Stomach and Duodenal Ulcers (Peptic Ulcers)

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What is a stomach or duodenal ulcer?

About one in 10 Americans develops at least one ulcer during his or her lifetime.

An ulcer is an open sore, or lesion, usually found on the skin or mucous membrane areas of the body.

• An ulcer in the lining of the stomach or duodenum is referred to as a peptic ulcer.

• When the ulcer is in the stomach, it is called a gastric ulcer.

• When the ulcer is in the duodenum, it is called a duodenal ulcer.

What causes gastric and duodenal ulcers?

In the past, it was believed lifestyle factors, such as stress and diet caused ulcers. Later, researchers determined that stomach acids-- hydrochloric acid and pepsin--contributed to ulcer formation.

Today, research shows that most ulcers (80 percent of gastric ulcers and 90 percent of duodenal ulcers) develop as a result of infection with a bacterium called Helicobacter pylori ( H. pylori).

It is believed that, although all three of these factors--lifestyle, acid and pepsin, and H. pylori--play a role in ulcer development, H. pylori is considered to be the primary cause, in most cases.

Factors in the development of peptic ulcers

Factors suspected of playing a role in the development of stomach or duodenal ulcers include:

• Helicobacter pylori. Research shows that most ulcers develop as a result of infection from the bacterium Helicobacter pylori ( H. pylori). The bacterium produces substances that weaken the stomach's protective mucus and make it more susceptible to the damaging effects of acid and pepsin.

• Smoking. Studies show smoking increases the chances of developing an ulcer, slows the healing process of existing ulcers, and contributes to ulcers recurring.

• Caffeine. Caffeine seems to stimulate acid secretion in the stomach, which can aggravate the pain of an existing ulcer. However, the stimulation of stomach acid cannot be attributed solely to caffeine.

• Alcohol. Although no proven link has been found between alcohol consumption and peptic ulcers, ulcers are more common in people who have cirrhosis of the liver, a disease often linked to heavy alcohol consumption.

• Stress. Emotional stress is no longer thought to be a cause of ulcers, however, people with ulcers often report that emotional stress increases ulcer pain.

• Physical stress. Physical stress may increase 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 treatment to prevent ulcers and ulcer-related complications, such as bleeding.

• Acid and pepsin. It is believed the stomach's inability to defend itself against the powerful digestive fluids, hydrochloric acid and pepsin, contributes to ulcer formation.

• Nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs (such as aspirin, ibuprofen, and naproxen sodium) make the stomach vulnerable to the harmful effects of acid and pepsin. They are present in many nonprescription medications used to treat fever, headaches, and minor aches and pains.

What are the symptoms of gastric and duodenal ulcers?

The following are the most common symptoms of ulcers. However, each individual may experience symptoms differently.

Although ulcers do not always cause symptoms, the most common ulcer symptom is a gnawing or burning pain in the abdomen between the breastbone and the navel. The pain often occurs between meals and in the early hours of the morning. It may last from a few minutes to a few hours. Less common ulcer symptoms may include:

• Belching

• Nausea

• Vomiting

• Poor appetite

• Loss of weight

• Feeling tired and weak

The symptoms of stomach and duodenal ulcers may resemble other medical conditions or problems. Always consult your doctor for a diagnosis.

What are some complications from ulcers?

People with ulcers may experience serious complications if they do not seek appropriate treatment. The most common problems include the following:

• Bleeding. As an ulcer eats into the muscles of the stomach or duodenal wall, blood vessels may become damaged, causing bleeding.

• Perforation. Sometimes, an ulcer eats a hole in the wall of the stomach or duodenum, and bacteria and partially digested food can spill through the opening into the sterile abdominal cavity (known as the peritoneum) and cause peritonitis, severe inflammation of the abdominal cavity and wall.

• Narrowing and obstruction. Ulcers located at the end of the stomach, where the duodenum is attached, can cause swelling and scarring, which can narrow or close the intestinal opening. This obstruction can prevent food from leaving the stomach and entering the small intestine, resulting in vomiting the contents of the stomach.

How are ulcers diagnosed?

Because protocols vary for different types of ulcers, it is important to diagnose the underlying cause of ulcer disease properly before starting treatment. For example, for an NSAID-induced ulcer, treatment is quite different from the treatment for a person diagnosed with an ulcer caused by the bacterium, H. pylori.

There are a number of options available for diagnosing ulcers, and for testing for the H. pylori bacterium. These diagnostic procedures include:

• Upper GI (gastrointestinal) series (also called barium swallow). A diagnostic test that examines the organs of the upper part of the digestive system: the esophagus, stomach, and duodenum (the first section of the small intestine). A fluid called barium (a metallic, chemical, chalky, liquid used to coat the inside of organs so that they will show up on an X-ray) is swallowed. X-rays are then taken to evaluate the digestive organs.

• Esophagogastroduodenoscopy (also called EGD or upper endoscopy). An EGD (upper endoscopy) is a procedure that allows the doctor to examine the inside of the esophagus, stomach, and duodenum. A thin, flexible, lighted tube, called an endoscope, is guided into the mouth and throat, then into the esophagus, stomach, and duodenum. The endoscope allows the doctor to view the inside of this area of the body, as well as to insert instruments through a scope for the removal of a sample of tissue for biopsy (if necessary).

• Blood, breath, and stomach tissue tests. These tests are performed to detect the presence of H. pylori. Although some of the tests for H. pylori may occasionally give false-positive results, or may give false-negative results in people who have recently taken antibiotics, omeprazole, or bismuth, research shows these tests can be helpful in detecting the bacteria and guiding treatment.

Treatment for stomach and duodenal ulcers

Specific treatment for stomach and duodenal ulcers will be determined by your doctor based on:

• Your age, overall health, and medical history

• Extent of the condition

• Your tolerance for specific medications, procedures, or therapies

• Expectations for the course of the condition

• Your opinion or preference

Treatment may include:

• Lifestyle changes. In the past, doctors advised people with ulcers to avoid spicy, fatty, or acidic foods. However, a bland diet is now known to be ineffective for treating or avoiding ulcers. No particular diet is helpful for most ulcer patients. People who find that certain foods cause irritation should discuss the problem with their doctors. Smoking has been shown to delay ulcer healing and has been linked to ulcer recurrence. Therefore, people with ulcers are discouraged from smoking.

• Medications. Doctors treat stomach and duodenal ulcers with several types of medications, including the following:

  • Antibiotics. Medications used to kill H. pylori if it has been detected.

  • H2-blockers. Medications used to reduce the amount of acid the stomach produces by blocking histamine, a powerful stimulant of acid secretion.

  • Acid pump inhibitors. Medications  that help to completely block stomach acid production by stopping the stomach's acid pump--the final step of acid secretion)

  • Mucosal protective agents. Medications that shield the stomach's mucous lining from the damage of acid, but do not inhibit the release of acid.

  When treating H. pylori, these medications are often used in combination.

• Surgery. In most cases, anti-ulcer medications heal ulcers quickly and effectively, and eradication of H. pylori prevents most ulcers from recurring. However, people who do not respond to medication, or who develop complications, may require surgery.

  At present, standard open surgery is performed to treat ulcers. Types include the following:

  • Vagotomy. A procedure that involves cutting parts of the vagus nerve (a nerve that transmits messages from the brain to the stomach) to interrupt messages sent through it, therefore, reducing acid secretion.

  • Antrectomy. An operation to remove the lower part of the stomach (antrum), which produces a hormone that stimulates the stomach to secrete digestive juices. Sometimes, a surgeon may also remove an adjacent part of the stomach that secretes pepsin and acid. A vagotomy is usually done in conjunction with an antrectomy.

  • Pyloroplasty. A surgical procedure that may be performed along with a vagotomy, in which the opening into the duodenum and small intestine (pylorus) are enlarged, enabling contents to pass more freely from the stomach.

  Laparoscopic surgery may also be used to treat ulcer disease. A laparoscope is a long, thin tube with a camera lens attached that allows the doctor to examine the organs inside the abdominal cavity to check for abnormalities, and to operate through small incisions.