Peptic ulcer

  • Definition
    • A peptic ulcer is an open sore or raw area in the lining of the stomach or intestine.

      • A gastric ulcer occurs in the stomach.
      • A duodenal ulcer occurs in the first part of the small intestine.
      Location of peptic ulcers
  • Alternative Names
    • Ulcer - peptic; Ulcer - duodenal; Ulcer - gastric; Duodenal ulcer; Gastric ulcer; Dyspepsia - ulcers; Bleeding ulcer; Gastrointestinal bleeding - peptic ulcer; Gastrointestinal hemorrhage - peptic ulcer; G.I. bleed - peptic ulcer; H. pylori - peptic ulcer; Helicobacter pylori - peptic ulcer

  • Causes
    • Normally, the lining of the stomach and small intestines can protect itself against strong stomach acids. But if the lining breaks down, the result may be:

      • Swollen and inflamed tissue, called (gastritis)
      • An ulcer
      Stomach ulcer

      Most ulcers occur in the first layer of the inner lining. A hole that goes all the way through the stomach or duodenum is called a perforation. A perforation is a medical emergency.

      Ulcer emergencies

      The most common cause of ulcers is infection of the stomach by bacteria called Helicobacter pylori (H pylori). Most people with peptic ulcers have these bacteria living in their digestive tract. Yet, many people who have these bacteria in their stomach do not develop an ulcer.

      The following factors raise your risk for peptic ulcers:

      • Drinking too much alcohol
      • Regular use of aspirin, ibuprofen, naproxen, or other nonsteroidal anti-inflammatory drugs (NSAIDs). Taking aspirin or NSAIDs once in a while is safe for most people.
      • Smoking cigarettes or chewing tobacco
      • Being very ill, such as being on a breathing machine
      • Having radiation treatments

      A rare condition called Zollinger-Ellison syndrome causes stomach and duodenal ulcers.

      Cause of peptic ulcers

      Many people believe that stress causes ulcers. It is not clear if this is true for normal stress.

  • Symptoms
    • Small ulcers may not cause any symptoms. Some ulcers can cause serious bleeding.

      Abdominal pain is a common symptom. The pain can differ from person to person, and some people have no pain.

      Other symptoms include:

      • Feeling of fullness and problems drinking as much fluid as usual
      • Hunger and an empty feeling in the stomach, often 1 to 3 hours after a meal
      • Mild nausea that may go away with vomiting
      • Pain or discomfort in the upper abdomen
      • Pain in the upper abdomen that wakes you up at night

      Other possible symptoms include:

  • Exams and Tests
    • To diagnose an ulcer, you may need a test called an upper endoscopy (EGD).

      • This is a test to examine the lining of the esophagus (the tube that connects your throat to your stomach), stomach, and first part of the small intestine.
      • It is done with a small camera (flexible endoscope) that is inserted down the throat.
      • This test most often requires sedation given through an IV
      Gastroscopy procedure

      Upper endoscopy is done on most people when peptic ulcers are suspected or when you:

      • Have a low blood count (anemia)
      • Have trouble swallowing
      • Are vomiting blood or your stools are blood or dark and tarry looking
      • Have been losing weight without trying
      • Have other findings that raise a concern for cancer in the stomach

      Testing for H. pylori is also needed.

      Other tests you may have include:

      Sometimes, you may need a test called an upper GI series. A series of x-rays are taken after you drink a thick substance called barium. This does not require sedation.

  • Treatment
    • In order for your ulcer to heal and to reduce the chance it will come back, you will be given medicines to:

      • Kill the H pylori bacteria (if present)
      • Reduce acid levels in the stomach

      Take all of your medicines as you have been told. Other changes in your lifestyle can also help.

      If you have a peptic ulcer with an H pylori infection, the standard treatment uses different combinations of the following medicines for 7 to 14 days:

      • Two different antibiotics to kill H pylori
      • Proton pump inhibitors such as omeprazole (Prilosec), lansoprazole (Prevacid), or esomeprazole (Nexium)
      • Bismuth (the main ingredient in Pepto-Bismol) may be added to help kill the bacteria

      If you have an ulcer without an H pylori infection, or one that is caused by taking aspirin or NSAIDs, you will likely need to take a proton pump inhibitor for 8 weeks.

      You may also be prescribed this type of medicine regularly if you must continue taking aspirin or NSAIDs for other health conditions.

      Other medicines used for ulcers are:

      • Misoprostol, a drug that may help prevent ulcers in people who take NSAIDs on a regular basis
      • Medicines that protect the tissue lining (such as sucralfate)

      If a peptic ulcer bleeds a lot, an EGD may be needed to stop the bleeding. Methods used to stop the bleeding include:

      • Injecting medicine in the ulcer
      • Applying metal clips or heat therapy to the ulcer

      Surgery may be needed if:

      • Bleeding cannot be stopped with an EGD
      • The ulcer has caused a tear
  • Outlook (Prognosis)
    • Peptic ulcers tend to come back if untreated. There is a good chance that the H pylori infection will be cured if you take your medicines and follow your health care provider's treatment advice. You will be much less likely to get another ulcer.

  • Possible Complications
    • Complications may include:

      • Severe blood loss
      • Scarring from an ulcer may make it harder for the stomach to empty
      • Perforation or hole of the stomach and intestines
  • When to Contact a Medical Professional
    • Get medical help right away if you:

      • Develop sudden, sharp abdominal pain
      • Have a rigid, hard abdomen that is tender to touch
      • Have symptoms of shock, such as fainting, excessive sweating, or confusion
      • Vomit blood or have blood in your stool (especially if it is maroon or dark, tarry black)

      Call your provider if:

      • You feel dizzy or lightheaded.
      • You have ulcer symptoms.
  • Prevention
    • Avoid aspirin, ibuprofen, naproxen, and other NSAIDs. Try acetaminophen instead. If you must take such medicines, talk to your provider first. Your provider may:

      • Test you for H. pylori before you take these medicines
      • Have you take proton pump inhibitors (PPIs) or an acid blocker
      • Have you take a drug called misoprostol

      The following lifestyle changes may help prevent peptic ulcers:

      • DO NOT smoke or chew tobacco.
      • Limit alcohol to no more than two drinks per day.
  • References
    • Chan FKL, Lau JYW. Peptic ulcer disease. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 53.

      Kuipers EJ, Blaser MJ. Acid peptic disease. In: Goldman L, Schafer AI, eds. Goldman's Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 139.

      Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345-360. PMID: 22310222

      Morgan DR, Crowe SE. Helicobacter pylori infection. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 51.