Definition and Overview

A peptic ulcer is a hole or an open sore that occurs when the stomach’s lining (gastric ulcer) or upper part of the small intestine (duodenal ulcer) is damaged by acidic digestive juices.

In normal circumstances, the body uses several substances to protect the digestive system against certain diseases and disorders including ulcers. Its first line of defense is the mucous layer, which coats the stomach and duodenum and neutralises digestive acids by secreting bicarbonate. The body also produces prostaglandins, a hormone-like substance that helps ensure good blood flow, stimulate bicarbonate production, and prevent injury. However, these defenses can be compromised when there’s overproduction of stomach acid. When this happens, acidic digestive juices are able to penetrate the lining of the stomach and duodenum, which results in peptic ulcers.

Peptic ulcers are very common, affecting millions of people worldwide and about 10% of the US population. However, the condition is rarely serious and is often adequately managed with medications. But when left untreated, it can lead to severe medical conditions including gastric or duodenal perforation, gastric outlet obstruction, upper GI haemorrhage, and stricture at the ulcer site.

Causes of Condition

In the past, it was widely thought that peptic ulcers are caused by lifestyle factors such as cigarette smoking, unhealthy eating habits, and high levels of stress. However, in 1982, two Australian scientists named Barry J. Marshall and J. Robin Warren identified Helicobacter pylori (H. pylori) infection as the main cause of the condition. The two researchers were awarded the Nobel Prize in Medicine in 2005 for their discovery.

H. pylori is a type of bacteria that can be contracted by consuming contaminated food and liquid or using contaminated utensils. It can survive in a highly acidic environment and evade detection of the immune system by altering certain immune factors. When triggered by certain factors, it produces a number of toxins that inflame and damage the stomach and intestinal lining.

The inflammation of the stomach and intestinal lining can also be caused by long-term use of certain medications, especially pain relievers such as ibuprofen and naproxen sodium. The risk of peptic ulcers can further increase if such medications are taken along with the following:

  • Alendronate and risedronate - Medications used to prevent or treat osteoporosis caused by menopause or steroids

  • Anticoagulants - Medicines that help prevent blood clots. These are prescribed for patients who have been diagnosed or treated for certain heart and valve diseases like stroke and deep vein thrombosis.

  • Low-dose aspirin

  • Selective serotonin reuptake inhibitors (SSRIs) - Medications used for the treatment of anxiety and major depressive disorder.

  • Steroids

It is important to note that many people who have H. pylori do not suffer from peptic ulcer because they do not have certain factors that trigger the condition. These include:

  • Genetic factors - Some H. pylori carriers do not have certain genes that are believed to make the bacteria more dangerous and increase the risk of peptic ulcers.

  • Intestinal immune response abnormality

  • Lifestyle factors, which include chronic stress and smoking

  • Interrupted sleep - Researchers found that working the night shift can weaken the immune system’s ability to fight pathogens.

Rarely, the following factors may cause ulceration in the intestine or stomach:

Key Symptoms

Peptic ulcer symptoms include:

  • A feeling of intense hunger between one and three hours after a meal

  • Belching

  • Bloating

  • Gastroesophageal reflux disease (GERD) symptoms

  • Indigestion

  • Vomiting

  • Burning pain in the upper abdomen and/or stabbing pain in the gut

  • Ulcer pain that may radiate to the chest or back

  • Anaemia

  • Weight loss

  • Fatigue

Who to See and Types of Treatments Available

Patients who experience persistent abdominal pain, belching, and bloating must consult a general or internal medicine practitioner for diagnosis and treatment.

To diagnose a peptic ulcer and rule out other medical conditions that share the same symptoms, the doctor will conduct a physical examination and review the person’s medical history. The following diagnostic tests will also be performed:

  • Urea breath test - This is the most useful and widely preferred noninvasive diagnostic test for people who are suspected of having a peptic ulcer. It is based on H. pylori’s ability to convert urea to carbon dioxide and ammonia. For this procedure, the patient will ingest a capsule or flavoured drink containing radioactive carbon and will be instructed to exhale in a plastic bag. The breath sample is then tested. If the urea is broken up and turned into carbon dioxide, it means that H. pylori is present in the stomach.

  • Rectal exam, fecal occult blood test, and complete blood count (CBC) - These are carried out to detect bleeding. When combined with urea breath test, the test results are often enough for a doctor to make a definitive diagnosis.

  • Endoscopy - In some cases, endoscopy is carried out to evaluate the stomach and duodenum using a thin tube with a tiny video camera. But because endoscopy is more invasive and expensive when compared to urea breath test and not suitable for everyone with dyspepsia, it is not often advised for the diagnosis of a peptic ulcer. However, it can be used if there’s bleeding and when assessing the effectiveness of treatment.

Treatment of peptic ulcer include:

  • Antibiotics - H. pylori is highly sensitive to amoxicillin and other antibiotics including tetracycline, ciprofloxacin, and metronidazole.

  • Proton pump inhibitors - These work by reducing stomach acid, which can result in immediate symptoms relief.

  • Antacids - Neutralise acid and protect the stomach by increasing mucous production and bicarbonate secretion.

  • Cytoprotective agents - Protect the tissues lining the stomach and small intestine.

High-risk patients with bleeding ulcers are usually treated in the hospital where their vital functions are supported with blood transfusion and fluid replacement. Depending on the severity of the condition, major abdominal surgery is performed. These could be:

  • Antrectomy - Involves the removal of the lower part of the stomach that stimulates digestive juices.

  • Pyloroplasty - Aims to enlarge the opening of the small intestine to allow stomach content to pass through it more easily.

  • Vagotomy - The procedure that cuts the vagus nerve to stop acid secretion in the stomach.

References:

  • Taha AS, McCloakwy C, Prasad R, Bezlyak V. Famotidine for the prevention of peptic ulcers and oesophagitis in patients taking low-dose aspirin (FAMOUS): A phase III, randomized, double-blind, placebo-controlled trial. Lancet. 2009:doi: 10.1016/S0140-6736(09)61246-0.

  • Take S, Mizuno M, Ishiki K, et al. Baseline gastric mucosal atrophy is a risk factor associated with the development of gastric cancer after Helicobacter pylori eradication therapy in patients with peptic ulcer disease. J Gastroenterol. 2007;42(suppl 17):21-27.

  • Peptic ulcer disease and H. pylori. National Institute of Diabetes and Digestive and Kidney Diseases. http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/peptic-ulcer/Pages/overview.aspx.

  • Peptic ulcer disease and NSAIDs. National Institute of Diabetes and Digestive and Kidney Diseases. http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/peptic-ulcer/Pages/overview.aspx.

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