Peptic Ulcer Disease

September 21, 2011

A peptic ulcer is an erosion in the lining of the stomach or of the duodenum, the first portion of the small intestine. Ulcers develop when the normal defense and repair mechanisms of the lining (mucosa) are impaired, making it susceptible to damage by stomach acid and the digestive enzyme, pepsin. The majority of peptic ulcer disease (PUD) is caused by an infection with a bacterium called Helicobacter pylori and by nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen and aspirin. Rarely, peptic ulcer disease may be due to Zollinger-Ellison syndrome (a disorder involving tumors in the pancreas and duodenum, which secrete a hormone that stimulates excess acid production leading to ulceration), viral infection, cocaine use, or Crohn’s disease. Smoking increases the risk for peptic ulcer disease and also impairs ulcer healing.

peptic ulcer disease is a very common problem. Duodenal ulcers are diagnosed four times more often than gastric (stomach) ulcers. Approximately 10% of men and 5% of women will have a duodenal ulcer at some point during their lifetime. Although gastric ulcers occur in similar frequencies in men and women, there is a female predominance of gastric ulcer disease among people taking nonsteroidal anti-inflammatory drugs. In recent years, there has been a fall in the number of duodenal ulcer diagnoses, which has been attributed to declining H. pylori infection in the general population. However, rates of gastric ulcer have been increasing with the rise attributed to greater nonsteroidal anti-inflammatory drug use.

In the United States, approximately 30% of the population is infected with H. pylori, in contrast to 80-90% of people in developing countries. Although H. pylori has been shown to be a strong risk factor for peptic ulcer disease, most infected people never develop ulcers. The factors that make one infected person more likely to get peptic ulcer disease than another are not well understood and are a subject of intense research. Chronic H. pylori infection has also been found to increase the risk for gastric cancer.

nonsteroidal anti-inflammatory drugs promote ulceration not only by direct damage to the mucosa through their weak acid properties, but also by blocking normal mucosal defense mechanisms. nonsteroidal anti-inflammatory drugs inhibit the production of the protective prostaglandins that are hormone-like substances important in maintaining the mucosal defense against acid and digestive enzymes. Approximately 2-5% of chronic nonsteroidal anti-inflammatory drug users are diagnosed with duodenal ulcers and as many as 10-20% are diagnosed with gastric ulcers. Among chronic nonsteroidal anti-inflammatory drug users, 1-2% will develop serious ulcer complications each year. These include gastrointestinal bleeding, perforation (extension of an ulcer through the stomach or duodenal wall), and gastric outlet obstruction (blockage of stomach contents from entering the duodenum). A number of factors have been found to increase the risk for major gastrointestinal complications in nonsteroidal anti-inflammatory drug users and these include a history of peptic ulcer disease, older age, corticosteroid (e.g., prednisone) use, clot-preventing medication (e.g., coumadin, heparin) use, high doses of nonsteroidal anti-inflammatory drugs, multiple nonsteroidal anti-inflammatory drugs, and poor overall medical condition. In recent years, a new class of nonsteroidal anti-inflammatory drug, “Cox-2 inhibitors,” has been introduced, which inhibits the prostaglandins responsible for pain and inflammation but does not affect prostaglandins important for gastroduodenal mucosa protection. They have been shown to cause fewer ulcers and ulcer-related complications.

Pain is the most common symptom of peptic ulcer disease and is typically located in the upper abdomen. However, many people who develop ulcer complications, including bleeding, will have had no prior symptoms. This is especially true in chronic nonsteroidal anti-inflammatory drug users. The pain usually comes and goes over a period of days to weeks and is frequently described as “gnawing,” “burning,” or “hunger-like.” Some people will describe a pain that is relieved by meals, particularly those with duodenal ulcers, while others will have pain without any relationship to eating. Sometimes the pain is relieved with antacids. Pain radiating to the back suggests a penetrating duodenal ulcer (extension of the ulcer through the duodenal wall into the pancreas). It is important to recognize that “ulcer-like” symptoms may be seen in many other disorders including gastritis, malignancy, gastroesophageal reflux, vascular disease, gallbladder and bile duct disease, and pancreatic disease.

People with “alarm” symptoms such as vomiting blood, bloody stool, and sharp, sudden, persistent abdominal pain should seek medical attention immediately. Bleeding is the most common ulcer complication, especially in the elderly, and the symptoms include vomiting red blood or “coffee grounds” (dark blood) and passing black, tar-like, or maroon stools. Pain that becomes abruptly worse and/or generalized suggests the possibility of perforation. Nausea and vomiting may indicate the presence of a gastric outlet obstruction. Weight loss suggests the possibility of gastric malignancy.

The diagnosis of peptic ulcer disease can be made either by an upper gastrointestinal (UGI) series (x-rays of the stomach and intestines are taken after the patient drinks barium, a thick white liquid) or by upper endoscopy (insertion of a thin flexible tube containing a camera into the mouth). Endoscopy is superior to UGI series in making the diagnosis, especially with small ulcers. It also has two other advantages, the ability to obtain biopsies and the ability to directly treat bleeding ulcers. Because of the association of gastric ulcers with malignancy, endoscopy allows for direct inspection and biopsies of suspiciousappearing or poorly healing gastric ulcers. During endoscopy, biopsies of the gastric mucosa can also be obtained and tested for the presence of H. pylori. However, endoscopy should not be performed solely for detecting H. pylori infection (see below). When a bleeding ulcer is suspected, there are a number of endoscopic treatments available, which can decrease blood transfusion requirements and prevent the need for surgery. Factors favoring endoscopy over UGI as the diagnostic test of choice are age over 50, weight loss, gastrointestinal bleeding, and severe symptoms or those which do not respond to treatment. A gastric ulcer found on UGI should be followed by endoscopy at approximately 8 weeks to assess healing and, if suspicious features for gastric cancer are present, to obtain biopsies.

In people with known peptic ulcer disease or who have ulcer symptoms, there are several methods, both invasive and noninvasive, for diagnosing H. pylori infection. Noninvasive methods test blood, urine, breath, and stool for evidence of infection whereas invasive methods involve endoscopically (using a small tube inserted into the body) obtained gastric biopsies. If endoscopy is indicated for a reason other than the diagnosis of the bacteria H. pylori, then gastric (stomach) biopsies can be obtained for either rapid urease testing or histologic examination. The rapid urease test is a quick and accurate test of stomach fluid with results in less than an hour. Histologic examination involves a pathologist reviewing the biopsy specimens under a microscope for the presence of H. pylori organisms and may take several days to a week for results to be reported. However, because rapid urease and breath tests may be falsely negative in patients taking some types of medication (proton [acid] pump inhibitors, PPI), antibiotics, or bismuth, microscopic cell testing (histology) should be performed.

The goals of peptic ulcer disease treatment are to relieve symptoms, promote ulcer healing, prevent ulcer recurrence, and prevent ulcer complications. Acid-suppressing medications, like H2 blockers and proton pump inhibitors, reduce the amount of gastric acid produced allowing ulcers to heal and reducing pain. proton pump inhibitorss, for example, omeprazole and lansoprazole, are the most effective peptic ulcer disease therapy, healing over 90% of duodenal ulcers within 4 weeks and gastric ulcers within 8 weeks of therapy. After peptic ulcer disease treatment is complete, continued proton pump inhibitors therapy is not generally recommended unless the individual also has gastroesophageal reflux disease or is a chronic nonsteroidal anti-inflammatory drug user. The elderly and people in poor general medical condition who have experienced an ulcer complication should also be considered for long-term (maintenance) therapy. Drugs that block specific receptors on the stomach lining, H2 blockers, like ranitidine and cimetidine, are less expensive alternatives to proton pump inhibitorss and have healing rates of approximately 80% at 4 weeks.

Treatment of H. pylori infection should be considered in all patients with gastric or duodenal ulcer or a documented history of peptic ulcer disease. Eradication of the organism is associated with a reduction in ulcer recurrence from 60-70% to less than 10%. The most effective treatment regimens for H. pylori include a 10to 14-day course of a combination of two antibiotics (amoxicillin, clarithromycin, and/or metronidazole) and a proton pump inhibitors or ranitidine bismuth citrate. Acid-suppressing medication is then continued for another 4 weeks in duodenal ulcers and 6 weeks in gastric ulcers.

In nonsteroidal anti-inflammatory drug-induced ulcers, the nonsteroidal anti-inflammatory drug should be discontinued if possible. If not, once daily proton pump inhibitors has been shown to be the most effective regimen in preventing nonsteroidal anti-inflammatory drug-induced ulcers with over 80% healing of gastric and duodenal ulcers at 8 weeks. In high-risk patients on chronic nonsteroidal anti-inflammatory drugs, a newer class of medications, the Cox-2 inhibitors, may be considered. Although effective in preventing ulcers in nonsteroidal anti-inflammatory drug users, many people suffer side effects such as cramping and diarrhea. Moreover, since misoprostol causes miscarriages, it absolutely must not be used by women of reproductive age who are not using contraception.

While peptic ulcer disease almost always responds to treatment, there are risk factors for poor ulcer healing. These include persistent H. pylori infection, continued nonsteroidal anti-inflammatory drug use, and smoking. Rarely, recurrent or poorly healing ulcers may indicate the presence of gastric cancer or Zollinger-Ellison syndrome. Surgery is rarely necessary and typically only required for ulcers that fail to heal or major ulcer complications, like perforation.

SEE ALSO: Abdominal pain, Chronic pain, Nausea, Pelvic pain

Suggested Reading

  • Del Valle, J., et al. (1999). Acid peptic disorders. In T. Yamada, D. H. Alpers, L. Laine, C. Owyang, & D. W. Powell (Eds.), Textbook of gastroenterology (3rd ed., pp. 1370-1444). Philadelphia: Lippincott, Williams & Wilkins.

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