of low blood pressure, such as dizziness and fainting.

Diagnosis

A doctor suspects an ulcer when a person has characteristic stomach pain. Sometimes the doctor simply treats the person for an ulcer to see whether the symptoms resolve, which suggests that the person had an ulcer that has healed.

Tests may be needed to confirm the diagnosis, especially when symptoms do not resolve after a few weeks of treatment, or when they first appear in a person who is over age 45 or who has other symptoms such as weight loss, because stomach cancer can cause similar symptoms. Also, when severe ulcers resist treatment, particularly if a person has several ulcers or the ulcers are in unusual places, a doctor may suspect an underlying condition that causes the stomach to overproduce acid.

To help diagnose ulcers and determine their cause, the doctor may use endoscopy (a procedure performed using a flexible viewing tube) or barium contrast x-rays (x-rays taken after a substance that outlines the digestive tract has been swallowed).

Endoscopy is usually the first diagnostic procedure ordered by a doctor. Endoscopy is more reliable than barium contrast x-rays for detecting ulcers in the duodenum and on the back wall of the stomach; endoscopy is also more reliable if the person has had stomach surgery. However, even a highly skilled endoscopist may miss a small number of gastric and duodenal ulcers. With an endoscope, a doctor can perform a biopsy (removal of a tissue sample for examination under a microscope) to determine if a gastric ulcer is cancerous and to help identify the presence of Helicobacter pylori bacteria. An endoscope also can be used to stop active bleeding and decrease the likelihood of recurring bleeding from an ulcer.

Barium contrast x-rays of the stomach and duodenum (also called a barium swallow or an upper gastrointestinal series) can help determine the severity and size of an ulcer, which sometimes cannot be completely seen during an endoscopy because it is further down the duodenum or hidden by a fold.

Treatment

Because infection with Helicobacter pylori bacteria is a major cause of ulcers, antibiotics are often used. Sometimes bismuth subsalicylate is used in combination with antibiotics. Neutralizing or reducing stomach acid by taking drugs that directly inhibit the stomach's production of acid promotes healing of peptic ulcers regardless of the cause. In most people, treatment is continued for 4 to 8 weeks. Although bland diets may help reduce acid, no evidence supports the belief that such diets speed healing or keep ulcers from recurring. Nevertheless, it makes sense for people to avoid foods that seem to make pain and bloating worse. Eliminating possible stomach irritants, such as NSAIDs, alcohol, and nicotine , is also important.

Antacids

Antacids do not effectively heal ulcers but they do relieve symptoms of ulcers by neutralizing stomach acid and thereby raising the pH level in the stomach. Their effectiveness varies with the amount of antacid taken and the amount of acid a person produces. Almost all antacids can be purchased without a doctor's prescription and are available in tablet or liquid form. However, antacids can interact with many different prescription drugs, so a pharmacist should be consulted about possible drug-drug interactions before antacids are taken.

Sodium bicarbonate (baking soda) and calcium carbonate, the strongest antacids, may be taken occasionally for fast, short-term relief. However, because they are absorbed by the bloodstream, continual use of these drugs may make the blood too alkaline (alkalosis—see see Alkalosis), resulting in nausea, headache, and weakness. Therefore, these antacids generally should not be used in large amounts for more than a few days. These products also contain a lot of salt and should not be used by people who need to follow a low-sodium diet or who have heart failure or high blood pressure.

Aluminum hydroxide is a relatively safe, commonly used antacid. However, aluminum may bind with phosphate in the digestive tract, thereby depleting the body of calcium, reducing phosphate levels in the blood, and causing weakness and a loss of appetite. The risk of these side effects is greater in people with alcoholism and in people with kidney disease, including those receiving dialysis. Aluminum hydroxide may also cause constipation.

Magnesium hydroxide is a more effective antacid than aluminum hydroxide. This antacid acts fast and neutralizes acids effectively. Bowel movements usually remain regular if only a few tablespoons a day are taken; more than four doses a day may cause diarrhea. Because small amounts of magnesium are absorbed into the bloodstream, people with kidney damage should take magnesium hydroxide only in small doses. Many antacids contain both magnesium hydroxide and aluminum hydroxide.

Anyone who has heart disease, high blood pressure, or a kidney disorder should consult a doctor before selecting an antacid.

Acid-reducing Drugs

Proton pump inhibitors are the most potent of the drugs that reduce acid production. Proton pump inhibitors promote healing of ulcers in a greater percentage of people in a shorter period of time than do histamine-2 (H 2 ) blockers. They are also very useful in treating conditions that cause excessive stomach acid secretion, such as Zollinger-Ellison syndrome.

Histamine-2 (H 2 ) blockers , such as cimetidine, famotidine, nizatidine, and ranitidine, relieve symptoms and promote ulcer healing by reducing the production of stomach acid. These highly effective drugs are taken once or twice a day. H 2 blockers usually do not cause serious side effects. However, cimetidine is more likely to cause side effects, particularly in older people, in whom the drug may cause confusion. In addition, cimetidine may interfere with the body's elimination of certain drugs—such as theophylline for asthma, warfarin for excessive blood clotting, and phenytoin for seizures.

Miscellaneous Drugs

Sucralfate may work by forming a protective coating in the base of an ulcer to promote healing. It works well on peptic ulcers and is a reasonable alternative to antacids. Sucralfate is taken 2 to 4 times a day and is not absorbed into the bloodstream, so it causes few side effects. It may, however, cause constipation, and in some cases it reduces the effectiveness of other drugs.

Misoprostol may be used to reduce the likelihood of developing stomach and duodenal ulcers caused by NSAIDs. Misoprostol may work by reducing production of stomach acid and by making the stomach lining more resistant to acid. Older people, people taking corticosteroids, and people who have a history of ulcers are at higher risk of developing an ulcer when they take NSAIDs and may also be potential candidates for misoprostol. However, misoprostol causes diarrhea and other digestive problems in more than 30% of people who take it. In addition, this drug can cause spontaneous abortions in pregnant women. Alternatives to misoprostol are available for people taking aspirin , NSAIDs, or corticosteroids. These alternatives, such as proton pump inhibitors, are just as effective for reducing the likelihood of developing an ulcer and cause fewer side effects.

Drugs Used to Treat Peptic Disorders

Drug Type

Some Side Effects

Comments

Antacids

  • Aluminum hydroxide

  • Calcium carbonate

  • Magnesium hydroxide

  • Sodium bicarbonate

Nausea, headache, weakness, loss of appetite, and constipation (aluminum hydroxide) or diarrhea (magnesium hydroxide)

These drugs are used mainly to relieve symptoms, not as a cure.

Histamine-2 blockers

  • Cimetidine

  • Famotidine

  • Nizatidine

  • Ranitidine

Rash, fever, muscle pains, and confusion (cimetidine or ranitidine)

May cause breast enlargement and erectile dysfunction in men

May interfere with elimination of certain drugs (cimetidine)

The once-daily dose is taken in the evening or at bedtime.

Doses taken in the morning are less effective.

Proton pump inhibitors

  • Lansoprazole

  • Omeprazole

  • Pantoprazole

  • Rabeprazole

  • Esomeprazole

Diarrhea, constipation, and headache

These drugs are usually well tolerated and are most effective means of reducing stomach acid.

Antibiotics

  • Amoxicillin

  • Clarithromycin

  • Metronidazole

  • Tetracycline

Diarrhea (amoxicillin, clarithromycin, or tetracycline), altered taste, and nausea

These drugs are effective for treating peptic ulcers caused by Helicobacter pylori infection.

Miscellaneous

  • Bismuth subsalicylate

  • Misoprostol

  • Sucralfate

Diarrhea (bismuth subsalicylate, misoprostol), darkening of the tongue and stool (bismuth subsalicylate), spontaneous abortion (misoprostol), and constipation (bismuth subsalicylate)

May reduce effectiveness of other drugs (sucralfate)

Bismuth subsalicylate is used in combination with antibiotics to cure Helicobacter pylori infection.

Surgery

Surgery for ulcers is now seldom needed because drugs so effectively heal peptic ulcers and endoscopy so effectively stops active bleeding. Surgery is used primarily to deal with complications of a peptic ulcer, such as a perforation, an obstruction that fails to respond to drug therapy or that recurs, two or more major episodes of bleeding ulcers, a gastric ulcer suspected of being cancerous, or severe and frequent recurrences of peptic ulcers. A number of different surgical procedures may be performed to treat these complications. However, ulcers may recur after surgery, and each procedure may cause problems of its own, such as weight loss, poor digestion, and anemia.

Resources In This Article

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • No US brand name
  • COMMIT, NICORETTE, NICOTROL
  • AXID
  • ZANTAC
  • ELIXOPHYLLIN
  • PEPCID
  • COUMADIN
  • DILANTIN
  • TAGAMET
  • ACHROMYCIN V
  • CYTOTEC
  • PREVACID
  • FLAGYL
  • BIAXIN
  • NEXIUM
  • PRILOSEC
  • CARAFATE
  • ACIPHEX
  • PROTONIX
  • AMOXIL