Gastric (Peptic) Ulcer

What is a Gastric (Peptic) Ulcer?

Peptic ulcers are open sores that develop as a result of the caustic effects of acid and pepsin on the inside lining of the esophagus (the hollow tube that carries food from the throat to the stomach), the stomach, or the duodenum (the upper portion of the small intestine).

The most common symptom of a peptic ulcer is abdominal pain. Peptic ulcers that occur in the stomach are named gastric ulcers, whereas ulcers found in the duodenum are referred to as duodenal ulcers.

Peptic ulcers can be minor (they only go through the first or the second layers of the stomach), or they can be considered a medical emergency (when they go through every layer of the stomach or duodenum lining, causing major internal bleeding).

Peptic ulcers occur when the lining of the stomach or duodenum is broken down by the digestive acids that help the body digest food. When the lining is broken down, the stomach and duodenum are more susceptible to infection.  The most common cause is an infection with a bacterium called Helicobacter pylori; long-term use of nonsteroidal anti-inflammatory medicines (NSAIDs) is another common cause.

What Causes Gastric Ulcers?

Peptic ulcers occur when acid in the digestive tract eats away at the inner surface of the esophagus, stomach, or small intestine. The acid can create a painful open sore that may bleed. The digestive tract is coated with a mucous layer that normally protects against acid. But if the amount of acid is increased or the amount of mucus is decreased, you can develop an ulcer.

Common causes include:

• Helicobacter pylori (H. pylori) bacteria, a type of bacteria that commonly live in the mucous layer that covers and protects tissues that line the stomach and small intestine,  is the major cause (60% of gastric and up to 90% of duodenal ulcers) of peptic ulcers. H. pylori typically causes no problems, but when the body is unable to clear the bacteria, it can cause inflammation of the stomach's inner layer, producing an ulcer. It's not clear how H. pylori spreads but it may be transmitted from person to person by close contact, such as kissing. People may also contract H. pylori through food and water.

NSAIDs Over-the counter and prescription pain relievers called NSAIDs can cause inflammation and damage to the lining of the stomach and small intestines. The lining of the stomach protects itself from gastric acid with a layer of mucus, the production  of which is stimulated by certain prostaglandins. NSAIDs block the production of these prostaglandins.  These pain relievers include aspirin, naproxen (Aleve, Anaprox, Naprosyn, and others), ibuprofen (Motrin, Advil, Midol, and others)

• Other medications. Medications used to treat osteoporosis called bisphosphonates (Actonel, Fosamax, others) can also lead to ulcers, as can potassium supplements.

Other risk factors include:

• Smoking may increase the risk of peptic ulcers in people who are infected with H. pylori.  Although some studies have found correlations between smoking and ulcer formation, others have been more specific in exploring the risks involved and have found that smoking by itself may not be much of a risk factor unless associated with H. pylori infection.
• Alcohol can irritate and erode the mucous lining of the stomach, and it increases the amount of stomach acid that's produced. While studies have found that alcohol consumption increases risk when associated with H. pylori infection, it does not seem to independently increase risk, and even when coupled with H. pylori infection, the increase is modest in comparison to the primary risk factor.
• Gastrinomas (Zollinger  Ellison syndrome) (rare gastrin-secreting tumors) can cause multiple and difficult-to-heal ulcers.

Caffeine and coffee, commonly thought to cause or exacerbate ulcers, have not been found to affect ulcers to any significant extent. And, it's a myth that spicy foods or stress can cause peptic ulcers.

What are the Symptoms of Gastric Ulcers?

Burning pain is the most common peptic ulcer symptom. The pain is caused by the ulcer and is aggravated by stomach acid coming in contact with the ulcerated area. The pain typically may:

• Be felt anywhere from the navel up to the breastbone
• Be worse when the stomach is empty
• Get worse or “flare” at night
• May be temporarily relieved by eating certain foods.
• May be temporarily relieved by antacids
• Be intermittent; disappear and then return for a few days or weeks

A doctor should be consulted if signs and symptoms persist. Over-the-counter antacids and acid blockers often temporarily relieve the gnawing pain, but the relief is short-lived. If pain persists, a doctor should be consulted.

Other less common signs and symptoms of Gastric Ulcers may include:

• Bloating and abdominal fullness
• Waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus - although this is more associated with gastroesophageal reflux disease)
• Nausea and vomiting
• Loss of appetite and weight loss
• Vomiting of blood (hematemesis,) which can occur due to bleeding directly from a gastric ulcer
• Dark, tarry, foul-smelling stool due to presence of oxidized iron from hemoglobin
• A history of heartburn, gastroesophageal reflux disease (GERD), and use of certain forms of medication can raise the suspicion for peptic ulcer. Medicines associated with peptic ulcer include NSAIDs (non-steroid anti-inflammatory drugs) that inhibit cyclooxygenase, and most glucocorticoids (e.g. dexamethasone and prednisolone).

How are Gastric Ulcers Diagnosed?

Although symptoms can suggest the presence of an ulcer, certain tests can be used to detect and confirm the diagnosis.

The most definitive test is direct examination of the upper digestive system by endoscopy. During endoscopy, a doctor passes a hollow tube equipped with a lens down the throat and into the esophagus, stomach, and small intestine to look for the presence of ulcers.

If an ulcer is detected, small tissue samples (biopsy) may be removed for examination in a lab. A biopsy can also identify the presence of H. pylori in the stomach lining.  A series of X-rays of the upper digestive system, sometimes called a barium swallow or upper gastrointestinal series, creates images of the esophagus, stomach, and small intestine. During the X-ray, the patient swallows a white liquid (containing barium) that coats the digestive tract and makes an ulcer more visible.

Tests for H. Pylori

A doctor may recommend tests to determine whether the H pylori bacterium is present in the body.  The type of testing recommended depends on each patient’s unique situation, but may include:

• Urea breath test (noninvasive and does not require EGD).  The breath test uses radioactive carbon atom to detect H. pylori. To perform this exam the patient will be asked to drink a tasteless liquid which contains the carbon as part of the substance that the bacteria breaks down. After an hour, the patient will be asked to blow into a bag that is sealed. If the patient is infected with H. pylori, the breath sample will contain radioactive carbon dioxide. This test provides the advantage of being able to monitor the response to treatment used to kill the bacteria.
• Blood Test:  Measurement of antibody levels in blood (does not require EGD). It is still somewhat controversial whether a positive antibody without EGD is enough to warrant eradication therapy.  One of the reasons that blood tests are not reliable for accurate peptic ulcer diagnosis on their own is their inability to differentiate between past exposure to the bacteria and current infection. Additionally, a false negative result is possible with a blood test if the patient has recently been taking certain drugs such as antibiotics or proton pump inhibitors.

What are the Complications of Gastric Ulcers?

Left untreated, peptic ulcers can result in severe complications.  Gastrointestinal bleeding is the most common complication and occurs when the ulcer erodes one of the blood vessels in the stomach Bleeding can occur as slow blood loss that leads to anemia or as severe blood loss that may require immediate intervention. Severe blood loss may cause black or bloody vomit or black or bloody stools. Other complications include:

• Perforation (a hole in the wall of the gastrointestinal tract) and penetration occur when the ulcer continues into adjacent organs such as the liver and pancreas. Perforation often leads to catastrophic consequences if left untreated. Erosion of the gastro-intestinal wall by the ulcer leads to spillage of stomach or intestinal content into the abdominal cavity. Perforation at the anterior surface of the stomach leads to acute peritonitis, initially chemical and later bacterial peritonitis. The first sign is often sudden intense abdominal pain; an example is Valentino's syndrome, named after the silent-film actor who experienced this pain before his death. Posterior wall perforation leads to bleeding due to involvement of gastroduodenal artery that lies posterior to the 1st part of duodenum.
• Gastric outlet obstruction is the narrowing of pyloric canal by scarring and swelling of gastric antrum and duodenum due to peptic ulcers. Patients experiencing gastric outlet obstruction often present with severe vomiting without bile.
• Infection occurs when a peptic ulcer eats a hole through the wall of the stomach or small intestine, increasing risk of serious infection of the abdominal cavity (peritonitis).

How are Gastric Ulcers Treated?

Treatment for peptic ulcers depends on the cause. Younger patients with ulcer-like symptoms are often treated with antacids or H2 antagonists before EGD is undertaken. Treatments can include:

Antibiotics to kill Heliobacter Pylori:  Doctors typically recommend antibiotics for two weeks, as well as additional medications to reduce stomach acid.  When H. pylori infection is present, the most effective treatments are combinations of two antibiotics (e.g. Clarithromycin, Amoxicillin, Tetracycline, Metronidazole) and one proton pump inhibitor (PPI).

Medications that block acid production and promote healing:  Proton pump inhibitors reduce stomach acid by blocking the action of the parts of cells that produce acid. These drugs include the prescription and over-the-counter medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium), and pantoprazole (Protonix).

Medications to reduce acid production: Acid blockers—also called histamine (H-2) blockers—reduce  the amount of stomach acid released into the digestive tract, which relieves ulcer pain and encourages healing. Available by prescription or over-the-counter, acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet), and nizatidine (Axid).

Antacids that neutralize stomach acid.  Antacids neutralize existing stomach acid and can provide rapid pain relief. Side effects can include constipation or diarrhea, depending on the main ingredients.  Antacids can provide symptom relief, but generally aren't used to heal an ulcer.

Medications that protect the lining of the stomach and small intestine: In some cases, a doctor may prescribe medications called cytoprotective agents that help protect the tissues that line the stomach and small intestine.  Options include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec). Another nonprescription cytoprotective agent is bismuth subsalicylate (Pepto-Bismol).

Treatment of Gastric Ulcers that fail to heal

Peptic ulcers that don't heal with treatment are called refractory ulcers. The main reasons why an ulcer fails to heal are:

• Individuals fail to take their prescribed medications according to directions.
• Some types of H. pylori are resistant to antibiotics.
• Continued use of tobacco or pain relievers that increase the risk of ulcers.
• Extreme overproduction of stomach acid as occurs in Zollinger-Ellison syndrome
• Cancer of the Stomach
• Infections other than H. pylori
• Presence of other diseases that may cause ulcer-like sores in the stomach and small intestine, such as Crohn's disease

Treatment for refractory ulcers generally involves eliminating factors that may interfere with healing, along with using different antibiotics.

Can Gastric Ulcers be Prevented?

The risk of peptic ulcer may be reduced by:

• Avoiding infections. It's not clear just how H. pylori spreads, but there's some evidence that it could be transmitted from person to person or through food and water. Taking steps to avoid infections, such as H. pylori, by frequent hand washing with soap and water and by eating foods that have been cooked completely, may help reduce risk.
• Using caution with pain relievers. For those who regularly use pain relievers that increase the risk of peptic ulcer can take steps to reduce the risk of stomach problems. For instance, medication can be taken with meals.