What Is a Peptic Ulcer? What Causes Peptic Ulcers?

A peptic ulcer is a hole in the lining of the stomach, duodenum, or esophagus. An ulcer is a sore or erosion that forms when the lining of the digestive system is corroded by acidic digestive juices. It is estimated that between 5% and 10% of adults globally are affected by peptic ulcers at least once in their lifetimes.

When a peptic ulcer affects the stomach it is called a gastric ulcer, one in the duodenum is called a duodenal ulcer, while an esophageal ulcer is an ulcer in the esophagus. When the lining of these organs is corroded by acidic digestive juices secreted by stomach cells peptic ulcers can form.

Peptic ulcer disease affects millions of Americans each year at an annual cost for the country estimated to run in the billions of dollars.

According to Medilexicon's medical dictionary, a peptic ulcer is "an ulcer of the alimentary mucosa, usually in the stomach or duodenum, exposed to acid gastric secretion."

Etymologies of peptic and ulcer

The English word "peptic" comes from the Latin word pepticus which comes from the Greek word peptikus which comes from the Greek word peptein, meaning "to digest".
The English word "ulcer" comes from the Latin word ulcus (genitive: ulceris), meaning "a sore, a wound, an ulcer".

Meanings of peptic and ulcer

The English word peptic means relating to digestion or promoting digestion.
The English word ulcer means an area of tissue erosion.
The term peptic ulcer literally means tissue erosion in the digestive system.

What are the signs and symptoms of peptic ulcers?

A symptom is something the patient feels and reports, such as a stomachache, while a sign is something other people, including the doctor detect, such as a rash.

The first symptom of peptic ulcer is usually stomach pain - caused by the ulcer and intensified by stomach acid coming in contact with it. However, it is not uncommon for people to have a peptic ulcer and no symptoms at all. Even though stomachache is the first symptom, most stomachaches are not serious and do not mean the individual is ill.

The most common signs or symptoms of peptic ulcers are:

• Indigestion-like pain. The pain can..
  
  ..be felt anywhere from the belly button to the breast bone
  ..last from a couple of minutes to a number of hours
  ..be more severe when the stomach is empty
  ..be worse during the night (during sleeping hours)
  ..be temporarily relieved after eating certain foods
  ..go away and return for a few days or weeks


• Difficulty getting food down (swallowing it)


• Food that is eaten regurgitates (comes back up)


• Retching after eating


• Feeling unwell after eating


• Weight loss


• Loss of appetite

Ulcers can cause severe signs and symptoms, such as (much less common):

• Vomiting blood
• Black and tarry stools, or stools with dark blood
• Nausea and vomiting
These symptoms should be treated as medical emergencies

When you should see a doctor:

A peptic ulcer should be treated with your doctor's help. OTC (over-the-counter) medications may temporarily provide some pain relief, but will not provide comprehensive treatment. If you have the signs and symptoms described above you should see your doctor.

What are the causes of peptic ulcers?

Peptic ulcers are usually caused by either Helicobacter pylori (H pylori) bacteria or non-steroidal anti-inflammatory drugs (NSAIDs). H Pylori bacteria are responsible for about four-fifths of all gastric ulcers and 95% of duodenal ulcers, while NSAIDs are known to cause about 20% of gastric ulcers and 5% of duodenal ulcers.

• H pylori
  
  Over 25% of people in Western Europe and North America carry H pylori. Experts are not certain why the bacteria do not cause ulcers in all people who carry H pylori. The bacterium spreads through food and water. As it is present in human saliva it can spread through mouth-to-mouth contact, such as kissing. It lives in the mucus that coats the lining of the stomach and duodenum and produces urease, an enzyme that neutralizes stomach acid by making it less acidic. To compensate for this the stomach makes more acid, which irritates the stomach lining.
  
  H pylori also weakens the defense system of the stomach and causes inflammation. Patients with peptic ulcers caused by H pylori need treatment to get rid of the bacterium from the stomach to prevent recurrences.


• NSAIDs (non-steroidal anti-inflammatory drugs)
  
  These are medications for headaches, period pains, and other minor pains. Examples include aspirin and ibuprofen. Many NSAIDs are OTC medications, while others, such as diclofenac, naproxen and meloxicam can only be acquired with a doctor's prescription.
  
  Non-steroidal anti-inflammatory drugs lower the stomach's ability to make a protective layer of mucus, making it more susceptible to damage by stomach acids. NSAIDs can also affect the flow of blood to the stomach, undermining the body's ability to repair cells.


• Genetics - a significant number of individuals with peptic ulcers have close relatives with the same problem, suggesting that genetic factors may also be involved.


• Smoking - people who regularly smoke tobacco are more likely to develop peptic ulcers compared to non-smokers.


• Alcohol consumption - regular heavy drinkers of alcohol have a higher risk of developing peptic ulcers.


• Mental stress - mental stress has not been linked to the development of new peptic ulcers. However, people with ulcers who experience sustained mental stress tend to have worse symptoms.

How are peptic ulcers diagnosed?

A patient's description of symptoms will usually make the doctor suspect a peptic ulcer. Some tests will be ordered so that diagnosis can be confirmed, such as:

• Blood test - a blood test can determine whether H pylori bacteria are present. However, a blood test cannot determine whether the patient had past exposure or is currently infected. Also, if the individual has been taking antibiotics or proton pump inhibitors a blood test can give a false-negative result.


• Breath test - a radioactive carbon atom is used to detect H pylori. The patient drinks a glass of clear liquid containing radioactive carbon as part of a substance (urea) that the H pylori will break down. An hour later the patient blows into a bag which is subsequently sealed. If the patient is infected with H pylori the breath sample will contain radioactive carbon in carbon dioxide. The breath test is also useful in checking to see how effective treatment has been in eliminating H pylori.


• Stool antigen test - this test determines whether H pylori is present in the feces (stools). This test is also useful in determining how effective treatment has been in getting rid of the bacteria.


• Upper gastrointestinal X-ray (upper GI X-ray) - the test outlines the esophagus, stomach and duodenum. The patient swallows a liquid which contains barium. The barium coats the digestive tract and shows up on the X-ray, making the ulcer easier to see. Upper GI X-rays are only useful in detecting some ulcers.


• Endoscopy - a long-narrow tube with a camera attached to the end is threaded down the patient's throat and esophagus into the stomach and duodenum. The doctor can see the upper digestive tract on a monitor and identify an ulcer if one is present. Endoscopies are also performed if the patient has other signs or symptoms, such as weight loss, vomiting (especially if blood is present), black stools, anemia, and swallowing difficulties.
  
  If an ulcer is detected the doctor may take a biopsy - a small sample of tissue is taken near the ulcer. The sample is examined under a microscope to rule out cancer. A biopsy can also be used to test for the presence of H pylori.
  
  Sometimes another endoscopy is performed a few months later to determine whether the ulcer is healing.

What are the treatment options for peptic ulcers?

The type of treatment is usually determined by what caused the peptic ulcer - H Pylori or NSAIDs. Treatment will focus on either lowering stomach acid levels so that the ulcer can heal, or eradicating the H pylori infection.

• PPIs (proton pump inhibitors)
  
  These tablets reduce the amount of acid the stomach produces and are prescribed for patients who tested negative for H pylori infection. Treatment usually lasts from one to two months - if the ulcer is severe treatment may last longer.
  
  Patients who have to undergo an endoscopy will have to stop taking PPIs for at least 14 days beforehand. PPIs make it harder to see the inside of the abdomen.
  
  If side effects do occur they are usually mild and go away when treatment stops. They may include:
  
  
  • Nausea
  • Skin rashes
  • Stomach pain
  • Dizziness
  • Headaches
  • Constipation
  • Diarrhea


• H pylori infection treatment
  
  Patients infected with H pylori will usually have to take a PPI (proton pump inhibitor) and two different antibiotics - twice a day for seven days. It is crucial that the patient adheres to dosage instructions. This treatment is effective in about 90% of patients, whose ulcer will start to disappear within a matter of days.
  
  When treatment is over the individual will have to be tested again to make sure the H pylori have gone, especially if such symptoms as indigestion persist. If the infection is still present he/she will undergo another course of antibiotics; this time with different antibiotics.
  
  A person who has a gastric ulcer caused by H pylori infection has a slightly higher risk of developing stomach cancer. Hence, confirming that treatment has been successful is important.


• NSAIDs (non-steroidal anti-inflammatory drugs)
  
  People whose peptic ulcer was caused by taking NSAIDs will have to stop taking them, if possible. The doctor will prescribe another painkiller, such as acetaminophen (Tylenol, paracetamol).
  
  Individuals with another condition that causes severe pain may have to stop taking NSAIDs for as long as possible until their ulcer has healed.
  
  In some cases it may not be possible to stop taking NSAIDs. The doctor may minimize the dosage and review the patient's need for them later on. The doctor may also prescribe a medication to be taken long term, alongside the NSAID - this might be either a PPI or an H2-receptor antagonist.


• Alginates
  
  Alginates help relieve indigestion caused by acid reflux and is often found in antacids. Alginates form a foam barrier on the surface of the stomach contents, keeping the stomach acid in the stomach. Antacids which contain alginates help medications stay in the stomach for longer.


• H2-receptor antagonists
  
  These medications reduce the amount of acid in the stomach. They are swallowed as tablets. Patients taking erythromycin or warfarin will not be able to take cimetidine (a type of H2-receptor antagonist).
  
  Individuals who are to undergo an endoscopy will have to stop taking H2-receptor antagonists for at least 14 before the procedure.
  
  If side effects do occur, they may include:
  
  
  • Headaches
  • Skin rashes
  • Fatigue
  • Diarrhea
  • Dizziness


• Follow-up treatment
  
  Even after the ulcer has healed and treatment has been completed the patient may still have indigestion. In such case the doctor may advise some eating and lifestyle changes. If symptoms persist the doctor may prescribe a low-dose PPI or H2-receptor antagonist.

What are the possible complications of peptic ulcers?

The risk of complications is much greater if the ulcer is left untreated, or if treatment was not completed. Examples include:

• Internal bleeding - slow blood loss can lead to anemia, while severe blood loss requires hospitalization and blood transfusions.


• Infection - a peptic ulcer can bore a hole through the wall of the stomach or small intestine, significantly increasing the risk of infection in the abdominal cavity - peritonitis. Peritonitis can be very painful and causes chills and fever, nausea, vomiting and a hard feeling in the abdomen. Individuals with peritonitis should seek medical attention as soon as symptoms are felt.


• Scar tissue - scar tissue caused by peptic ulcers can obstruct the passage of food through the digestive tract, making the patient feel full more easily. Scarring may also cause vomiting and weight loss.


• Pyloric stenosis - chronic inflammation in the lining of the stomach or duodenum caused by a peptic ulcer can result in a narrowing of the pylorus (small passage that links the stomach and the duodenum). Pyloric stenosis is the narrowing of the pylorus. Food will not pass through to the intestines, causing vomiting and weight loss.


• Recurrence of peptic ulcers - People with the highest risk of developing peptic ulcers are those who have had them before. Somebody who had a peptic ulcer caused by H pylori infection runs a 5% risk of having another one during their lifetime; even after their original ulcer was successfully treated and healed.
  
  Somebody who had a peptic ulcer caused by H pylori infection and still has the bacteria runs a 60% risk of having another gastric ulcer during their lifetime and a 80% risk of having another duodenal ulcer.