Peptic ulcer facts*
*Peptic ulcer disease facts medically edited by: Jay W. Marks, MD
Peptic ulcers are sores in the lining of the stomach or duodenum.
Peptic ulcer formation is related to H. pylori bacteria in the stomach andnonsteroidal anti-
inflammatory medications(NSAIDs) in 50% of patients. For the remaining 50% there are
miscellaneous or unknown causes.
Ulcer pain may not correlate with the presence or severity of ulceration.
The main symptom of peptic ulcer is upper abdominal pain which can be dull, sharp, or burning.
(Bloatingand burping are not symptoms of peptic ulcer, and vomiting, poor appetite,
and nausea are uncommon symptoms of peptic ulcer.)
Diagnosis of ulcer is made with upper GI series orendoscopy.
Treatment of ulcers involves antibiotic combinations along with stomach acid suppression to
eradicate H. pylori, eliminating precipitating factors such as NSAIDs and stomach acid
suppression with medications alone .
Complications of ulcers include bleeding, perforation, and blockage of the stomach (gastric
obstruction).
If a person with peptic ulcers smokes or take NSAIDs, the ulcers may recur after treatment.
What is a peptic ulcer?
A peptic ulcer is a sore in the lining of your stomach or duodenum. The duodenum is the first part of
your small intestine. A peptic ulcer in the stomach is called a gastric ulcer. One that is in the
duodenum is called a duodenal ulcer. A peptic ulcer also may develop just above your stomach in
the esophagus, the tube that connects the mouth to the stomach. But most peptic ulcers develop in
the stomach or duodenum.
Many people have peptic ulcers. You can have both gastric and duodenal ulcers at the same time
and you also can have more than one ulcer in your lifetime.
Peptic ulcers can be treated successfully. Seeing your doctor is the first step.
What causes of peptic ulcers?
Most peptic ulcers are caused by
Helicobacter pyloricus (H. pylori) a germ that causes infection
nonsteroidal anti-inflammatory drugs NSAIDs), such as aspirin andibuprofen
H. pylori is the most common cause of peptic ulcers. Doctors think H. pylorimay be spread through
unclean food or water or by mouth-to-mouth contact, such as kissing. Even though many people
have an H. pylori infection, most of them never develop an ulcer.
Use of NSAIDs is the second most common cause of peptic ulcers. But not everyone who takes
NSAIDs gets a peptic ulcer. Ulcers caused by NSAIDs are more often found in people who
are age 60 or older
are female
have taken NSAIDs for a long time
have had an ulcer before
Other causes of peptic ulcers are rare. One rare cause is Zollinger-Ellison syndrome - a disease that
makes the body produce too much stomach acid, which harms the lining of the stomach or
duodenum.
Stress or spicy food does not cause peptic ulcers, but either can make ulcer symptoms worse.
What are symptoms of peptic ulcers?
A dull or burning pain in your stomach is the most common symptom of peptic ulcers. You may feel
the pain anywhere between your belly button and breastbone. The pain often
starts between meals or during the night
briefly stops if you eat or take antacids
lasts for minutes to hours
comes and goes for several days or weeks.
Other symptoms of peptic ulcers may include
weight loss
poor appetite
bloating
burping
vomiting
feeling sick to your stomach
Even if your symptoms are mild, you may have peptic ulcers. You should see your doctor to talk
about your symptoms. Peptic ulcers can get worse if they aren't treated.
Call your doctor right away if you have
sudden or sharp pain that doesn't go away
black or bloody stools
bloody vomit or vomit that looks like coffee grounds
These symptoms could be signs that an ulcer has
broken a blood vessel
gone through, or perforated, your stomach or duodenal wall
stopped food from moving from you stomach into the duodenum
These symptoms must be treated quickly. You may need surgery.
How are peptic ulcers diagnosed?
Tell your doctor about your symptoms and which medicines you take. Be sure to mention those you
get without a prescription, such as Bayer, Motrin, Advil, or Aleve. These medicines are all NSAIDs.
To see if you have an H. pylori infection, your doctor will test your blood, breath, or stool. About half
of all people who develop an ulcer from NSAIDs also have an H. pylori infection.
Your doctor also may want to look inside your stomach and duodenum by doing an endoscopy or an
upper gastrointestinal (GI) series - a type of X-ray. Both procedures are painless.
For an endoscopy, you will be given medicine to relax you. Then the doctor will pass an endoscope -
a thin, lighted tube with a tiny camera - through your mouth to your stomach and duodenum. Your
doctor also may take a small piece of tissue - no bigger than a match head-to look at through a
microscope. This process is called a biopsy.
For an upper GI series, you will drink a liquid called barium. The barium will make your stomach and
duodenum show up clearly on the X-rays.
What is the treatment for peptic ulcers?
If you have peptic ulcers, they can be cured. Depending on what caused your ulcers, your doctor
may prescribe one or more of the following medicines:
a proton pump inhibitor (PPI) or histamine receptor blocker (H2 blocker) to reduce stomach acid
and protect the lining of your stomach and duodenum
one or more antibiotics to kill an H. pylori infection
a medicine that contains bismuth subsalicylate, such as Pepto-Bismol, to coat the ulcers and
protect them from stomach acid
These medicines will stop the pain and help heal the ulcers.
If an NSAID caused your peptic ulcers, your doctor may tell you to
stop taking the NSAID
reduce how much of the NSAID you take
take a PPI or H2 blocker with the NSAID
switch to another medicine that won't cause ulcers
You should take only the medicines your doctor tells you to take all medicines exactly as your
doctor tells you to, even if your pain stops
Tell your doctor if the medicines make you feel sick or dizzy or causediarrhea or headaches. Your
doctor can change your medicines.
And if you smoke, quit. You also should avoid alcohol. Smoking and drinking alcohol slow the
healing of ulcers and can make them worse.
Can antacids or milk help peptic ulcers heal?
Neither antacids - such as Tums - nor milk can heal peptic ulcers, although each may make you feel
better briefly. Check with your doctor before taking antacids or drinking milk while your ulcers are
healing.
Some of the antibiotics used for H. pylori infection may not work as well if you take antacids. And
while antacids may make ulcer pain go away for a while, they won't kill the H. pylori germ. Only
antibiotics can do that.
Many people used to think that drinking milk helped peptic ulcers heal. But doctors know now that
while milk may make ulcers feel better briefly, it also increases stomach acid. Too much stomach
acid makes ulcers worse.
What if peptic ulcers don't heal?
In many cases, medicines heal ulcers. If anH. pylori infection caused your ulcers, you must finish all
antibiotics and take any other medicines your doctor prescribes. The infection and ulcers will only
heal if you take all medicines as prescribed.
When you have finished your medicines, your doctor will do a breath or stool test to be sure the H.
pylori infection is gone. Sometimes, the H. pylori germ is still there, even after a person has taken all
the medicines correctly. If that happens, your doctor will prescribe different antibiotics to get rid of
the infection and cure your ulcers.
Rarely, surgery is needed to help ulcers heal. You may need surgery if your ulcers
don't heal
keep coming back
bleed
perforate the stomach or duodenal wall
block food from moving out of the stomach
Surgery can
remove the ulcers
reduce the amount of acid in your stomach
Can peptic ulcers come back?
Yes. If you smoke or take NSAIDs, your ulcers may come back. If you need to take an NSAID, your
doctor may switch you to a different medicine or add medicines to help prevent ulcers.
What can I do to prevent peptic ulcers?
To help prevent ulcers caused by H. pylori,
wash your hands with soap and water after using the bathroom and before eating
eat food that has been washed well and cooked properly
drink water from a clean, safe source
To help prevent ulcers caused by NSAIDs,
stop using NSAIDs, if possible
take NSAIDs with a meal, if you still need NSAIDs
use a lower dose of NSAIDs
ask your doctor about medicines to protect your stomach and duodenum while taking NSAIDs
ask your doctor about switching to a medicine that won't cause ulcers
http://www.medicinenet.com/peptic_ulcer/
Peptic ulcer is basically a lesion located at the level of the stomach, duodenum or esophagus. Ulcer tends
to affect the entire gastrointestinal tract, starting from the lining of the mouth and ending with the rectal
region. Peptic ulcer suggests the involvement of hydrochloric acid and pepsin in the development of the
disorder. When gastric acid is produced in excess, the mucosal membrane that protects the stomach and
internal organs from danger is damaged, enabling the bacteria Helicobacter pylori to penetrate the barrier
and cause internal infections. Therefore, in the case of peptic ulcer, both gastric acid and bacteria are
responsible for the development of the disorder.
Peptic ulcer located in the stomach is called gastric ulcer; peptic ulcer located at the level of the
duodenum is called duodenal ulcer and peptic ulcer developed at the level of the esophagus is called
esophageal ulcer.
Peptic ulcer is very common, millions of Americans being diagnosed with different forms of the disorder
each year. The advance of modern medicine has allowed scientists to find out more valuable information
about these disorders, enabling them to develop new medical treatments. Although in the past peptic
ulcer was known to affect mostly male persons, more and more women suffer from forms of peptic ulcer
nowadays. Statistics indicate that the predominance of smoking among women has determined an
increase of peptic ulcer incidence with the female gender.
Peptic ulcers can sometimes develop into more serious disorders. As a result of complications, peptic
ulcer may lead to perforate or bleeding ulcer. These two forms of ulcer are considered to be very
dangerous, research results indicating a high probability of death due to such complications. Perforate
ulcer involves severe tearing of the mucosal membrane, causing acute pain and sourness at the
abdominal level. Bleeding ulcer involves internal hemorrhages and it needs immediate medical
intervention. Most forms of perforate and bleeding ulcer require surgery due to their gravity. If the
bleeding is severe, the medical intervention is primarily focused on stopping the hemorrhage and
resuscitating the patient. The patient requires blood transfusions to compensate for the loss of blood and
needs to be kept under constant monitoring until recovered.
The most common symptoms of bleeding ulcer are: nausea, fever, vomiting blood, presence of blood in
the feces, black feces, dehydration, fatigue and body weakness. Due to loss of blood, such forms of ulcer
may lead to anemia.
Some peptic ulcers are therefore more difficult to treat than others. When dealing with peptic ulcer, it is
very important too keep away from alcohol, caffeine, cigarettes and cola, as these may all aggravate the
symptoms of the disorder. You should try to respect a healthy diet and follow the medical treatment
prescribed by your physician. If you respect these directions, your ulcer symptoms will most likely
ameliorate within the first week of treatment, ensuring the remission of the disorder.
http://www.streetdirectory.com/etoday/pathophysiology-of-peptic-ulcer-ppleul.html
Peptic Ulcers Overview
In the digestive system, an ulcer is an area where tissue has been destroyed by gastric 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, about 10% of the population will develop a duodenal ulcer at some point in their lives.
Peptic ulcer disease affects about 4.6 million people annually. The occurrence of peptic ulcer disease is similar in men and women. Approximately 11%-14% of men
and 8%-11% of women will develop peptic ulcer disease in their lifetime. The mortality rate for peptic ulcer disease is approximately one death per 10,000 cases. The mortality
rate due to ulcer hemorrhage is approximately 5%.
Ulcers can occur at any age, although they are rare in children and teenagers.
The good news is that we have learned a lot about ulcers in the past 20 years and effective therapies are now available.
Peptic Ulcers 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 erode the mucosal wall.
In the past it was throught that ulcers were caused by lifestyle factors such as eating habits, cigarette smoking, and stress.
Now it is understood that people with ulcers had an imbalance between acid and pepsin coupled with the digestive tract's inability to protect itself from these harsh substances.
Research done in the 1980s showed that ulcers are caused by infection with a bacterium named Helicobacter pylori, usually called H pylori.
Not everyone who gets an ulcer is infected with H pylori. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) can cause ulcers if taken regularly.
Some types of medical therapy can contribute to ulcer formation. The following factors can weaken the protective mucosal barrier of the stomach increasing 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 prior ulcers or intestinal bleeding are at higher-than-normal risk. If a person takes these medications regularly, alternatives should be discussed with a health care
professional. This is especially true if the affected individual has an upset stomach or heartburn after taking 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.
Peptic Ulcer 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 isabdominal 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
Severe ulcers may 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, rapid heartbeat
(tachycardia), and pales skin (pallor).
When to Seek Medical Care
If you have burning pain in your upper stomach that is relieved by eating or taking antacids, call a health care professional for an appointment. Don't assume you have an ulcer. Certain other conditions can cause similar symptoms.
If you vomit blood or have other signs ofgastrointestinal bleeding, go to an emergency department right away. Peptic ulcers can cause massive bleeding, which requires blood transfusion or surgery.
Severe abdominal pain suggests perforation or tearing of an ulcer. This is an emergency that may require surgery to fix a hole in your stomach.
Vomiting and abdominal pain also can be a sign of an obstruction, another complication of peptic ulcers. This also may require emergency surgery.
Peptic Ulcer PreventionPeptic ulcers can be prevented by avoiding things that break down the stomach's protective barrier and increase stomach acid secretion. These include alcohol, smoking, aspirin, nonsteroidal anti-inflammatory drugs, and caffeine.
Preventing infection with H pylori is a matter of avoiding contaminated food and water and adhering to strict standards of personal hygiene. Wash hands carefully with warm water and soap every time the bathroom is used, diaper changed, and before and after preparing food.If you need the pain relief and anti-inflammatory action of aspirin or an NSAID, you can reduce your risk of ulcers by trying the following:
Try a different NSAID, one that is easier on the stomach. Reduce the dose or the number of times you take the medication. Substitute another medication, such as acetaminophen (Tylenol). Talk to your health care professional about how you can protect yourself.
Following the treatment recommendations of your health care professional can help prevent recurrence of ulcers. This includes taking all medications as prescribed, especially if you have H pylori infection.http://www.emedicinehealth.com/peptic_ulcers/page9_em.htm#Prevention
What Is Peptic Ulcer Disease?Peptic ulcer disease refers to painful sores or ulcers in the lining of the stomach or first part of the small intestine, called the duodenum.
What Causes Ulcers?
No single cause has been found for ulcers. However, it is now clear that an ulcer is the end result of an imbalance between digestive fluids in the stomach and duodenum. Ulcers can be caused by:
Infection with a type of bacteria called Helicobacter pylori (H. pylori) Use of painkillers called nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, naproxen (Aleve,
Anaprox, Naprosyn, and others), ibuprofen (Motrin, Advil, Midol, and others), and many others available by prescription. Even aspirin coated with a special substance can still cause ulcers.
Excess acid production from gastrinomas, tumors of the acid producing cells of the stomach that increases acid output; seen in Zollinger-Ellison syndrome.
What Are the Symptoms of an Ulcer?
An ulcer may or may not have symptoms. When symptoms occur, they include:
A gnawing or burning pain in the middle or upper stomach between meals or at night Bloating Heartburn Nausea or vomiting
In severe cases, symptoms can include:
Dark or black stool (due to bleeding) Vomiting blood (can have a "coffee-grounds" appearance) Weight loss Severe pain in the mid to upper abdomen
How Serious Is an Ulcer?
Though ulcers often heal on their own, you shouldn't ignore their warning signs. If not properly treated, ulcers can lead to serious health problems, including:
Bleeding Perforation (a hole through the wall of the stomach) Gastric outlet obstruction from swelling or scarring that blocks the passageway leading from the stomach
to the small intestine.
Taking NSAIDs can cause any of the above without warning. The risk is especially concerning for the elderly and for those with a prior history of having peptic ulcer disease.
Who Is More Likely to Get Ulcers?
You may be more likely to develop ulcers if you:
Are infected with the H. pylori bacterium Take NSAIDs such as aspirin, ibuprofen, naproxen, and many others Have a family history of ulcers Have another illness, such as liver, kidney, or lung disease Drink alcohol regularly Are 50 years old or older
How Are Ulcers Diagnosed?
Your doctor may be able to make an ulcer diagnosis just by talking with you about your symptoms. However, to confirm the diagnosis one of several tests should be taken. First, your doctor may ask you to take an acid-blocking medication such as those used to treat heartburn for a short period of time to see if your symptoms improve.
If needed, your doctor may recommend a procedure called an upper endoscopy. It involves inserting a small, lighted tube (endoscope) through the throat and into the stomach to look for abnormalities. This procedure is usually given if you are having severe symptoms of ulcers.
Often, doctors will frequently treat without confirming the diagnosis using endoscopy. If the cause is not likely to be from NSAIDs, then it is very likely to be from H. pylori. Most doctors will now test for H. pylori and will treat specifically for that in addition to giving medications to reduce the symptoms.
What Is Peptic Ulcer Disease?(continued)
How Are Ulcers Treated?
Though ulcers often heal on their own, you shouldn't ignore their warning signs. If not properly treated, ulcers can lead to serious health problems.
There are several ways in which ulcers can be treated, including making changes to ones lifestyle, taking medication, and/or undergoing surgery.
Lifestyle Changes to Treat an Ulcer
To treat an ulcer, first eliminate substances that can be causing the ulcers. If you smoke or drink alcohol, stop. If the ulcer is believed to be caused by the use of NSAIDs, they need to be stopped.
Ulcer Medications
Ulcer medications can include:
Proton pump medications (PPI). Proton pump medications reduce acid levels and allow the ulcer to heal. They include Prilosec, Prevacid, Aciphex, Protonix, Kapidex, Zegerid, and Nexium.
Antibiotics. If you have H. pylori infection, then antibiotics are used. There are multiple combinations of antibiotics that are taken for one to two weeks along with a PPI. Some doctors also recommend taking Pepto-Bismol.
Upper Endoscopy . Some bleeding ulcers can be treated through the endoscope. Surgery. Sometimes an operation is needed if the ulcer has created a hole in the wall of the stomach or if
there is serious bleeding.
Will Drinking Milk Help Cure an Ulcer?
No. Milk can make your ulcer worse. Milk provides brief relief of ulcer pain because it coats the stomach lining. But milk can also stimulate your stomach to produce more acid and digestive juices, which can aggravate ulcers.
How Can I Prevent Ulcers?
To try and prevent ulcers from developing:
Don't smoke. Avoid alcohol. Don't overuse aspirin and/or NSAIDs. If you have symptoms of an ulcer, contact your doctor.
http://www.webmd.com/digestive-disorders/digestive-diseases-peptic-ulcer-disease?page=2
A peptic ulcer, also known as PUD or peptic ulcer disease,[1] is the most common ulcer of an area of
thegastrointestinal tract that is usually acidic and thus extremely painful. It is defined as mucosal erosions
equal to or greater than 0.5 cm. As many as 70–90% of such ulcers are associated with Helicobacter
pylori, a spiral-shaped bacterium that lives in the acidic environment of the stomach; however, only 40%
of those cases go to a doctor. Ulcers can also be caused or worsened by drugs such
as aspirin, ibuprofen, and other NSAIDs.
Four times as many peptic ulcers arise in the duodenum—the first part of the small intestine, just after the
stomach—as in the stomach itself. About 4% of gastric ulcers are caused by a malignant tumor, so
multiple biopsies are needed to exclude cancer. Duodenal ulcers are generally benign.
Contents
[hide]
1 Classification
2 Signs and symptoms
o 2.1 Complications
3 Cause
o 3.1 Stress
4 Diagnosis
o 4.1 Macroscopic appearance
o 4.2 Microscopic appearance
o 4.3 Differential diagnosis
5 Treatment
6 Epidemiology
7 History
8 Notes
9 References
10 External links
11 Notes
[edit]Classification
By Region/Location
Duodenum (called duodenal ulcer)
Oesophagus (called esophageal ulcer)
Stomach (called gastric ulcer)
Meckel's diverticulum (called Meckel's diverticulum ulcer; is very tender with palpation)
Modified Johnson Classification of peptic ulcers:
Type I: Ulcer along the body of the stomach, most often along the lesser curve at incisura angularis
along the locus minoris resistantiae.
Type II: Ulcer in the body in combination with duodenal ulcers. Associated with acid oversecretion.
Type III: In the pyloric channel within 3 cm of pylorus. Associated with acid oversecretion.
Type IV: Proximal gastroesophageal ulcer
Type V: Can occur throughout the stomach. Associated with chronic NSAID use (such as aspirin).
[edit]Signs and symptoms
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;
waterbrash (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 andprednisolone).
In patients over 45 with more than two weeks of the above symptoms, the odds for peptic ulceration are
high enough to warrant rapid investigation byesophagogastroduodenoscopy.
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.[2] 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 ashunger, 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.[3] However, peptic ulcer disease symptoms may be
different for every sufferer.[4]
[edit]Complications
Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be life-
threatening.[5] 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.[2]
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.[2]
[edit]Cause
A major causative factor (60% of gastric and up to 90% of duodenal ulcers) is chronic inflammation due
to Helicobacter pylori that colonizes the antral mucosa [citation needed]. The immune system is unable to clear
the infection, despite the appearance of antibodies. Thus, the bacterium can cause a chronic
activegastritis (type B gastritis), resulting in a defect in the regulation of gastrin production by that part of
the stomach, and gastrin secretion can either be increased, or as in most cases, decreased, resulting in
hypo- or achlorhydria. Gastrin stimulates the production of gastric acid by parietal cells and, in H.
pylori colonization responses that increase gastrin, the increase in acid can contribute to the erosion of
the mucosa and therefore ulcer formation.
Another major cause is the use of NSAIDs (see above). The gastric mucosa protects itself from gastric
acid with a layer of mucus, the secretion of which is stimulated by certain prostaglandins. NSAIDs block
the function of cyclooxygenase 1 (cox-1), which is essential for the production of these prostaglandins.
COX-2 selective anti-inflammatories (such as celecoxib or the since withdrawn rofecoxib) preferentially
inhibit cox-2, which is less essential in the gastric mucosa, and roughly halve the risk of NSAID-related
gastric ulceration. As the prevalence of H. pylori-caused ulceration declines in the Western world due to
increased medical treatment, a greater proportion of ulcers will be due to increasing NSAID use among
individuals with pain syndromes as well as the growth of aging populations that develop arthritis.
The incidence of duodenal ulcers has dropped significantly during the last 30 years, while the incidence of
gastric ulcers has shown a small increase, mainly caused by the widespread use of NSAIDs. The drop in
incidence is considered to be a cohort-phenomenon independent of the progress in treatment of the
disease. The cohort-phenomenon is probably explained by improved standards of living which has
lowered the incidence of H. pylori infections.[6]
Although some studies have found correlations between smoking and ulcer formation,[7] others have been
more specific in exploring the risks involved and have found that smoking by itself may not be much of a
risk factor unless associated with H. pylori infection.[8][9][10][nb 1] Some suggested risk factors such
as diet,spice consumption and blood type, were hypothesized as ulcerogens (helping cause ulcers) until
late in the 20th century, but have been shown to be of relatively minor importance in the development of
peptic ulcers.[11] Similarly, while studies have found that alcohol consumption increases risk when
associated with H. pylori infection, it does not seem to independently increase risk, and even when
coupled with H. pylori infection, the increase is modest in comparison to the primary risk factor.[8][12][nb 2]
Gastrinomas (Zollinger Ellison syndrome), rare gastrin-secreting tumors, also cause multiple and difficult-
to-heal ulcers.
[edit]Stress
Researchers also continue to look at stress as a possible cause, or at least complication, in the
development of ulcers. There is debate as to whether psychological stress can influence the development
of peptic ulcers. Burns and head trauma, however, can lead to physiologic stress ulcers, which are
reported in many patients who are on mechanical ventilation.
An expert panel convened by the Academy of Behavioral Medicine Research concluded that ulcers are
not purely an infectious disease and that psychological factors do play a significant role.[1] Researchers
are examining how stress might promote H. pylori infection. For example, Helicobacter pylori thrives in an
acidic environment, and stress has been demonstrated to cause the production of excess stomach acid.
This was supported by a study on mice showing that both long-term water-immersion-restraint stress
and H. pylori infection were independently associated with the development of peptic ulcers.[13]
A study of peptic ulcer patients in a Thai hospital showed that chronic stress was strongly associated with
an increased risk of peptic ulcer, and a combination of chronic stress and irregular mealtimes was a
significant risk factor.[14]
[edit]Diagnosis
Endoscopic image of gastric ulcer, biopsy proven to be gastric cancer.
The diagnosis is mainly established based on the characteristic symptoms. Stomach pain is usually the
first signal of a peptic ulcer. In some cases, doctors may treat ulcers without diagnosing them with specific
tests and observe whether the symptoms resolve, this indicating that their primary diagnosis was
accurate.
Confirmation of the diagnosis is made with the help of tests such as endoscopies or barium contrast x-
rays. The tests are typically ordered if the 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.[2]
An esophagogastroduodenoscopy (EGD), a form of endoscopy, also known as a gastroscopy, is carried
out on patients in whom a peptic ulcer is suspected. By direct visual identification, the location and
severity of an ulcer can be described. Moreover, if no ulcer is present, EGD can often provide an
alternative diagnosis.
One of the reasons that blood tests are not reliable for accurate peptic ulcer diagnosis on their own is
their inability to differentiate between past exposure to the bacteria and current infection. Additionally, a
false negative result is possible with a blood test if the patient has recently been taking certain drugs,
such as antibiotics or proton pump inhibitors.[15]
The diagnosis of Helicobacter pylori can be made by:
Urea breath test (noninvasive and does not require EGD);
Direct culture from an EGD biopsy specimen; this is difficult to do, and can be expensive. Most labs
are not set up to perform H. pylori cultures;
Direct detection of urease activity in a biopsy specimen by rapid urease test;
Measurement of antibody levels in blood (does not require EGD). It is still somewhat controversial
whether a positive antibody without EGD is enough to warrant eradication therapy;
Stool antigen test;
Histological examination and staining of an EGD biopsy.
The breath test uses radioactive carbon atom to detect H. pylori.[16] To perform this exam the patient will
be asked to drink a tasteless liquid which contains the carbon as part of the substance that the bacteria
breaks down. After an hour, the patient will be asked to blow into a bag that is sealed. If the patient is
infected with H. pylori, the breath sample will contain radioactive carbon dioxide. This test provides the
advantage of being able to monitor the response to treatment used to kill the bacteria.
The possibility of other causes of ulcers, notably malignancy (gastric cancer) needs to be kept in mind.
This is especially true in ulcers of the greater (large) curvature of the stomach; most are also a
consequence of chronic H. pylori infection.
If a peptic ulcer perforates, air will leak from the inside of the gastrointestinal tract (which always contains
some air) to the peritoneal cavity (which normally never contains air). This leads to "free gas" within the
peritoneal cavity. If the patient stands erect, as when having a chest X-ray, the gas will float to a position
underneath the diaphragm. Therefore, gas in the peritoneal cavity, shown on an erect chest X-ray or
supine lateral abdominal X-ray, is an omen of perforated peptic ulcer disease.
[edit]Macroscopic appearance
A benign gastric ulcer (from the antrum) of a gastrectomy specimen.
Gastric ulcers are most often localized on the lesser curvature of the stomach. The ulcer is a round to
oval parietal defect ("hole"), 2 to 4 cm diameter, with a smooth base and perpendicular borders. These
borders are not elevated or irregular in the acute form of peptic ulcer, regular but with elevated borders
and inflammatory surrounding in the chronic form. In the ulcerative form of gastric cancer the borders are
irregular. Surrounding mucosa may present radial folds, as a consequence of the parietal scarring.
[edit]Microscopic appearance
A gastric peptic ulcer is a mucosal defect which penetrates the muscularis mucosae and muscularis
propria, produced by acid-pepsin aggression. Ulcer margins are perpendicular and present chronic
gastritis. During the active phase, the base of the ulcer shows 4 zones: inflammatory exudate, fibrinoid
necrosis, granulation tissue and fibrous tissue. The fibrous base of the ulcer may contain vessels with
thickened wall or with thrombosis.[17]
[edit]Differential diagnosis
Peptic ulcer
Gastritis
Stomach cancer
Gastroesophageal reflux disease
Pancreatitis
Hepatic congestion
Cholecystitis
Biliary colic
Inferior myocardial infarction
Referred pain (pleurisy, pericarditis)
Superior mesenteric artery syndrome
[edit]Treatment
Younger patients with ulcer-like symptoms are often treated with antacids or H2 antagonists before EGD
is undertaken. Bismuth compounds may actually reduce or even clear organisms[citation needed], though the
warning labels of some bismuth subsalicylate products indicate that the product should not be used by
someone with an ulcer.[18]
Patients who are taking nonsteroidal anti-inflammatories (NSAIDs) may also be prescribed
a prostaglandin analogue (Misoprostol) in order to help prevent peptic ulcers, which may be a side-
effect of the NSAIDs.
When H. pylori infection is present, the most effective treatments are combinations of 2 antibiotics
(e.g. Clarithromycin, Amoxicillin, Tetracycline, Metronidazole) and 1 proton pump inhibitor (PPI),
sometimes together with a bismuth compound. In complicated, treatment-resistant cases, 3 antibiotics
(e.g. amoxicillin + clarithromycin + metronidazole) may be used together with a PPI and sometimes with
bismuth compound. An effective first-line therapy for uncomplicated cases would
be Amoxicillin + Metronidazole + Pantoprazole (a PPI). In the absence of H. pylori, long-term higher dose
PPIs are often used.
Treatment of H. pylori usually leads to clearing of infection, relief of symptoms and eventual healing of
ulcers. Recurrence of infection can occur and retreatment may be required, if necessary with other
antibiotics. Since the widespread use of PPI's in the 1990s, surgical procedures (like "highly
selective vagotomy") for uncomplicated peptic ulcers became obsolete.
Perforated peptic ulcer is a surgical emergency and requires surgical repair of the perforation. Most
bleeding ulcers require endoscopy urgently to stop bleeding with cautery, injection, or clipping.
Ranitidine provides relief of peptic ulcers, heartburn, indigestion and excess stomach acid and prevention
of these symptoms associated with excessive consumption of food and drink. Ranitidine is available over
the counter from a pharmacy and works by decreasing the amount of acid the stomach produces allowing
healing of ulcers. Zantac tablets contain Ranitidine 150 mg as the active ingredient which can also be
bought generically.[19]
Sucralfate, (Carafate) has also been a successful treatment of peptic ulcers.[20]
[edit]Epidemiology
Disability-adjusted life year for peptic ulcer disease per 100,000 inhabitants in 2004.[21]
no data
less than 20
20–40
40–60
60–80
80–100
100–120
120–140
140–160
160–180
180–200
200–220
more than 220
The lifetime risk for developing a peptic ulcer is approximately 10%.[22]
In Western countries the prevalence of Helicobacter pylori infections roughly matches age (i.e., 20% at
age 20, 30% at age 30, 80% at age 80 etc.). Prevalence is higher in third world countries. Transmission is
by food, contaminated groundwater, and through human saliva (such as from kissing or sharing food
utensils).[23]
A minority of cases of H. pylori infection will eventually lead to an ulcer and a larger proportion of people
will get non-specific discomfort, abdominal pain or gastritis.
Peptic ulcer disease had a tremendous effect on morbidity and mortality until the last decades of the 20th
century, when epidemiological trends started to point to an impressive fall in its incidence.[24] The reason
that the rates of peptic ulcer disease decreased is thought to be the development of new effective
medication and acid suppressants and the discovery of the cause of the condition, H. pylori.
In the United States about 4 million people have active peptic ulcers and about 350,000 new cases are
diagnosed each year. Four times as many duodenal ulcers as gastric ulcers are diagnosed.
Approximately 3,000 deaths per year in the United States are due to duodenal ulcer and 3,000 to gastric
ulcer.[25]
[edit]History
See also: Timeline of peptic ulcer disease and Helicobacter pylori
John Lykoudis, a general practitioner in Greece, treated patients for peptic ulcer disease with antibiotics,
beginning in 1958, long before it was commonly recognized that bacteria were a dominant cause for the
disease.[26]
Helicobacter pylori was rediscovered in 1982 by two Australian scientists, Robin Warren and Barry J.
Marshall as a causative factor for ulcers.[27] In their original paper, Warren and Marshall contended that
most gastric ulcers and gastritis were caused by colonization with this bacterium, not by stress or spicy
food as had been assumed before.[28]
The H. pylori hypothesis was poorly received,[29] so in an act of self-experimentation Marshall drank
a Petri dish containing a culture of organisms extracted from a patient and five days later developed
gastritis. His symptoms disappeared after two weeks, but he took antibiotics to kill the remaining bacteria
at the urging of his wife, since halitosis is one of the symptoms of infection.[30] This experiment was
published in 1984 in the Australian Medical Journal and is among the most cited articles from the journal.
In 1997, the Centers for Disease Control and Prevention, with other government agencies, academic
institutions, and industry, launched a national education campaign to inform health care providers and
consumers about the link between H. pylori and ulcers. This campaign reinforced the news that ulcers are
a curable infection, and that health can be greatly improved and money saved by disseminating
information about H. pylori.[31]
In 2005, the Karolinska Institute in Stockholm awarded the Nobel Prize in Physiology or Medicine to Dr.
Marshall and his long-time collaborator Dr. Warren "for their discovery of the bacterium Helicobacter
pylori and its role in gastritis and peptic ulcer disease." Professor Marshall continues research related
to H. pyloriand runs a molecular biology lab at UWA in Perth, Western Australia.
Some believed that mastic gum, a tree resin extract, actively eliminates the H. pylori bacteria.[32] However,
multiple subsequent studies have found no effect of using mastic gum on reducing H. pylori levels.[33][34]
http://en.wikipedia.org/wiki/Peptic_ulcer