Family doctor

What is peptic ulcer?

A peptic ulcer is a sore on the lining of the stomach or duodenum. Peptic indicates it is related to digestion. It occurs in tissues which are bathed by secretions containing acid and pepsin.

The stomach is a unique organ which has the ability to hold very concentrated solutions of acid, as well as the protein digestive enzyme pepsin, without damage to itself. This unique ability is due to a highly specialised protective barrier made up of a continuous mucous layer which maintains a near alkaline pH at the cell surface in spite of the concentrated acid in the stomach sac, very tight junctions between the cells, and a very good blood supply.

Peptic ulcers are common, often silent, but may first present with life threatening bleeding.

What causes peptic ulceration?

The main cause of peptic ulceration is bacterial infection. Some ulcers are caused by use of non-steroidal anti-inflammatory agents (NSAIDs). Uncommonly cancerous tumours of the stomach cause ulcers.

There is an old adage "no acid, no ulcer". Peptic ulcers only occur where there is acid, and acid is a necessary accompaniment for ulcer formation.

Peptic ulcers are not caused by spicey foods or by emotional stress.

What is the bacterial infection causing peptic ulcers?

Helicobacter pylori (H.pylori) is the bacterium which causes around 80 percent of stomach ulcers and over 90 percent of duodenal ulcers. It is a common infection, infecting about 20 percent of those under 40 years of age and over 50 percent of those over 60. Most infected people do not develop ulcers and many have no symptoms. Although not firmly proven, it is believed most people are infected through food or water, with the less likely possibility that some may be infected through kissing.

The organism lives exclusively in the mucus of the stomach or in duodenal mucus bathed by stomach acid. Mucus provides an ideal environment for this highly mobile bacterium. It is protected from the high acid of the stomach and mucus is its principal food source providing all the nutrients required for its existence. However, by digesting mucus H.pylori weakens the stomach's protective coating permitting acid damage. At the same time bacteria produce their own gastric mucosal cell toxins. The result of these activities is to allow acid to bath the cells adding to the damage caused by irritants eventually leading to loss of the integrity of surface cells and ulceration.

How do nonsteroidal anti-inflammatories (NSAIDs) cause ulcers?

NSAIDs are inhibitors of prostaglandins, a group of hormone-like substances with many different functions. Prostaglandins are prominent in arthritis causing the painful swelling and limitation of movement. NSAIDs block prostaglandin action relieving joint pain and swelling, painful muscles and general pain, and therefore have wide use and acceptance in the community.

The down side of NSAIDs is they inhibit the prostaglandins that are needed for the maintenance of the mucous protective layer of the stomach and the whole of the hollow gut. NSAIDs weaken the protection of the stomach, permitting damage by the acid/pepsin gastric juice with the development of gastric ulcers.

NSAIDs account for many of the stomach ulcers that are not due to H.pylori infection.

Sometimes NSAIDs may be responsible for a H.pylori duodenum to ulcerate and bleed.

Do stomach ulcers lead to cancer?

Stomach ulcers rarely, if ever, lead to cancer. Cancerous growths of the stomach can appear to be simple ulcers. Biopsies are needed to be sure a gastric ulcer is benign and not malignant.

What symptoms might you expect if you have a peptic ulcer?

Many people have no symptoms or have symptoms irregularly.

Pain is the most common symptom. Usually the pain is described as being:

• dull and gnawing
• present for a period and followed by a pain-free period
• occurs 2 to 3 hours after meals and often wakening the person in the early hours of the morning
• is relieved by food, or antacids

Other symptoms include loss of appetite, loss of weight, bloating feeling, burping, and nausea with or without vomiting. Less commonly there may be vomiting of blood or the passage of tarry black unpleasantly smelling stools.

How is a peptic ulcer diagnosed?

Visualisation of the stomach and duodenum with x-rays after barium ingestion or more preferred by endoscopy. Endoscope is a flexible, lighted tube which allows direct vision of the stomach and duodenum while the patient is under light sedation. Biopsies are taken to confirm the nature of the ulcer and surrounding tissue.

How is H.pylori diagnosed?

H.pylori is diagnosed by tests on blood tests, breath tests, and examination of biopsy tissues taken at endoscopy.

The blood test is either a finger prick or blood taken for other investigations. The blood is tested for antibodies to H.pylori.

The breath test is based on the breakdown of urea by the bacterium to form a specific carbon which is released in breath gas. A drink containing urea is given and a sample of breath obtained. The urea breath test has a high degree of accuracy.

Biopsy tissue can be used in three ways to make and/or confirm the diagnosis. The organism has an enzyme (urease) which breaks down urea to release ammonia. The ammonia gives a colour reaction with a specific dye.

Microscopic examination allows finding and identification of the bacteria.

Culturing the tissue allows growth of the H.pylori from the tissue sample.

What is the treatment of H.pylori infection?

Antibiotics are the core to a treatment programme. A wide variety have been tried, with four being the most commonly used. The common antibiotics are metronidazole, tetracycline, amoxicillin, clarithromycin. Usually these are given in combination.

At the same time as antibiotics is given, the acid production of the stomach is reduced. This can be either using an H2-receptor (cimetidine, ranitidine, famotidine, or nizatidine), or with almost total acid suppression with a proton pump inhibitor (omeprazole, lansoprazole, or pantoprazole).

For the best results two antibiotics are combined with an acid suppressing agent - 'triple therapy'. Because of the powerful combination of drugs, good results are obtained in most patients, but at a high risk of side effects of nausea, vomiting and diarrhoea.

It is usual to asses the effectiveness of treatment by repeating the test which confirmed the original diagnosis.

What is the treatment of NSAID associated ulcers?

The principles are simple - stop the NSAIDs and aid ulcer healing by acid reduction. Stopping the NSAIDs may mean that alternative treatments will be required for management of arthritis or other causes of pain.

Prevention of the undesirable effects of NSAIDs is an option. Two possibilities are available. The first to reduce ulcer risk by giving acid reducing agents with NSAIDs. The second is addition of a prostaglandin (misoprostil) which is protective to the stomach, does not interfere with NSAID action in pain relief, and is still active with the NSAID.

What is the role of lifestyle factors?

Traditional dietary treatment has been a bland often milky diet. This is not necessary and may delay healing. People with an ulcer need a nutritious diet, exercise, and with the only restrictions being alcohol and coffee.

What are the complications of peptic ulcers?

Bleeding and perforation are the two main complications. Obstruction of the stomach outlet is another possibility.

And surgery?

The complications of bleeding, perforation, and obstruction are clear indications for surgery. With modern treatment, a failure of an ulcer to heal is uncommon but when it occurs this can be managed by surgery. The presence of a cancerous ulcer is another indication for surgery.

Conclusion

Most peptic ulcers are readily treatable by a short course of medicinal drugs. The possibility of preventing the establishment of H.pylori by vaccination remains to developed an implemented. The role of NSAIDs in peptic ulceration is clearly defined but is still not widely recognised.