Peptic Ulcer

Peptic ulcer disease (PUD) is a common gastrointestinal disorder that affects millions of people worldwide. It occurs when the protective mucus layer of the stomach or duodenum is compromised, allowing the digestive acids to erode the lining and cause ulcers. In this article, we will explore the causes, symptoms, diagnosis, and treatment of peptic ulcers to provide a comprehensive overview of this prevalent gastrointestinal condition.

What is Peptic Ulcer?

A peptic ulcer is an open sore that develops on the inner lining of the stomach (gastric ulcer) or the upper part of the small intestine, known as the duodenum (duodenal ulcer). These ulcers form when the protective mucus layer that shields the stomach and duodenum from digestive acids is weakened or breaks down, allowing the acids to eat away at the underlying tissue. Peptic ulcers can cause significant discomfort and may lead to complications if left untreated, making early diagnosis and appropriate treatment crucial.

The various types of peptic ulcers include:

• Gastric ulcer: Gastric ulcers occur in the stomach lining. Symptoms may include pain that is exacerbated by eating and relieved by antacids. The pain pattern can be less consistent compared to duodenal ulcers.

• Duodenal ulcer: Duodenal ulcers occur in the first part of the small intestine (duodenum). They are often associated with H. pylori infection and can cause pain that is relieved by eating and worsened by hunger.

• Oesophageal ulcer: Oesophageal ulcers, though less common, occur in the lower oesophagus. They are often associated with gastro-esophageal reflux disease (GERD) and can cause symptoms such as heartburn and difficulty swallowing.

Identifying the specific type of peptic ulcer is essential for determining the most effective treatment approach and managing potential complications.

The early signs of peptic ulcer include:

• Dull or burning stomach pain that occurs between meals or at night and lasts from a few minutes to hours

• Feeling full quickly after eating only a small amount of food, indicating the ulcer may be affecting digestion

• Burping and indigestion, especially when accompanied by a gnawing sensation in the stomach

• Nausea and vomiting, which are common early signs if the ulcer is obstructing the digestive tract

• Unintentional weight loss that occurs without trying due to difficulties eating or absorbing nutrients

The symptoms of peptic ulcers can vary among individuals, but they commonly include the following:

• Abdominal pain: Many individuals experience dull or burning pain located between the breastbone and the belly button, which typically occurs between meals or at night.

• Indigestion and heartburn: Patients often suffer from persistent indigestion and heartburn, which may worsen after consuming certain trigger foods.

• Nausea and vomiting: Intermittent nausea and vomiting can occur, but these symptoms may be temporarily relieved by eating or taking antacids.

• Feeling full quickly: Some individuals may notice sensations of feeling full quickly or bloated, particularly if the ulcer affects the duodenum.

• Signs of bleeding: Vomiting blood or passing black, tarry stools are alarming signs that indicate a bleeding ulcer requiring urgent medical care.

• Severe abdominal pain: Sudden and severe abdominal pain may suggest that an ulcer has perforated through the stomach or duodenal wall, signalling a medical emergency.

The stages of peptic ulcers include:

• Acute: Acute peptic ulcers are new and typically have a sudden onset. They are often associated with severe pain and bleeding. Acute ulcers can heal quickly if treated promptly, but they can also lead to complications such as perforation or obstruction if left untreated.

• Chronic: Chronic peptic ulcers are long-standing and may recur over time. They often result from persistent infection with H. pylori or continued use of NSAIDs. Chronic ulcers can lead to scarring and narrowing of the stomach or duodenum, which can cause complications like gastric outlet obstruction.

The most common causes of peptic ulcers include:

• Helicobacter pylori infection: Infection with the bacterium Helicobacter pylori (H. pylori) can damage the protective lining of the stomach and duodenum, leading to ulcer formation.

• Prolonged use of NSAIDs: The extended use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, and naproxen, can reduce the stomach's protective mucus layer, increasing the risk of ulcers.

• Excess stomach acid secretion: This can occur due to gastrinomas, which are tumours that secrete excessive amounts of gastrin, leading to increased acid production.

• Severe physiological stress: High levels of stress, such as from surgery, trauma, or serious illness, can contribute to ulcer formation.

• Smoking: Tobacco use can increase stomach acid production and reduce the effectiveness of the stomach's protective mechanisms, leading to a higher risk of ulcer development.

Several factors can increase the likelihood of developing these ulcers, including:

• Frequent use of NSAIDs, especially at high doses and long durations

• H. pylori infection

• Smoking and alcohol use, which can increase stomach acid production

• Age over 50 years old

• Family history of peptic ulcers

• Serious illness or physical trauma

• Radiation treatment to the abdomen

Who's at Risk?

Certain populations are more at risk for developing peptic ulcers, including:

• People who frequently use NSAIDs for pain relief from conditions like arthritis

• Those living in areas with high rates of H. pylori infection

• Older adults over age 50

• Smokers and heavy alcohol drinkers

• Individuals with a family history of ulcers

• People under extreme physiological stress

• Those undergoing radiation therapy targeting the abdomen

Understanding personal risk helps with the prevention and early detection of peptic ulcers through lifestyle changes and regular check-ups.

Peptic ulcers can lead to several serious complications if not properly managed. Some of the potential complications include:

• Haemorrhage or bleeding: The most common complication occurs when the ulcer erodes into a blood vessel, resulting in bleeding. Symptoms include vomiting blood or coffee-ground material, passing black, tarry stools, and signs of blood loss such as weakness, dizziness, and pale skin.

• Perforation: This serious complication arises when the ulcer creates a hole in the stomach or duodenum wall, allowing bacteria and partially digested food to leak into the abdominal cavity. This can cause peritonitis, a life-threatening infection. Symptoms include sudden, severe abdominal pain and signs of infection, such as fever and abdominal rigidity.

• Penetration: In some cases, the ulcer may penetrate the wall of the stomach or duodenum but remain contained by adhesions or nearby organs. This is known as penetration or confined perforation, with symptoms including intense, persistent pain that may radiate to the back.

• Gastric outlet obstruction: This complication occurs when inflammation or scarring from the ulcer narrows the opening between the stomach and small intestine, preventing food from passing through. Symptoms include repeated vomiting of undigested food, bloating, early satiety, and unintentional weight loss.

Preventing peptic ulcers involves addressing common causes and risk factors. Some of the preventative measures include:

• Avoiding NSAIDs: One key strategy is to limit the long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), as these can damage the stomach lining.

• Eradicating H. pylori: Another important preventive measure is the eradication of Helicobacter pylori (H. pylori) infection, a major cause of peptic ulcers. Treatment typically involves a combination of antibiotics and proton pump inhibitors (PPIs) to eliminate the bacteria and reduce stomach acid production.

• Healthy lifestyle choices: Maintaining a healthy diet and managing stress can be beneficial. Additionally, avoiding smoking and excessive alcohol consumption can help reduce the risk of developing peptic ulcers.

Diagnosing peptic ulcers involves a combination of medical history, physical examination, and diagnostic tests. The most common tests used to diagnose peptic ulcers include:

• Upper gastrointestinal (GI) endoscopy: This procedure involves inserting a flexible tube with a camera (endoscope) down the throat and into the stomach and duodenum. The endoscope allows the doctor to visualise the ulcer and take a biopsy if necessary.

• Barium swallow or upper GI series: In this test, the patient drinks a chalky liquid containing barium, which coats the lining of the digestive tract. X-rays are then taken to visualise the stomach and duodenum, revealing any ulcers or abnormalities.

• Urea breath test or stool antigen test: These tests are used to detect the presence of H. pylori bacteria. The urea breath test involves drinking a solution containing urea labelled with carbon-13, which the bacteria break down, releasing labelled carbon dioxide that can be detected in the breath. The stool antigen test detects H. pylori proteins in a stool sample.

• Blood tests: While blood tests cannot directly diagnose peptic ulcers, they can check for anaemia (a sign of bleeding) and test for H. pylori antibodies, indicating a current or past infection.

The management of peptic ulcer disease involves several treatment options tailored to the specific cause and complications of the ulcer. The treatment options include:

• H. pylori-induced ulcers: The standard first-line treatment for peptic ulcers caused by Helicobacter pylori is a triple regimen consisting of two antibiotics and a proton pump inhibitor (PPI).

• NSAID-induced ulcers: For ulcers induced by nonsteroidal anti-inflammatory drugs (NSAIDs), the primary step is to discontinue the NSAID. If stopping NSAIDs is not possible, treatment with PPIs is recommended.

• Second-line therapies: If first-line therapy fails, second-line options may include sequential therapy, non-bismuth-based quadruple therapy, or bismuth-based quadruple therapy.

• Bleeding ulcers: For bleeding ulcers, endoscopic treatment combined with intravenous PPI therapy is typically recommended to manage the bleeding effectively.

• Perforation or stenosis: In cases of perforation or significant narrowing (stenosis), conservative management or surgical intervention may be necessary to address these complications.

• Maintenance therapy: After initial treatment, maintenance therapy with PPIs or histamine 2-receptor antagonists may be prescribed to prevent ulcer relapse, particularly for patients with a history of ulcers or those who continue NSAID or low-dose aspirin use.

Medication for Peptic Ulcer

The medications used in the treatment of peptic ulcers are designed to reduce gastric acid production, protect the mucosa, and eradicate bacterial infections. Proton pump inhibitors (PPIs) such as pantoprazole, omeprazole, and lansoprazole are the most commonly prescribed medications for peptic ulcers. They work by blocking the enzyme responsible for acid production in the stomach. Histamine 2-receptor antagonists like ranitidine and famotidine are also used to reduce acid production. Antibiotics such as amoxicillin, clarithromycin, and metronidazole are used in combination with PPIs to eradicate H. pylori infections. Prostaglandin analogs like misoprostol may be used to protect the stomach lining and prevent NSAID-induced ulcers.

It is essential to seek medical attention if you experience symptoms of a peptic ulcer, such as persistent stomach pain, nausea, vomiting, or dark stools. If left untreated, peptic ulcers can lead to serious complications like bleeding, perforation, or obstruction. You should also consult a doctor if you have a history of peptic ulcers and are taking NSAIDs or low-dose aspirin, as these medications can increase the risk of ulcer recurrence.

• Peptic ulcers are sores that develop in the lining of the stomach or duodenum, often caused by H. pylori infection or prolonged use of NSAIDs.

• Common symptoms include abdominal pain, nausea, vomiting, and unintentional weight loss.

• Diagnosis involves a combination of tests, such as endoscopy, biopsy, and breath or stool tests for H. pylori.

• Treatment typically involves a combination of antibiotics and acid-reducing medications, such as proton pump inhibitors.

• Lifestyle modifications, including avoiding NSAIDs, quitting smoking, and managing stress, can help prevent peptic ulcers and promote healing.

• Seek medical attention if you experience symptoms suggestive of a peptic ulcer or if your diagnosed ulcer does not improve with treatment.