What is Peptic Ulcer Disease?
Peptic ulcer disease (PUD) is a condition where the inner lining of your digestive system gets disrupted due to stomach acid or an enzyme called pepsin. It mainly affects the stomach and the beginning part of the small intestine, called the duodenum. It could also impact the lower part of the esophagus, the ending part of the duodenum, or a section of the small intestine known as the jejunum.
Patients with a stomach ulcer typically experience upper stomach pain about 15 to 30 minutes after eating. However, those with a duodenal ulcer may feel this pain around 2 to 3 hours after a meal. It’s recommended that everyone diagnosed with peptic ulcer disease be tested for a bacteria known as Helicobacter pylori. In certain cases, to confirm the diagnosis, especially with more severe symptoms, a camera-assisted examination of the digestive tract called endoscopy might be necessary.
These days, most patients are treated with a combination of three drugs, including one that reduces stomach acid production, called a proton pump inhibitor (PPI).
What Causes Peptic Ulcer Disease?
Peptic ulcer disease, or PUD, can be caused by a number of things. The most common causes are an infection from a bacterium called Helicobacter pylori, or from nonsteroidal anti-inflammatory drugs also known as NSAIDs.
There are also other less common causes such as Zollinger-Ellison syndrome, various cancers, stress from serious illnesses, burns or head injuries, viral infections, inadequate blood supply, radiation therapy, Crohn’s disease and chemotherapy.
The bacterium H. pylori, which is found inside the lining of the stomach, is responsible for 90% of duodenal ulcers and 70-90% of gastric ulcers. Common in those with lower economic status, this bacterium is often picked up during childhood. It has a range of factors that let it stick to and inflame the stomach lining, resulting in a decrease or total loss of stomach acid, leading to ulcers.
The H. pylori bacterium has three main ways to harm the stomach lining:
1. It produces urease, an enzyme that breaks down urea into ammonia, which neutralizes the acidic stomach environment and protects the bacterium.
2. It releases toxins that cause inflammation and damage to the stomach lining.
3. It has flagella, whip-like appendages that allow it to move towards the stomach lining.
Use of NSAIDs is the second most common cause of PUD after H. pylori infection. NSAIDs normally block the creation of prostaglandin, a compound that protects the stomach lining. When this happens, there is less mucus and bicarbonate produced and less blood flow to the stomach lining.
Other medications like corticosteroids, bisphosphonates, potassium chloride, and fluorouracil can also contribute to PUD. In addition, smoking is linked to the formation of duodenal ulcers, though the correlation is not direct. Alcohol can also irritate the stomach lining and increase acidity.
Conditions that create a hypersecretory environment, meaning they cause an overproduction of stomach acid, can also lead to PUD. This includes Zollinger Ellison syndrome, systemic mastocytosis, cystic fibrosis, hyperparathyroidism, and antral G cell hyperplasia.
Risk Factors and Frequency for Peptic Ulcer Disease
Peptic ulcer disease, or PUD, is a worldwide issue that 5-10% of people face in their lifetime. While we’ve seen a decrease in cases because of better hygiene, sanitation and effective treatments, it is still common. Duodenal ulcers, a type of PUD, are four times more common than gastric ulcers. They are also seen more frequently in men than women.
- PUD is a global issue affecting 5% to 10% of people in their lifetime.
- Improved hygiene, sanitation, and effective treatments have contributed to a decrease in PUD worldwide.
- Duodenal ulcers, a type of PUD, are four times more prevalent than gastric ulcers.
- Duodenal ulcers are more commonly found in men than in women.
Signs and Symptoms of Peptic Ulcer Disease
Peptic ulcer disease can present differently based on where the ulcer is located and the age of the patient. Generally, stomach and duodenal ulcers can be told apart by when the symptoms occur in relation to meals. People with duodenal ulcers often report pain at night, while those with obstructions at the exit of the stomach frequently experience feelings of bloating or fullness.
The typical signs and symptoms can be summarized as:
- Upper abdomen (epigastric) pain
- Bloating
- Abdominal fullness
- Nausea and vomiting
- Changes in weight (loss or gain)
- Vomiting blood (hematemesis)
- Black, tar-like stools (melena)
There are also some warning signs that indicate the need for urgent medical attention:
- Unintended weight loss
- Increasing difficulty swallowing (progressive dysphagia)
- Visible bleeding in the digestive tract
- Anemia due to iron deficiency
- Frequent vomiting
- A family history of cancer in the upper digestive tract
Testing for Peptic Ulcer Disease
If you’re suspected to have peptic ulcer disease (PUD), which is a sore in the lining of your stomach or upper part of your small intestine, your doctor will take your medical history, perform a physical examination, and carry out certain medical tests. The doctor might be looking for signs such as abdominal pain, not feeling hungry, and feeling full quickly after eating. These symptoms can raise suspicion of a stomach or duodenal ulcer.
Stomach ulcers can typically cause pain a few hours after eating and might cause you to lose weight. On the other hand, duodenal ulcers, located in the upper part of your small intestine, often cause pain that reduces after eating, which can lead to weight gain. Other symptoms that need immediate attention include anemia (low count of healthy red blood cells), melena (black, tarry stool), hematemesis (vomiting blood), or sudden weight loss. These could be indicative of serious complications of PUD, such as bleeding, perforation (hole in the stomach or intestinal wall), or even cancer.
The doctor may detect tenderness when pressing your abdomen and signs of anemia during the physical examination. If suspicion of PUD is present, the doctor might suggest further testing.
Investigations that might be needed include:
- Esophagogastroduodenoscopy (EGD): This is a procedure that uses a tiny camera on a long, flexible tube to examine your stomach and small intestine. It is one of the most accurate tests for diagnosing ulcers.
- Barium swallow: This is a special type of X-ray involving swallowing a white, chalky liquid that coats the digestive tract and helps enhance the X-ray images. This test is considered if an EGD is not suitable for some reason.
- Blood tests: These tests might be done to check liver function and the levels of certain proteins called enzymes.
- Helicobacter pylori tests: H.pylori is a bacterium that can cause ulcers. Your doctor may order a breath test or a stool test for this bacterium.
- CT scan: While a CT scan may not directly diagnose PUD, it can help detect complications like holes or blockages in the digestive tract.
These investigations provide the necessary details for your doctor to make an accurate diagnosis and decide the best form of treatment.
Treatment Options for Peptic Ulcer Disease
For the treatment of peptic ulcer disease (PUD), which is a sore that forms on the lining of the stomach, doctors often prescribe medicines that reduce the production of acid in the stomach. These medicines include H2-receptor antagonists and proton pump inhibitors (PPIs). PPIs are more popular and effective compared to H2 receptor blockers as they provide relief from symptoms and help the ulcers to heal. But, long-term use of PPIs can increase the chance of bone fractures, so treatment may include calcium supplements to lower this risk.
Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause PUD. In such cases, doctors might recommend stopping the use of NSAIDs or using them in lower doses. Doctors may also advise discontinuation of certain other medicines like steroids, bisphosphonates, and blood thinners if possible. Sometimes, prostaglandin analogs (a type of medicine that can reduce stomach acid and protect the stomach lining) might be used to prevent NSAID-induced peptic ulcers.
If the cause of PUD is an infection with a bacteria known as H. pylori, which is common, the first line of treatment usually involves two antibiotics and a PPI. The choice of antibiotic should consider the fact that some bacteria may be resistant to certain antibiotics in certain areas.
If the ulcer does not heal with the first treatment, an alternative treatment involving bismuth (a type of antacid) and different antibiotics may be used. This is referred to as quadruple therapy.
For individuals with a refractory peptic ulcer, which is an ulcer that does not heal despite 8-12 weeks of treatment with PPI, surgery may be needed. This kind of ulcer can be caused by persistent H.pylori infection, continued use of NSAIDs, or other health conditions that affect the healing of the ulcer, like gastrinoma (a rare tumor) or gastric cancer. In such cases, if the person has tried managing the risky factors but the ulcer still persists, surgical options such as vagotomy (cutting of parts of the vagus nerve to reduce acid secretion) or partial gastrectomy (removal of part of the stomach) might be considered.
What else can Peptic Ulcer Disease be?
When diagnosing peptic ulcer disease, doctors need to take into account other conditions that can cause similar symptoms. Some of these conditions include:
- Gastritis – inflammation of the stomach lining, often due to an infection or immune response. This can cause symptoms like abdominal pain and nausea that are similar to peptic ulcer disease.
- Gastroesophageal reflux disease (GERD) – people with GERD often describe a burning feeling in their abdomen and chest area, excessive salivation, or the feeling of food coming back up their throat.
- Gastric cancer – can also cause abdominal pain, but might be accompanied by more alarming symptoms like unexplained weight loss, dark stool, recurrent vomiting, or signs of disease in other areas of the body due to metastasis (spread of cancer).
- Pancreatitis – chronic pain in the upper abdomen or right side of the rib cage. It tends to get worse when you’re lying on your back. It’s usually seen in patients with a history of alcohol abuse or gallstones. Doctors often use blood tests for the enzymes amylase and lipase to diagnose this condition.
- Biliary colic and cholecystitis – these are conditions related to gallstones. They cause intermittent, severe stomach pain, especially after fatty meals. In the case of cholecystitis, the pain can last for hours and may be associated with nausea and vomiting, fever, a fast heartbeat and a positive Murphy’s sign, which is a specific physical exam finding. Blood tests may show signs of inflammation and abnormal liver function.
In addition, there are a few serious, potentially life-threatening conditions that can mimic symptoms of peptic ulcer disease:
- Myocardial infarction (heart attack) – Particularly with certain types of heart attacks, patients may present with upper abdominal pain, nausea and vomiting. Other symptoms like feeling light headed, shortness of breath, and abnormal vital signs should alert the health care professional to consider this diagnosis.
- Mesenteric ischemia and vasculitis – These are disorders related to blood flow and inflammation in the digestive tract. Acute mesenteric ischemia usually presents with sudden, severe abdominal pain. The chronic form can cause ongoing stomach pain after eating. In older patients, or those with risk factors for heart disease or weight loss, this diagnosis may need to be considered. Mesenteric vasculitis may cause unexplained abdominal symptoms and possibly lower gastrointestinal bleeding. This should be considered particularly in patients who have other signs of systemic vasculitis.
What to expect with Peptic Ulcer Disease
The outlook for peptic ulcer disease (PUD), which is a condition marked by painful sores in your stomach lining, is generally very good once the root cause is effectively treated. However, you can help prevent the ulcer from coming back by practicing good hygiene, and avoiding alcohol, tobacco, and non-steroidal anti-inflammatory drugs (NSAIDs), like ibuprofen. Still, it’s worth noting that recurrence is fairly common, with a majority of cases seeing the return of the ulcer at some point.
It’s also important to be aware that using NSAIDs can lead to a complication known as gastric perforation, essentially a hole in the stomach, at a rate of 0.3% per patient each year. Despite these risks, the good news is that mortality rates associated with peptic ulcer disease have significantly decreased compared to the past.
Possible Complications When Diagnosed with Peptic Ulcer Disease
If you don’t diagnose and treat peptic ulcer disease (PUD) quickly, it can result in significant health issues. Here is a list of possible complications from PUD:
- Bleeding in the upper section of your digestive tract
- A blockage at the point where your stomach meets your small intestine
- Formation of a hole in your stomach
- The ulcer breaking through the stomach
- Increased risk of stomach cancer
Preventing Peptic Ulcer Disease
Patients experiencing peptic ulcers (sores in the lining of the stomach, upper small intestine or esophagus) should be informed about certain substances that could make their condition worse. These include nonsteroidal anti-inflammatory drugs (NSAIDs — non-prescription medicine often used to reduce fever and relieve mild to moderate pain from conditions), aspirin, alcohol, tobacco, and caffeine. If it’s necessary to take NSAIDs for other health conditions, patients should only use the minimum amount required, and may also need additional treatment to help protect their stomachs.
Being overweight is closely linked with peptic ulcer disease, so patients should be encouraged to lose weight. In some cases, learning how to reduce stress can also be beneficial in managing peptic ulcers.
