Diseases

The pain of ulcer disease correlates poorly with the presence or severity of active ulceration. Some individuals have persistent pain even after an ulcer is almost completely healed by medication. Others experience no pain at all. Ulcers often come and go spontaneously without the individual ever knowing that they are present unless a serious complication (like bleeding or perforation) occurs.

The diagnosis of an ulcer is made by either a barium upper gastrointestinal X-ray (upper GI series) or an upper gastrointestinal endoscopy (EGD or esophagogastroduodenoscopy). The barium upper gastrointestinal (GI) X-ray is easy to perform and involves no risk (other than exposure to radiation) or discomfort. Barium is a chalky substance that is swallowed. It is visible on X- rays, and allows the outline of the stomach to be seen on X-rays; however, barium X-rays are less accurate and may miss ulcers up to 20% of the time.An upper gastrointestinal endoscopy is more accurate than X-rays, but usually involves sedation of the patient and the insertion of a flexible tube through the mouth to inspect the esophagus, stomach, and duodenum. Upper endoscopy has the added advantage of having the capability of removing small tissue samples (biopsies) to test for H. pylori infection. Biopsies are also examined under a microscope to exclude a cancerous ulcer. While virtually all duodenal ulcers are benign, gastric ulcers can occasionally be cancerous. Therefore, biopsies often are performed on gastric ulcers to exclude cancer.

There is no conclusive evidence that dietary restrictions and bland diets play a role in ulcer healing. No proven relationship exists between peptic ulcer disease and the intake of coffee and alcohol. However, since coffee stimulates gastric acid secretion, and alcohol can cause gastritis, moderation in alcohol and coffee consumption is recommended.

Patients with ulcers generally function quite comfortably. Some ulcers probably heal even without medications (though they probably recur as well). Therefore, the major problems resulting from ulcers are related to ulcer complications. Complications include bleeding, perforation, and obstruction of emptying of the passage of food.Patients with bleeding ulcers may report passage of black tarry stools (melena), weakness, a sense of light-headedness or ay even pass out upon standing (orthostatic hypotension or syncope) and vomiting blood (hematemesis). Initial treatment involves rapid replacement of fluids intravenously. Patients with persistent or severe bleeding may require blood transfusions. An endoscopy is performed to establish the site of bleeding and to stop active ulcer bleeding with the aid of specialized endoscopic instruments.Perforation through the stomach leads to the leakage of stomach contents into the abdominal (peritoneal) cavity, resulting in acute peritonitis (infection of the abdominal cavity). These patients report a sudden onset of extreme abdominal pain, which is worsened by any type of motion. Abdominal muscles become rigid and board-like. Urgent surgery usually is required. A duodenal ulcer that has perforated can burrow into adjacent organs such as the pancreas or behind the abdomen and into the back. An esophageal ulcer that perforates can cause severe inflammation of the tissues that surround it (mediastinitis).If an ulcer occurs in the narrow outlet from the stomach, it can obstruct the flow of stomach contents into the duodenum. Duodenal ulcers sometimes also may obstruct the flow of intestinal contents. Patients with obstruction often report increasing abdominal pain, vomiting of undigested or partially digested food, diminished appetite, and weight loss. The obstruction usually occurs at or near the pylorus of the stomach. Endoscopy is useful in establishing the diagnosis of obstruction from an ulcer and excluding gastric cancer as the cause of the obstruction. In some patients, gastric obstruction can be relieved by suction of the stomach contents with a tube for 72 hours, along with intravenous anti-ulcer medications, such as cimetidine (Tagamet) and ranitidine (Zantac). Patients with persistent obstruction require surgery.

Symptoms of esophageal, duodenal or stomach ulcer disease vary. Many people with ulcers experience minimal indigestion, abdominal discomfort that occurs after meals or no discomfort at all. Commonly people complain of upper abdominal burning or hunger pain one to three hours after meals or in the middle of the night. Food or antacids that neutralize stomach acid often promptly relieve these symptoms.

For many years, excess acid was believed to be the major cause of ulcer disease. Accordingly, the emphasis of treatment was on neutralizing and inhibiting the secretion of stomach acid. While acid is still considered necessary for the formation of ulcers and its suppression is still the primary treatment, the two most important initiating causes of ulcers are infection of the stomach by a bacterium named "Helicobacter pylori" (H. pylori) and chronic use of nonsteroidal anti-inflammatory medications or NSAIDs, including aspirin. Cigarette smoking also is an important cause of ulcers as well as failure of ulcer healing.Infection with H. pylori is very common, affecting more than a billion people worldwide. It is estimated that half of the United States population older than age 60 has been infected with H. pylori. Infection usually persists for many years, leading to ulcer disease in 10% to 15% of those infected. In the past, H. pylori was found in more than 80% of patients with gastric and duodenal ulcers. With increasing appreciation, diagnosis and treatment of this infection, the prevalence of infection with H. pylori as well as the proportion of ulcers caused by the bacterium has decreased. It is estimated that currently only 20% of ulcers are associated with the bacterium. While the mechanism by which H. pylori causes ulcers is complex, elimination of the bacterium by antibiotics has clearly been shown to heal ulcers and prevent their recurrence.NSAIDs are medications used for the treatment of arthritis and other painful inflammatory conditions in the body. Aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), and etodolac (Lodine) are a few examples of this class of medications. Prostaglandins are substances produced by the body, which are important in helping the linings of the esophagus, stomach, and duodenum to resist damage by the acidic digestive juices of the stomach. NSAIDs cause ulcers by interfering with the production of prostaglandins in the stomach.Cigarette smoking not only causes ulcers, but it also increases the risk of complications from ulcers such as bleeding, obstruction, and perforation. Cigarette smoking also is a leading cause of failure of treatment for ulcers.Contrary to popular belief, alcohol, coffee, colas, spicy foods, and caffeine have no proven role in ulcer formation. Similarly, there is no conclusive evidence to suggest that life stresses or personality types contribute to ulcer disease.

Peptic Ulcer Illustration - Peptic Ulcer Disease

A peptic ulcer (stomach or duodenal) is a break in the inner lining of the esophagus, stomach, or duodenum. A peptic ulcer of the stomach is called a gastric ulcer; of the duodenum, a duodenal ulcer; and of the esophagus, an esophageal ulcer. Peptic ulcers occur when the lining these organs is eroded by the acidic digestive (peptic) juices that the cells of the lining secrete of the stomach secrete. A peptic ulcer differs from an erosion because it extends deeper into the lining and incites more of an inflammatory reaction from the tissues that are involved, occasionally with scaring. Peptic ulcer also is referred to as peptic ulcer disease.Peptic ulcer disease is common, affecting millions of Americans yearly. Moreover, peptic ulcers are a recurrent problem; even healed ulcers can recur unless treatment is directed at preventing their recurrence. The medical cost of treating peptic ulcer and its complications runs into billions of dollars annually. Recent medical advances have increased our understanding of ulcer formation. Improved and expanded treatment options now are available.

With modern treatment, people with ulcer disease can lead normal lives without lifestyle changes or dietary restrictions. Cigarette smokers have been found to have more complications from ulcers and treatment failure. Eradication of the bacteria H. pylori not only heals ulcers but also prevents the recurrence of ulcer disease.

The goal of ulcer treatment is to relieve pain, heal the ulcer, and prevent complications. The first step in treatment involves the reduction of risk factors (NSAIDs and cigarettes). The next step is medications.H. pylori treatmentMany people harbor H. pylori in their stomachs without ever having pain or ulcers. It is not completely clear whether these patients should be treated with antibiotics. More studies are needed to answer this question.Patients with documented ulcer disease and H. pylori infection should be treated for both the ulcer and the H. pylori. H. pylori can be very difficult to completely eradicate. Treatment requires a combination of several antibiotics, sometimes in combination with a proton-pump inhibitor, H2 blockers, or Pepto-Bismol. Commonly used antibiotics are tetracycline, amoxicillin, metronidazole (Flagyl), clarithromycin (Biaxin), and levofloxacin (Levaquin). Eradication of H. pylori prevents the return of ulcers (a major problem with all other ulcer treatment options). Elimination of this bacteria also may decrease the risk of developing gastric cancer in the future.Treatment with antibiotics carries the risk of allergic reactions, diarrhea, and sometimes severe antibiotic-induced colitis (inflammation of the colon).

Doctors who commonly treat peptic ulcer disease include primary care providers, such as general medicine physicians, family medicine doctors, and internists. Specialists in the diagnosis and treatment of peptic ulcer disease are gastroenterologists.