Ulcer disease

What is an ulcer?

Ulcers are sores that are slow to heal or keep returning. They can take many forms and can appear both on the inside and the outside of your body. They can be found on places of your body you can see, such as a leg ulcer found on the skin, or in places you can’t see, such as a peptic ulcer in the lining of your stomach or upper intestine. From your eye to your foot, you can get them just about anywhere on your body.

What is peptic ulcer disease?

Peptic ulcer disease refers to painful sores or ulcers in the lining of the stomach or first part of the small intestine, called the duodenum.

What causes ulcers?

No single cause has been found for ulcers. However, it is now clear that an ulcer is the end result of an imbalance between digestive fluids in the stomach and duodenum. Most ulcers are caused by an infection with a type of bacteria called Helicobacter pylori (H. pylori).

Factors that can increase your risk for ulcers include:

• Use of painkillers called nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, naproxen, ibuprofen, and many others available by prescription; even safety-coated aspirin and aspirin in powered form can frequently cause ulcers.
• Excess acid production from gastrinomas, tumors of the acid producing cells of the stomach that increases acid output (seen in Zollinger-Ellison syndrome)
• Excessive drinking of alcohol
• Smoking or chewing tobacco
• Serious illness
• Radiation treatment to the area

What are the symptoms of an ulcer?

An ulcer may or may not have symptoms. When symptoms occur, they may include:

• A gnawing or burning pain in the middle or upper stomach between meals or at night
• Bloating
• Heartburn
• Nausea or vomiting

In severe cases, symptoms can include:

• Dark or black stool (due to bleeding)
• Vomiting blood (that can look like "coffee-grounds")
• Weight loss
• Severe pain in the mid to upper abdomen

How serious is an ulcer?

Though ulcers often heal on their own, you shouldn't ignore their warning signs. If not properly treated, ulcers can lead to serious health problems, including:

• Bleeding
• Perforation (a hole through the wall of the stomach)
• Gastric outlet obstruction from swelling or scarring that blocks the passageway leading from the stomach to the small intestine

When does ulcer disease require immediate attention?

Call your doctor about an ulcer if:

• You've been diagnosed with an ulcer and begin having symptoms of anemia, such as dizziness, weakness, fatigue, and a pale complexion; your ulcer may be bleeding.
• You have symptoms of an ulcer and develop severe back pain; your ulcer may be perforating the stomach wall.
• You have symptoms of an ulcer and vomit blood or material that looks like coffee grounds, or you pass dark red, bloody, or black stools, or stools that resemble currant jelly; you may be bleeding internally.
• You have an ulcer and become cold and clammy, and feel faint or actually do faint; you could be in shock from massive blood loss.

Who Is More Likely to Get Ulcers?

You may be more likely to develop ulcers if you:

• Are infected with the H. pylori bacterium
• Take NSAIDs such as aspirin, ibuprofen, or naproxen
• Have a family history of ulcers
• Have another illness such as liver, kidney, or lung disease
• Drink alcohol regularly
• Are age 50 or older

How Are Ulcers Diagnosed?

Your doctor may suspect you have an ulcer just by talking with you about your symptoms. Describing your symptoms may lead your doctor to suspect that you have a peptic ulcer, but it will not likely help determine the type, because the symptoms of stomach and duodenal ulcers are so similar. To make a specific diagnosis, your doctor may conduct several tests.

First, your doctor may ask you to take an acid-blocking medication, such as those used to treat heartburn, for a short period of time to see if symptoms improve.

If needed, your doctor may recommend a procedure called an upper endoscopy. It involves inserting a small, lighted tube (endoscope) through the throat and into the stomach to look for abnormalities. This procedure is usually given if you are having severe or recurring symptoms of ulcers.

• Endoscopy, in which a flexible fiber-optic tube is inserted down the throat to give the doctor a direct view of the inside of your esophagus, stomach, and duodenum, is the most accurate diagnostic test to diagnose a peptic ulcer. This allows the doctor to determine the presence and cause of bleeding and test for any bacterial infection. During this exam, your doctor may also conduct a biopsy to check for cancer.
• For people who can't have an endoscopy, a barium swallow (or upper GI series of X-rays) can also allow your doctor to identify and locate the ulcer and determine its type and severity. The test requires you to drink a "barium milkshake," which has a liquid that will show up on an X-ray. You may be asked to eat only bland, easily digestible foods for two or three days before the test. After drinking the chalky liquid, you lie down on a tilting examining table, which evenly distributes the barium around your upper digestive tract and allows the X-ray to capture images at different angles.

How Are Ulcers Treated?

If not properly treated, ulcers can lead to serious health problems. There are several ways in which ulcers can be treated, including making lifestyle changes, taking medication, and/or undergoing surgery.

Lifestyle Changes to Treat an Ulcer

To treat an ulcer, first eliminate substances that can be causing the ulcers. If you smoke or drink alcohol, stop. If the ulcer is believed to be caused by the use of NSAIDs, they need to be stopped.

Ulcer Medications

Ulcer medications can include:Proton pump inhibitors (PPI). Proton pump medications reduce acid levels and allow the ulcer to heal. They include dexlansoprazole, esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole.

Antibiotics

If you have H. pylori infection, then antibiotics are also used. There are multiple combinations of antibiotics that are taken for one to two weeks along with a PPI. Bismuth is also part of some treatment regimens.

Upper endoscopy

Some bleeding ulcers can be treated through an endoscope.

Surgery

Sometimes an operation is needed if the ulcer has created a hole in the wall of the stomach, or if there is serious bleeding that can't be controlled with an endoscope.

How can I prevent ulcers?

To reduce the risk of developing ulcers:

• Don't smoke.
• Avoid alcohol.
• Don't overuse aspirin and/or NSAIDs.
• If you have symptoms of an ulcer, contact your health care provider.

What are the treatments for an ulcer?

Medications are usually used to treat mild-to-moderate ulcers. If the cause is bacterial, antibiotics can help cure the ulcer. For recurrent, severe cases that do not respond to medication, surgery may be necessary.

Although alternative therapies have been shown to aid in the relief of symptoms, they should be used only as supplements to conventional treatment.

You should not treat an ulcer on your own without first seeing your doctor. Over-the-counter antacids and acid blockers may relieve some or all of the pain, but the relief is always short-lived. With a doctor's help, you can find relief from the ulcer pain, as well as a lifelong cure from the disease.

The chief goals of treatment are reducing the amount of acid in the stomach, strengthening the protective linings that come in direct contact with gastric acids, and, if your ulcer is caused by bacterial infection, treating the H. pylori infection with medication. Your doctor will likely prescribe triple therapy, which is a combination of antibiotics, such as amoxicillin and clarithromycin, along with a proton pump inhibitor, such as omeprazole or esomeprazole. Metronidazole can be substituted for amoxicillin in patients who are allergic to penicillin. In patients who have been repeatedly exposed to these antibiotics, or in areas where there is resistance to clarithromycin or metronidazole, quadruple therapy with bismuth, a proton-pump inhibitor, and 2 antibiotics (like metronidazole and tetracycline) is more effective. Regardless of the regimen, all medications should be taken for 10-14 days.

Surgical treatment of peptic ulcers is reserved for ulcer disease unresponsive to medical management or emergency treatment of complications, such as bleeding. If your ulcer is hemorrhaging, the surgeon will identify the source of the bleeding (usually a small artery at the base of the ulcer) and repair it. Perforated ulcers, holes in the entire stomach or duodenal wall, must be surgically closed. This is an emergent procedure.

In some cases, an elective surgery to decrease stomach acid secretion may be necessary. However, you should have an in-depth discussion with your doctor as there are many potential complications associated with the procedures, including ulcer recurrence, liver complications, and ''dumping syndrome,'' which causes chronic abdominal pain, diarrhea, vomiting, and/or sweating after eating.

If you have had ulcers, what precautions should you take?

• If you have an ulcer, be cautious when choosing over-the-counter pain relievers. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen may not only irritate the ulcer but also prevent a bleeding ulcer from healing. Your best choice may be paracetamol (Crocin), which does not cause or promote stomach ulcers.
• Don't overdose on iron supplements. Although people with bleeding ulcers can develop anemia and may need to take iron as a treatment, taking too much can irritate the stomach lining and the ulcer. Ask your doctor how much iron you need.
• Learn how to deal with stress. Practicing relaxation techniques, including deep breathing, guided imagery, and moderate exercise, can help alleviate stress and promote healing.