Peptic Ulcer Disease

What is an Ulcer?

An ulcer is a sore or break in the lining of the digestive tract. Most ulcers are found in the duodenum, the portion of the small intestine just beyond the stomach. Ulcers may also form in the stomach, and these are called gastric ulcers. The terms duodenal ulcer and gastric ulcer refer to the location of the ulcer. Peptic ulcer indicates the ulcer is due to the damaging effects of acid and peptic, or digestive juices. In the past it was felt that peptic ulcer disease was a chronic, recurrent disease of unknown cause. An ulcer could be healed, but nothing could be done to alter the underlying tendency to develop ulcers.

What Causes an Ulcer?

The stomach produces hydrochloric acid and enzymes to help digest the food you eat. Normally, the stomach and duodenum are protected from damage by these substances. In the stomach, a layer of mucous covers the lining to protect it from the acid. In the duodenum, fluid from the pancreas neutralizes the acid before any damage occurs. An ulcer forms either because of too much acid or some weakness in these normal protective mechanisms, Many people with gastric ulcer produce normal or less than normal amounts of acid. For this reason, we know that acid is not the only factor involved in the formation of ulcers.

Helicobacter Pylori

Many patients develop ulcer disease as a result of infection of the stomach lining with a bacteria called Helicobacter pylori. This infection weakens the lining and may allow an ulcer to form. These ulcers may heal with the usual antiulcer drugs, but often recur when treatment is stopped. Antibiotics and Pepto-Bismol may cure the infection and allow the ulcer to heal. In addition to helping the ulcer heal, eradication of this infection may eliminate the tendency to develop recurrent ulcers.

NSAIDs

Aspirin, ibuprofen, and many antiarthritis drugs (Non Steroidal Anti Inflammatory Drugs or NSAIDs) weaken the lining of the stomach and can cause ulcers. These drugs slow the production of prostaglandins. These are chemicals which help protect the stomach lining from damage by acid. Cytotec is a synthetic prostaglandin which can prevent ulcers from occurring as a result of taking NSAIDs. The most common side effects of Cytotec are nausea and diarrhea. PPIs (proton pump inhibitors--see below) are also useful in prevention of ulcers in patients taking NSAIDs.

A new class of drugs for arthritis has been developed, called Cox-2 inhibitors. These drugs , Celebrex and Vioxx, are significantly safer in terms of their effect on the stomach. Both drugs have a lower risk of ulcers than the NSAIDs. Unfortunately, some patients still develop stomach irritation and ulcers while on these drugs. Gastrointestinal bleeding can also occur.

When ulcers occur in patients on these drugs, the drug should be stopped in order to aid in healing the ulcer. If necessary for pain control, another drug should be substituted, preferably acetominophen or other medications that will not irritate the stomach. If the NSAID must be continued, continuous use of a PPI is often necessary.

What are the Symptoms of an Ulcer?

Ulcer pain is often described as a burning or gnawing sensation. It is usually located in the upper abdomen or lower chest. Typical duodenal ulcer pain occurs 30-60 minutes after a meal and is relieved by eating again. Pain is usually worse when the stomach is empty, and often awakens the patient from sleep. Gastric ulcer pain generally worsens immediately with eating. Nausea, vomiting, belching, loss of appetite, bloating, indigestion, and heartburn are other symptoms which can occur with an active ulcer. At times, an ulcer may cause no pain at all and is only found when the patient presents with bleeding or other complication. This occurs most often in older patients, especially if they are taking NSAIDs.

Complications of Ulcer Disease

Black stools or vomiting blood indicate that the ulcer is bleeding. Severe abdominal pain may be the result of a perforated ulcer. Either of these complications is an emergency, requiring immediate medical care. Scarring from recurrent ulcers may narrow the lower end of the stomach or duodenum. If this causes a blockage, surgery could be required. Many cases can be treated by stretching open the narrowed area with a balloon at the time of gastroscopy.

How is an Ulcer diagnosed?

The two tests used to identify ulcers are the upper GI series and gastroscopy. The upper GI series is an x-ray done after drinking barium to outline the stomach and duodenum. Gastroscopy is looking inside the stomach with a lighted fiberoptic instrument. Gastroscopy is the more accurate test. Between 10 and 25% of ulcers are not seen on an upper GI series. Gastroscopy also allows diagnosis of Helicobacter Pylori and other conditions which cannot be diagnosed by x-ray.

If an ulcer is suspected, medication is often tried before any testing is done. Patients who respond promptly may not require any testing. If a person has weight loss, bleeding, difficulty swallowing, or does not respond to treatment, then gastroscopy should be performed.

Gastric ulcers pose a special concern. Small, early stomach cancers can sometimes resemble an ulcer. For this reason, most gastric ulcers should be biopsied. After 6-8 weeks of treatment, gastroscopy is repeated to be certain the ulcer has healed. When an ulcer does not heal, it raises the suspicion of cancer, even if biopsies are negative. Surgery may be recommended for a non healing gastric ulcer.

What Can I Do For My Ulcer?

Antacids are the first medication which is usually prescribed by the physician or tried by the patient. If antacids are not effective then stronger medication may be necessary. If symptoms improve with antacids, it usually indicates they are related to acid.

Most of the drugs for treatment of ulcers reduce acid production in the stomach. These include Tagamet, Zantac, Axid, and Pepcid. These are all H2 (histamine) blockers and work by the same mechanism. They decrease, but may not completely eliminate acid production, so antacids may still be necessary while taking these drugs. Prilosec, Prevacid, Aciphex, and Protonix are more powerful drugs which are capable of completely turning off acid production.

Carafate works by creating a protective coating over the ulcer to protect it from acid and digestive juices, thus allowing it to heal. It also helps to strengthen the defenses of the stomach lining. Carafate may be more effective than H2 blockers in patients who smoke.

Smoking

Smoking increases acid production and also weakens the defenses of the stomach lining, probably by altering the circulation in the lining. This delays ulcer healing and increases the risk of recurrent ulcers. Smoking at bedtime is particularly harmful. This is another excellent reason to stop smoking.

Diet

Most ulcer patients do not need to be on a special diet. Diet was the only treatment available many years ago. Modern medications are so effective that diet no longer plays a significant role in ulcer treatment. Certain foods may cause pain or other symptoms when you have an ulcer. Avoiding such foods is only necessary for your comfort. These foods will probably not keep the ulcer from healing. Coffee and alcohol may cause symptoms and delay ulcer healing, and make recurrence more likely.

Is Stress Important?

Emotional stress rarely causes ulcers. Stress causes increased acid production, and can also cause bowel spasms. These can cause symptoms which might suggest an ulcer or other digestive disorder. Testing is often necessary to identify the cause of these symptoms.