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Acute Peptic Ulcer

Gastric Ulcer, Duodenal Ulcer, Gastroduodenal Ulcer, Stress Ulcer

What is Peptic ulcer?

A peptic ulcer disease is a sore that forms in the gastrointestinal tract. It occur when stomach acid and digestive juices break down and corrode the lining of the esophagus, stomach or duodenum, the upper portion of the small intestine. Peptic ulcers get their name from pepsin, one of the stomach enzymes that helps digest food. Although many people think that peptic ulcers occur only in the stomach, the majority of them occur in the duodenum.

The stomach and the surrounding portions of the GI tract provide a delicately balanced environment to process food. Strong acids and other chemicals in the stomach break down food into more basic components that can move through the digestive system. These chemicals, or gastric juices, are also strong enough to damage the lining that protects the stomach and other GI organs. A complex, multilayered coating forms a barrier to protect the lining.

This barrier is composed of many elements, including mucus, bicarbonate and chemicals called prostaglandins. Any change among the balance of these elements can weaken the barrier, allowing gastric juices to damage the underlying tissue. At first this damage may only irritate or inflame the lining, a condition called gastritis. Eventually enough corrosion forms a sore called a peptic ulcer.

Most peptic ulcers are the size of a pencil eraser or smaller. Peptic ulcers may heal on their own, only to recur after some time. Peptic ulcer disease refers to a tendency to develop these recurrent ulcers.

Peptic ulcers are quite common. According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), one in every 10 Americans will develop a peptic ulcer at some time in their lives. Duodenal ulcers occur most frequently in patients between the ages of 30 and 50 years and are twice as common in men as in women, according to the American College of Gastroenterology (ACG). Gastric ulcers tend to occur after the age of 60 years and are more common in women.

Peptic ulcers are generally referred to by their locations and sometimes by how they were formed. Different types of peptic ulcers include:

  • Duodenal ulcers. This most common type of peptic ulcer forms in the duodenum.
  • Gastric ulcers. Occur in the stomach, usually along the upper curve of the stomach.
  • Esophageal ulcers. Occur in the lower section of the esophagus, where they form when stomach acid backs up or refluxes into the esophagus.
  • Stress ulcers. May develop in the stomach or duodenum following severe illness, injury or trauma, such as severe burns or peritonitis.
  • Marginal ulcers. Also known as anastamotic ulcers, these may occur following the removal of part of the stomach (partial gastrectomy), where the remaining stomach connects to the small intestine.

How is it diagnosed?

Signs and symptoms of Peptic ulcer

Symptoms of peptic ulcers may vary greatly from person to person. Children and the elderly tend to have symptoms that do not follow the usual patterns or no symptoms at all. Patients who are very ill or taking corticosteroids may have less intense symptoms. When symptoms are absent, peptic ulcers may only be discovered when complications, which can be potentially life-threatening, arise. However, most peptic ulcers are cured without the development of complications.

The most common symptom of peptic ulcers is pain just below the breastbone. It is usually a steady, burning or gnawing sore pain or dull pain. It generally only lasts for minutes but may wake the patient up at night. The pain often occurs once or a few times daily, typically two to three hours after eating and usually lasts for one to several weeks. In some cases, pain may disappear and recur. Drinking or eating generally relieves the pain briefly because it helps buffer the stomach acid. However, it may actually make the pain worse over time.

Some other symptoms associated with peptic ulcers include:
  • Nausea and vomiting
  • Hunger or loss of appetite
  • Weight loss or gain
  • Fatigue
These symptoms, especially nausea and vomiting, may occur after eating.

It is important for patients experiencing symptoms of a peptic to consult a physician (often a gastroenterologist) because ulcers may not heal properly without medical attention. Peptic ulcers are usually diagnosed following an evaluation of medical history, a physical examination and diagnostic tests. Some physicians and gastroenterologists may simply treat a patient for peptic ulcers if the medical history and physical exam strongly suggest their presence. This is particularly likely if the patient is experiencing the characteristic abdominal pain. However, tests are usually needed to confirm the diagnosis and determine the cause of the ulcers.

Endoscopy is usually the first test used to diagnose peptic ulcers. While the patient is mildly sedated, a tiny camera attached to a thin tube is inserted through the mouth and esophagus into the stomach and duodenum. Endoscopy can be used to view the lining and sometimes obtain a tissue sample. The biopsy, or laboratory examination, of this tissue sample can be used to determine if an ulcer is cancerous or to identify an infection with the Helicobacter pylori (H. pylori) bacteria.

Barium x-rays may also be used to determine the severity and size of an ulcer. In an upper GI barium test, the patient consumes barium before an x-ray is performed. Barium acts as a contrast medium to make the intestinal organs stand out better on an x-ray. Barium x-rays were formerly the most commonly used diagnosis method for peptic ulcers. However, endoscopy has proven more reliable, especially in detecting smaller ulcers. In addition, endoscopy provides the option of removing tissue for biopsy.

Other tests may also be used to help determine the particular cause of peptic ulcers. Blood tests may be used to detect anemia and antibodies to H. pylori infections. The presence of these antibodies demonstrates that the patient has been infected at some point in the past. It does not necessarily indicate a current infection. Breath tests may be used to measure the activity of urease, an enzyme produced by H. pylori. Fecal tests may be used to detect active infections of H. pylori and signs of gastrointestinal bleeding that may not otherwise be noticeable.

In addition, researchers are currently investigating easier and more cost effective methods of identifying the presence of H. pylori bacteria. One such method that shows a great deal of promise is a simple string test in which patients swallow a capsule that contains a string. A portion of the string is held outside the patient’s mouth, allowing for easy retrieval. The string is then removed from the mouth and analyzed for the presence of the bacteria.

How is Peptic ulcer treated?

Use of nonsteroidal anti-inflammatory drugs (NSAID) should be discontinued if possible. Treatment may include drugs that inhibit or block acid secretions, or sucralfate (forms a protective covering) promoting healing of the stomach lining.

All H. pylori associated ulcers should be treated with a combination of antisecretory agents and anti-H. pylori therapy. Other associated infections (tuberculosis, syphilis) would require appropriate antibiotic therapy.

Ulcers that are resistant to treatment (refractory) may require surgery. Surgical intervention might include ulcer excision, vagotomy (cutting the vagus nerve fibers that control the production of digestive acid), pyloroplasty (operation to repair pylorus), or gastrectomy (surgical removal of a portion of the stomach).

If bleeding from the ulcer was substantial, a blood transfusion may be necessary.

Antibiotics to kill H. pylori bacteria

Information
Brand
Generic
Label
http://www.nmihi.com/m/metronidazole.html
Flagyl
Metronidazole
Off-Label
http://www.nmihi.com/a/amoxicillin.html
Amoxil
Amoxicillin
On-Label
http://www.nmihi.com/a/amoxicillin.html
Principen
Ampicillin
Off-Label
http://www.nmihi.com/c/co-amoxiclav.html
Augmentin
Off-Label

Sumycin (Tetracycline), Biaxin (Clarithromycin), Noroxin (Norfloxacin)

Medications to reduce acid production

Information
Brand
Generic
Label
http://www.nmihi.com/e/esomeprazole.html
Nexium
Esomeprazole
On-Label

Pepcid (Famotidine), Prevacid (Lansoprazole), Prilosec (Omeprazole), Protonix (Pantoprazole), Zantac (Ranitidine), Aciphex (Rabeprazole), Carafate (Sucralfate)

NSAID-Induced Ulcer Prophylaxis

Information
Brand
Generic
Label
http://www.nmihi.com/m/misoprostol.html
Cytotec
Misoprostol
On-Label

Pepcid (Famotidine), Prevacid (Lansoprazole), Prilosec (Omeprazole), Protonix (Pantoprazole), Zantac (Ranitidine), Aciphex (Rabeprazole), Carafate (Sucralfate)

What might complicate it?

Peptic ulcers sometimes produce no symptoms, and as a consequence, may go undetected while they worsen. Left untreated, ulcers continue to corrode the GI lining and may eventually lead to serious complications. Potential complications of peptic ulcers include:

  • Hemorrhage (bleeding). Bleeding ulcers may not produce pain, but may include hematemesis (vomiting blood), melena (black, tarry stool), dizziness and fainting.
  • Penetration. An ulcer cuts through the wall of the stomach or duodenum and continues into a nearby organ (e.g., liver, pancreas).
  • Perforation. An ulcer cuts through the stomach or duodenum wall and creates a direct opening to the abdominal cavity (peritoneum), allowing the contents of the organ to spill out. This invasion of the peritoneum may lead to an infection or inflammation called peritonitis, which can be fatal if left untreated.
  • Obstruction. Swelling or scarring around an ulcer narrows the opening from the stomach to the duodenum, preventing food from properly passing through. Patients often vomit large volumes of food eaten hours before.

Peptic ulcers with complications such as bleeding or perforation may produce other symptoms. Some of these include:

  • Bleeding ulcers may cause hematemesis (vomiting blood), melena (black, tarry stools), dizziness and fainting. When vomiting blood, the blood may be bright red or there may be reddish brown clumps of partially digested blood resembling coffee grounds.
  • An ulcer that penetrates to another organ may cause pain that radiates to other areas and worsens with motion.
  • A perforated ulcer that spills stomach contents into the abdomen can produce radiating pain, difficulty breathing and fever.
  • An ulcer that obstructs the opening to the small intestine may cause vomiting. Patients often vomit large volumes of food eaten hours before. Prolonged obstruction with frequent vomiting may lead to weight loss, dehydration and an imbalance of electrolytes. Obstruction may also result in pain and cramping, feeling unusually full after eating small amounts, bloating, loss of appetite, constipation or diarrhea.

Predicted outcome

In more than two-thirds of the cases, drug therapy effectively promotes healing within six to eight weeks of the start of treatment. In the remaining third, long-term drug therapy is usually required. Surgery may be required if the ulcer fails to respond to drug therapy.

Alternatives

Conditions with similar symptoms include stomach cancer, biliary tract disease, irritable bowel syndrome, hiatal hernia, Zollinger-Ellison syndrome (a pancreatic tumor), pancreatitis, GI vascular insufficiency, and bleeding esophageal varices.

Appropriate specialists

Gastroenterologist and general surgeon.

Seek Medical Attention

  • You or a family member has symptoms of an ulcer.
  • Vomiting begins that is bloody or looks like coffee grounds.
  • Stool is bloody, black or tarry-looking.
  • Diarrhea begins which may be caused by antacids.
  • Pain is severe, despite treatment.
  • You are unusually weak or pale.

Questions for your doctor

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following peptic ulcer-related questions:
  1. Are you certain that I have a peptic ulcer?
  2. What kind of peptic ulcer do I have?
  3. What may have caused my peptic ulcer?
  4. Do I need to change my diet? Should I see a dietician?
  5. I take aspirin on my doctor's advice. What can I do to reduce the risk of ulcers?
  6. Does it seem like I have any complications?
  7. Which medication do you recommend for me?
  8. For how long will I have to take this medication?
  9. How many times a day will I have to take this medication?
  10. How can I prevent peptic ulcers?

Last updated 23 June 2015