What is a peptic ulcer?
A peptic ulcer is a break in the surface lining of the stomach or in the first part of the small intestine, known as the duodenum.
What causes a peptic ulcer?
An ulcer occurs when the natural defense mechanisms in the stomach or duodenum are overwhelmed by aggressive factors. In the stomach acid and pepsin (a digestive enzyme) are the aggressors. Gastric mucus, bicarbonate ions (which neutralize acid), the surface cells of the stomach and compounds known as prostaglandins protect the stomach from ulceration.
Almost all peptic ulcers occur in people taking non-steroidal anti-inflammatory drugs (NSAIDs) or those infected with Helicobacter Pylori (H. Pylori). NSAIDs are anti-inflammatory medications like aspirin, naproxen, and ibuprofen. H. Pylori is a bacterium that has adapted to living on the surface lining of the stomach. H. Pylori and nonsteroidal anti-inflammatories impair the ability of the stomach and duodenum to protect themselves from acid and pepsin and are thus predisposed to ulcer formation. Emotional stress in itself does not cause ulcers, but it may contribute to their development in a small degree.
What are some symptoms of an ulcer?
Ulcers can cause pain or may result in bleeding. The pain is typically described as a gnawing or burning, is felt in the upper abdomen, and may be relieved by antacids. Bleeding may appear as black stools. Occasionally an ulcer may erode through the wall of the stomach or small intestine and result in a perforation. Please note that many patients with an ulcer may have no symptoms at all.
How are ulcers diagnosed?
We can identify ulcers by looking into the stomach or small bowel with an instrument called an endoscope. This instrument is a thin, flexible tube with a light on the end that is passed through the throat into the stomach. The endoscope allows us to view the lining. Patients are sedated for the procedure, are comfortable during it, and tolerate it very well. This instrument also allows the examiner to take biopsies (tissue samples for testing), which may be helpful in deciding treatment.
Ulcers may also be diagnosed using special X-ray techniques. Patients swallow a chalky liquid, which outlines the anatomy of the intestinal tract.
Occasionally, a doctor may feel that a patient's symptoms are so characteristic of an ulcer that they will treat the patient without performing these special investigations.
What are some effects of H. Pylori?
H. Pylori is probably responsible for up to 80 percent of gastric and 95 percent of duodenal ulcers. It is also implicated as a cause of stomach cancer. Infection usually occurs in childhood, predominantly in people growing up in overcrowded environments. The bacterium is primarily transmitted from one person to another.
H. Pylori can adhere to the lining of the stomach, regulate its environment, and thus can protect itself from the acid produced by the stomach. It then produces substances that damage cells and has the ability to recruit other cells that further aggravate inflammation.
Most individuals infected with H. Pylori remain asymptomatic throughout their lives. About one person in six will develop a peptic ulcer and only a very small number will develop stomach cancer.
How is H. Pylori diagnosed?
A stomach lining biopsy can be used for the diagnosis, but other, less invasive tests have been developed.
Tissue from the biopsy can be placed on special slides that contain a substance known as urea. H. pylori has an enzyme that converts urea to ammonia and carbon dioxide. Because ammonia has a different pH (degree of acidity) to urea, the slide changes color. The biopsy tissue can also be examined under a microscope and the H. Pylori organism can be seen.
H. pylori infection causes the body to produce antibodies against the bacterium. These antibodies can be detected in the blood and are also useful for diagnosing infection. A different diagnostic test involves the patient drinking urea. One of the carbon atoms in the urea is marked in a special way. If H. pylori is present in the person's stomach, its enzyme converts the urea to carbon dioxide and ammonia. The carbon dioxide is exhaled by the patient and the carbon atom, which is now part of the carbon dioxide, is detected in the patient's breath.
How is H. Pylori treated?
It is difficult to cure H. Pylori. Therapy with two antibiotics in combination with one or two non-antibiotic agents is necessary to eradicate the bacterium. Successful regimens use the antibiotic clarithromycin in combination with either metronidazole or amoxicillin.
Non-antibiotic agents include Bismuth, which is a topical antimicrobial, proton pump inhibitors (Prevacid, Prilosec, Protonix, Aciphex, or Nexium), which are medications that effectively suppress acid production in the stomach and drugs called H2 blockers (Tagamet, Zantac, or Pepcid), which also suppress acid production.
An example of therapy would be a proton pump inhibitor taken twice a day combined with clarithromycin and amoxicillin, both taken twice a day. Therapy in the United States is given for two weeks.
Cure rates of 90 percent are attainable and regimens achieving at least an 85 percent cure should be the minimum standard. Resistance to antibiotics is now being seen and is becoming a concern. Compliance is extremely important for a successful cure.
If a patient being treated for H. Pylori had complications from his or her ulcer such as bleeding or perforation, we test to make sure the bacterium has been eradicated after therapy. If the patient had uncomplicated disease, we monitor for recurrent symptoms rather than performing specific tests to check for eradication.
Attempts are being made to develop a vaccine. There is a suggestion that the vaccine may be curative rather than just preventative.
Non-steroidal anti-inflammatory drugs (NSAIDs)
These drugs are one of the most used medications in the world today. They are anti-inflammatory, effective pain relievers, and antipyretic (help lower a fever). They are very effective for common ailments such as osteoarthritis and other musculoskeletal disorders.
Side effects are seen throughout the gastrointestinal tract and an association with ulcer formation in the stomach is clearly apparent.
If an endoscopy is performed, "ulcers" will be seen in about five to 25 percent of patients using anti-inflammatories. However less than fewer than two percent will develop clinical ulcers, i.e., ulcers causing symptoms. Patients older than 70 years, females, smokers, long-term users, those with a history of peptic ulcer disease, and patients receiving co-therapy with either corticosteroids or anticoagulants are at greatest risk for complications. Fifty percent of patients with NSAID ulcers will have H. Pylori.
How are NSAID ulcers treated?
The most effective treatment is to discontinue the NSAID. If continued use is absolutely necessary, proton pump inhibitors will help the ulcer heal while the patient continues using the NSAID. H2 blockers in high doses are also effective. Treatment of H. Pylori is also recommended if the bacterium is found to be present.
One daily dose of a proton pump inhibitor is protective against the development of ulcers, and high doses of H2 blockers may offer the same protection. A medication called misoprostol has been approved by the FDA as a protective agent. It may cause diarrhea and abdominal cramps as a side effect, and this restricts its use.
© Copyright 1995-2008, The Cleveland Clinic Foundation. All rights reserved.
Can't find the health information you’re looking for?
Ask a Health Educator, Live!
Click here to go to the Department of Gastroenterology and Hepatology Web site.
Know someone who could use this information?....send them this link.
This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 1/12/2005
