During normal digestion, food moves from the mouth down the esophagus into the stomach. The stomach produces hydrochloric acid and an enzyme called pepsin to digest the food. From the stomach, food passes into the upper part of the small intestine, called the duodenum, where digestion and nutrient absorption continue.
An ulcer is a sore or lesion that forms in the lining of the stomach or duodenum where acid and pepsin are present. Ulcers in the stomach are called gastric or stomach ulcers. Those in the duodenum are called duodenal ulcers. In general, ulcers in the stomach and duodenum are referred to as peptic ulcers.
About 20 million Americans develop at least one ulcer during their lifetime. Each year:
Ulcers can develop at any age, but they are rare among teenagers and even more uncommon in children. Duodenal ulcers occur for the first time usually between the ages of 30 and 50. Stomach ulcers are more likely to develop in people over age 60. Duodenal ulcers occur more frequently in men than women; stomach ulcers develop more often in women than men.
Smoking--Studies show that cigarette smoking increases one's chances of getting an ulcer. Smoking slows the healing of existing ulcers and also contributes to ulcer recurrence.
Caffeine--Coffee, tea, colas, and foods that contain caffeine seem to stimulate acid secretion in the stomach, aggravating the pain of an existing ulcer. However, the amount of acid secretion that occurs after drinking decaffeinated coffee is the same as that produced after drinking regular coffee. Thus, the stimulation of stomach acid cannot be attributed solely to caffeine.
Alcohol--Research has not found a link between alcohol consumption and peptic ulcers. However, ulcers are more common in people who have cirrhosis of the liver, a disease often linked to heavy alcohol consumption.
Stress--Although emotional stress is no longer thought to be a cause of ulcers, people with ulcers often report that emotional stress increases ulcer pain. Physical stress, however, increases the risk of developing ulcers particularly in the stomach. For example, people with injuries such as severe burns and people undergoing major surgery often require rigorous treatment to prevent ulcers and ulcer complications.
Acid and pepsin--Researchers believe that the stomach's inability to defend itself against the powerful digestive fluids, acid and pepsin, contributes to ulcer formation. The stomach defends itself from these fluids in several ways. One way is by producing mucus--a lubricant-like coating that shields stomach tissues. Another way is by producing a chemical called bicarbonate. This chemical neutralizes and breaks down digestive fluids into substances less harmful to stomach tissue. Finally, blood circulation to the stomach lining, cell renewal, and cell repair also help protect the stomach.
Nonsteroidal anti-inflammatory drugs (NSAIDs) make the stomach vulnerable to the harmful effects of acid and pepsin. NSAIDs such as aspirin, ibuprofen, and naproxen sodium are present in many non-prescription medications used to treat fever, headaches, and minor aches and pains. These, as well as prescription NSAIDs used to treat a variety of arthritic conditions, interfere with the stomach's ability to produce mucus and bicarbonate and affect blood flow to the stomach and cell repair. They can all cause the stomach's defense mechanisms to fail, resulting in an increased chance of developing stomach ulcers. In most cases, these ulcers disappear once the person stops taking NSAIDs.
H. pylori survives in the stomach because it produces the enzyme urease. Urease generates substances that neutralize the stomach's acid--enabling the bacteria to survive. Because of their shape and the way they move, the bacteria can penetrate the stomach's protective mucous lining. Here, they can produce substances that weaken the stomach's protective mucus and make the stomach cells more susceptible to the damaging effects of acid and pepsin.
The bacteria can also attach to stomach cells further weakening the stomach's defensive mechanisms and producing local inflammation. For reasons not completely understood, H. pylori can also stimulate the stomach to produce more acid.
Excess stomach acid and other irritating factors can cause inflammation of the upper end of the duodenum, the duodenal bulb. In some people, over long periods of time, this inflammation results in production of stomach-like cells called duodenal gastric metaplasia. H. pylori then attacks these cells causing further tissue damage and inflammation, which may result in an ulcer.
Within weeks of infection with H. pylori, most people develop gastritis--an inflammation of the stomach lining. However, most people will never have symptoms or problems related to the infection. Scientists do not yet know what is different in those people who develop H. pylori-related symptoms or ulcers. Perhaps, hereditary or environmental factors yet to be discovered cause some individuals to develop problems. Alternatively, symptoms and ulcers may result from infection with more virulent strains of bacteria. These unanswered questions are the subject of intensive scientific research.
Studies show that H. pylori infection in the United States varies with age, ethnic group, and socioeconomic class. The bacteria are more common in older adults, African Americans, Hispanics, and lower socio- economic groups. The organism appears to spread through the fecal-oral route (when infected stool comes into contact with hands, food, or water). Most individuals seem to be infected during childhood, and their infection lasts a lifetime.
Less common ulcer symptoms include nausea, vomiting, and loss of appetite and weight. Bleeding from ulcers may occur in the stomach and duodenum. Sometimes people are unaware that they have a bleeding ulcer, because blood loss is slow and blood may not be obvious in the stool. These people may feel tired and weak. If the bleeding is heavy, blood will appear in vomit or stool. Stool containing blood appears tarry or black.
An alternative diagnostic test is called an endoscopy. During this test, the patient is lightly sedated and the doctor inserts a small flexible instrument with a camera on the end through the mouth into the esophagus, stomach, and duodenum. With this procedure, the entire upper GI tract can be viewed. Ulcers or other conditions can be diagnosed and photographed, and tissue can be taken for biopsy, if necessary.
Once an ulcer is diagnosed and treatment begins, the doctor will usually monitor clinical progress. In the case of a stomach ulcer, the doctor may wish to document healing with repeat x-rays or endoscopy. Continued monitoring of a stomach ulcer is important because of the small chance that the ulcer may be cancerous.
Blood tests--Blood tests such as the enzyme-linked immunosorbent assay (ELISA) and quick office-based tests identify and measure H. pylori antibodies. The body produces antibodies against H. pylori in an attempt to fight the bacteria. The advantages of blood tests are their low cost and availability to doctors. The disadvantage is the possibility of false positive results in patients previously treated for ulcers since the levels of H. pylori antibodies fall slowly. Several blood tests have FDA approval.
Breath tests--Breath tests measure carbon dioxide in exhaled breath. Patients are given a substance called urea with carbon to drink. Bacteria break down this urea and the carbon is absorbed into the blood stream and lungs and exhaled in the breath. By collecting the breath, doctors can measure this carbon and determine whether H. pylori is present or absent. Urea breath tests are at least 90 percent accurate for diagnosing the bacteria and are particularly suitable to follow-up treatment to see if bacteria have been eradicated. These tests are awaiting FDA approval.
Tissue tests--If the doctor performs an endoscopy to diagnose an ulcer, tissue samples of the stomach can be obtained. The doctor may then perform one of several tests on the tissue. A rapid urease test detects the bacteria's enzyme urease. Histology involves visualizing the bacteria under the microscope. Culture involves specially processing the tissue and watching it for growth of H. pylori organisms.
H2-blockers--Currently, most doctors treat ulcers with acid-suppressing drugs known as H2-blockers. These drugs reduce the amount of acid the stomach produces by blocking histamine, a powerful stimulant of acid secretion.
H2-blockers reduce pain significantly after several weeks. For the first few days of treatment, doctors often recommend taking an antacid to relieve pain.
Initially, treatment with H2-blockers lasts 6 to 8 weeks. However, because ulcers recur in 50 to 80 percent of cases, many people must continue maintenance therapy for years. This may no longer be the case if H. pylori infection is treated. Most ulcers do not recur following successful eradication. Nizatidine (Axid) is approved for treatment of duodenal ulcers but is not yet approved for treatment of stomach ulcers. H2-blockers that are approved to treat both stomach and duodenal ulcers are:
Acid pump inhibitors--Like H2-blockers, acid pump inhibitors modify the stomach's production of acid. However, acid pump inhibitors more completely block stomach acid production by stopping the stomach's acid pump--the final step of acid secretion. The FDA has approved use of omeprazole for short-term treatment of ulcer disease. Similar drugs, including lansoprazole, are currently being studied.
Mucosal protective medications--Mucosal protective medications protect the stomach's mucous lining from acid. Unlike H2-blockers and acid pump inhibitors, protective agents do not inhibit the release of acid. These medications shield the stomach's mucous lining from the damage of acid. Two commonly prescribed protective agents are:
Two common non-prescription protective medications are:
Antibiotics--The discovery of the link between ulcers and H. pylori has resulted in a new treatment option. Now, in addition to treatment aimed at decreasing the production of stomach acid, doctors may prescribe antibiotics for patients with H. pylori. This treatment is a dramatic medical advance because eliminating H. pylori means the ulcer may now heal and most likely will not come back.
The most effective therapy, according to the NIH Panel, is a 2-week, triple therapy. This regimen eradicates the bacteria and reduces the risk of ulcer recurrence in 90 percent of people with duodenal ulcers. People with stomach ulcers that are not associated with NSAIDs also benefit from bacterial eradication. While triple therapy is effective, it is sometimes difficult to follow because the patient must take three different medications four times each day for 2 weeks.
As an alternative to triple therapy, several 2-week, dual therapies are about 80 percent effective. Dual therapy is simpler for patients to follow and causes fewer side effects. A dual therapy might include an antibiotic, such as amoxicillin or clarithromycin, with omeprazole, a drug that stops the production of acid.
Again, an accurate diagnosis is important. Accurate diagnosis and appropriate treatment prevent people without ulcers from needless exposure to the side effects of antibiotics and should lessen the risk of bacteria developing resistance to antibiotics.
Although all of the above antibiotics are sold in the United States, the FDA has not yet approved the use of antibiotics for treatment of H. pylori or ulcers. Doctors may choose to prescribe antibiotics to their ulcer patients as "off label" prescriptions as they do for many conditions.
At present, standard open surgery is performed to treat ulcers. In the future, surgeons may use laparoscopic methods. A laparoscope is a long tube-like instrument with a camera that allows the surgeon to operate through small incisions while watching a video monitor. The common types of surgery for ulcers--vagotomy, pyloroplasty, and antrectomy--are described below:
If a damaged blood vessel is large, bleeding is dangerous and requires prompt medical attention. Symptoms include feeling weak and dizzy when standing, vomiting blood, or fainting. The stool may become a tarry black color from the blood.
Most bleeding ulcers can be treated endoscopically_the ulcer is located and the blood vessel is cauterized with a heating device or injected with material to stop bleeding. If endoscopic treatment is unsuccessful, surgery may be required.
Fedotin MS. Helicobacter pylori and peptic ulcer disease: Reexamining the therapeutic approach. Postgraduate Medicine, 1993; 94(3): 38-45.
Gilbert G, Chan CH, Thomas E. Peptic ulcer disease: how to treat it now. Postgraduate Medicine, 1991; 89(4): 91-98.
Larson DE, Editor-in-Chief. Mayo Clinic Family Health Book. New York: William Morrow and Company, Inc., 1990. General medical guide with sections on stomach problems and ulcers.
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