Acute Peptic Ulcer

Gastric Ulcer, Duodenal Ulcer, Gastroduodenal Ulcer, Stress Ulcer

What is Peptic ulcer?

Peptic ulcer disease is a raw area (erosion) of the lining of the intestinal tract caused by gastric acid and the enzyme pepsin. Glands in the lining of the stomach secrete acid and pepsin to help break down food for digestion. If other cells in the lining did not secrete a protective mucus, the acid and pepsin would quickly eat away the stomach and duodenum (first part of the small intestine). When damaging influences overcome this protective factor in the stomach or duodenal lining, the mucous layer and mucous-secreting cells are eroded and an ulcer forms.

Peptic ulcers are most common in the first part of the duodenum or lower half of the stomach. Ulcers of the lower esophagus occur when there is a reflux of acid from the stomach. Rarely, ulcers may occur in the jejunum (Zollinger-Ellison syndrome) when there is a massive out-pouring of gastric acid, or in the ileum (Meckel's diverticulum) when misplaced gastric lining grows there.

Gastric ulcers develop as a result of an imbalance between irritating factors and the mucosal defense mechanisms. Causes of gastric ulcers include the presence of the Helicobacter pylori organism, NSAIDs (nonsteroidal anti-inflammatory drugs), and cancer (malignancy).

Individuals whose immune system is deficient (immunodeficiency) are at risk of contracting infections which can create ulcers (cytomegalovirus, tuberculosis, syphilis).

Other common causes of peptic ulcer disease include conditions that increase acid secretion, reduce mucus production, or factors that irritate the lining. Alcohol and smoking are common irritating factors. Psychological stress, although not a prime cause of ulcers, may aggravate an existing ulcer.

Peptic ulcers most commonly occur between the ages of 30 and 55. Overall, nine percent of women and twelve percent of all men will acquire this disease sometime in their lives. There are 500,000 new cases with four million recurrences annually.

How is it diagnosed?

Signs and symptoms of Peptic ulcer

  • The most typical symptom is a gnawing, hunger-like pain in the upper middle abdomen that fluctuates in intensity, especially when the stomach is empty. Antacids and eating may relieve the pain or, at times, make it worse.
  • Other symptoms may include heartburn, a sour taste in the mouth, nausea, blood in the stool that makes it a black tarry color (melena), vomiting of blood, weakness, fatigue, belching, bloating, or weight loss.
  • In some cases, no symptoms may be present.

Physical exam of the abdomen may reveal tenderness over the epigastric (stomach) area. Paleness (pallor) occurs in about 25 % of the cases due to anemia caused by chronic blood loss.

Tests: A guaiac test (test done on a stool sample) shows positive when blood is present in the stool. Although an upper gastrointestinal series (x-ray done using barium as the contrast medium) is an effective screening test for detecting a gastric ulcer, an upper endoscopy (small lighted microscope passed down the esophagus) enables the physician to not only view the stomach lining, but also to perform biopsies of any visualized gastric ulcer. Multiple biopsies from the margins of the ulcer are required to rule out cancer (malignancy).

Other tests may include a complete blood count (CBC) to rule out anemia, a fasting serum gastrin and gastric secretory studies to help identify the cause. Underlying organisms, such as H. pylori, must be identified from biopsies of the mucous lining.

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 Rating
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 Amoxicillin/Clavulanate Off-Label

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


Medications to reduce acid production

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

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

What might complicate it?

Complications include chronic blood loss (which can cause iron deficiency anemia) and the possibility of a perforation in the wall of the digestive tract. A perforation would allow blood, partially digested food, and hydrochloric acid into the abdominal cavity. Leaking digestive juices can cause inflammation of the abdominal lining (peritonitis) that produces sudden, severe pain and requires emergency hospital admission.

Chronic ulcers can cause extensive scarring that can result in pyloric stenosis (narrowing of the outlet between the stomach and the duodenum), obstructing the passage of food.

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.

Last updated 23 May 2012


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