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Peptic ulcer
By Mayo Clinic staffMayo Clinic Health Manager
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Definition
Peptic ulcers are open sores that develop on the inside lining of your stomach, upper small intestine or esophagus. The most common symptom of a peptic ulcer is abdominal pain.
It wasn't too long ago that lifestyle factors, such as a love of spicy foods or a stressful job, were thought to be at the root of most peptic ulcers. Doctors now know that a bacterial infection or some medications — not stress or diet — cause most peptic ulcers.
Peptic ulcers are common, affecting as many as 10 percent of Americans at some point in their lives. The good news is that successful treatment of peptic ulcers is possible.
Symptoms
Burning pain is the most common peptic ulcer symptom. The pain is caused by the ulcer and is aggravated by stomach acid coming in contact with the ulcerated area. The pain typically may:
- Be felt anywhere from your navel up to your breastbone
- Last from a few minutes to several hours
- Be worse when your stomach is empty
- Flare at night
- Often be temporarily relieved by eating certain foods that buffer stomach acid or by taking an acid-reducing medication
- Disappear and then return for a few days or weeks
Less often, ulcers may cause severe signs or symptoms such as:
- The vomiting of blood — which may appear red or black
- Dark blood in stools or stools that are black or tarry
- Nausea or vomiting
- Unexplained weight loss
- Appetite changes
When to see a doctor
An ulcer isn't something that you should treat on your own, without a doctor's help. Over-the-counter antacids and acid blockers may relieve the gnawing pain, but the relief is short-lived. If you have signs or symptoms of an ulcer, see your doctor for treatment.
Causes
Depending on their location, peptic ulcers have different names:
- Gastric ulcer. This is a peptic ulcer that occurs in your stomach.
- Duodenal ulcer. This type of peptic ulcer develops in the first part of the small intestine (duodenum).
- Esophageal ulcer. An esophageal ulcer is usually located in the lower section of your esophagus. It's often associated with chronic gastroesophageal reflux disease (GERD).
The culprit in most cases
Although stress and spicy foods were once thought to be the main causes of peptic ulcers, doctors now know that the cause of most ulcers is the corkscrew-shaped bacterium Helicobacter pylori (H. pylori).
H. pylori lives and multiplies within the mucous layer that covers and protects tissues that line the stomach and small intestine. Often, H. pylori causes no problems. But sometimes it can disrupt the mucous layer and inflame the lining of your stomach or duodenum, producing an ulcer.
H. pylori is a common gastrointestinal infection. In the United States, one in five people younger than 30 and half the people older than 60 are infected. Although it's not clear exactly how H. pylori spreads, it may be transmitted from person to person by close contact, such as kissing. People may also contract H. pylori through food and water.
H. pylori is the most common, but not the only, cause of peptic ulcers. Besides H. pylori, other causes of peptic ulcers, or factors that may aggravate them, include:
- Regular use of pain relievers. Nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate or inflame the lining of your stomach and small intestine. These medications, which are available both by prescription and over-the-counter, include aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve), ketoprofen and others. To help avoid digestive upset, take NSAIDs with meals. If you have been diagnosed with an ulcer, make sure your doctor knows this when prescribing any pain reliever. Other medications that contain NSAIDs are Alka-Seltzer and bismuth subsalicylate (Pepto-Bismol, others). Unfortunately, some people take these medications for symptoms of peptic ulcer, but they can make the condition worse. Other prescription medications that can also lead to ulcers include medications used to treat osteoporosis called bisphosphonates (Actonel, Fosamax and others).
NSAIDs inhibit production of an enzyme (cyclooxygenase) that produces prostaglandins. These hormone-like substances help protect your stomach lining from chemical and physical injury. Without this protection, stomach acid can erode the lining, causing bleeding and ulcers.
- Smoking. Nicotine in tobacco increases the volume and concentration of stomach acid, increasing your risk of an ulcer. Smoking may also slow healing during ulcer treatment.
- Excessive alcohol consumption. Alcohol can irritate and erode the mucous lining of your stomach and increases the amount of stomach acid that's produced. It's uncertain, however, whether this alone can progress into an ulcer or if it just aggravates the symptoms of an existing ulcer.
- Stress. Although stress per se isn't a cause of peptic ulcers, it's a contributing factor. Stress may aggravate symptoms of peptic ulcers and, in some cases, delay healing. You may undergo stress for a number of reasons — an emotionally disturbing circumstance or event, surgery, or a physical trauma, such as a burn or other severe injury.
Complications
Left untreated, peptic ulcers can result in:
- Internal bleeding. Bleeding can occur as slow blood loss that leads to anemia or as severe blood loss that may require hospitalization or a blood transfusion.
- Infection. Peptic ulcers can eat a hole through the wall of your stomach or small intestine, putting you at risk of serious infection of your abdominal cavity (peritonitis).
- Scar tissue. Peptic ulcers can also produce scar tissue that can obstruct passage of food through the digestive tract, causing you to become full easily, to vomit and to lose weight.
Preparing for your appointment
You'll probably first see your family doctor or a general practitioner. However, he or she may then refer you to a gastroenterologist for further diagnosis and treatment.
It's a good idea to be well prepared for your appointment so that you have enough time to cover everything you want to with your doctor. Here's some information to help you get ready for your appointment, and what you can expect from your doctor.
What you can do
- Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet. Certain medications can affect peptic ulcer tests, so your doctor may want you to stop taking them, and he or she may be able to suggest alternatives to these drugs.
- Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment. It's also a good idea to keep written track of your symptoms as well as the food you're eating. People with peptic ulcers often experience more symptoms when their stomachs are empty.
- Write down key personal information, including any major stresses or recent life changes.
- Make a list of all medications, as well as any vitamins or supplements, that you're taking. It's especially important to note any NSAID use and the usual dose that you take.
- Write down questions to ask your doctor.
Preparing a list of questions ahead of time will help you make the most of your limited time with your doctor. List your questions from most important to least important in case time runs out. For peptic ulcers, some basic questions to ask your doctor include:
- What's the most likely cause of my symptoms?
- Are there other possible causes for my symptoms?
- What kinds of tests do I need, and how do I need to prepare for them?
- Is my condition likely temporary or chronic?
- What treatment do you recommend? How quickly will I start to feel better?
- What if my symptoms don't improve?
- What are the alternatives to the primary approach that you're suggesting?
- Are there any dietary restrictions that I need to follow?
- Is there a generic or over-the-counter alternative to the medicine you're prescribing me?
- Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?
- What caused me to develop this ulcer?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to cover. Your doctor may ask:
- When did you first begin experiencing symptoms?
- Have your symptoms been continuous, or intermittent?
- How severe are your symptoms?
- Are your symptoms worse when you're hungry?
- Does anything seem to improve your symptoms?
- What, if anything, appears to worsen your symptoms?
- Do you take pain relievers? If yes, how often?
- Do you feel nauseated or have you been vomiting?
- Have you ever vomited blood or black material?
- Have you noticed blood in your stool or black stools?
- What, if anything, have you been taking to relieve your symptoms?
What you can do in the meantime
While you're waiting to see your doctor, avoiding smoking, alcohol, spicy foods and stress may help lessen your discomfort. If you take NSAIDs for pain relief, try switching to acetaminophen (Tylenol, others). Additionally, for short-term relief, you can also take over-the-counter antacids or acid-blocking medications.
Tests and diagnosis
In order to detect an ulcer, you may have to undergo diagnostic tests, such as:
- Blood test. This test checks for the presence of H. pylori antibodies. A disadvantage of this test is that it sometimes can't differentiate between past exposure and current infection. Additionally, a false-negative is possible if you've recently been taking certain drugs, such as antibiotics or proton pump inhibitors.
-
Breath test. This procedure uses a radioactive carbon atom to detect H. pylori. For the test, you drink a small glass of clear, tasteless liquid. The liquid contains radioactive carbon as part of a substance (urea) that will be broken down by H. pylori. Less than an hour later, you blow into a bag, which is then sealed. If you're infected with H. pylori, your breath sample will contain the radioactive carbon in the form of carbon dioxide.
The advantage of the breath test is that it can monitor the effectiveness of treatment used to eradicate H. pylori, detecting whether the bacteria have been killed or eradicated.
- Stool antigen test. This test checks for H. pylori in stool samples. It's useful both in helping to diagnose H. pylori infection and in monitoring the success of treatment.
- Upper gastrointestinal (upper GI) X-ray. This test outlines your esophagus, stomach and duodenum. During the X-ray, you swallow a white, metallic liquid (containing barium) that coats your digestive tract and makes an ulcer more visible. An upper GI X-ray can detect some ulcers, but not all.
- Endoscopy. This procedure may follow an upper GI X-ray if the X-ray suggests a possible ulcer, or your doctor may perform endoscopy first. In this more sensitive procedure, a long, narrow tube with an attached camera is threaded down your throat and esophagus into your stomach and duodenum. With this instrument, your doctor can view your upper digestive tract and identify an ulcer. Your doctor will perform this test if you have other signs or symptoms, such as difficulty swallowing, weight loss, vomiting (particularly vomiting red or black material that looks like coffee grounds), black stools or anemia.
If your doctor detects an ulcer, he or she may remove small tissue samples (biopsy) near the ulcer. These samples are examined under a microscope to rule out cancer. A biopsy can also identify the presence of H. pylori in your stomach lining. Depending on where the ulcer is found, your doctor may recommend a repeat endoscopy after two to three months to confirm that the ulcer is healing.
Treatments and drugs
Because many ulcers stem from H. pylori bacteria, doctors use a two-pronged approach to peptic ulcer treatment:
- Kill the bacteria.
- Reduce the level of acid in your digestive system to relieve pain and encourage healing.
Accomplishing these two goals requires the use of at least two, and sometimes three or four, of the following medications:
- Antibiotic medications. Doctors use combinations of antibiotics to treat H. pylori because one antibiotic alone isn't always sufficient to kill the organism. For the treatment to work, follow your doctor's instructions precisely. Antibiotics prescribed for treatment of H. pylori include amoxicillin (Amoxil), clarithromycin (Biaxin) and metronidazole (Flagyl). Combination drugs that include two antibiotics together with an acid suppressor or cytoprotective agent (Helidac, Prevpac) have been designed specifically for the treatment of H. pylori infection. You'll likely need to take antibiotics for two weeks, depending on their type and number. Other medications prescribed along with antibiotics generally are taken for a longer period.
- Acid blockers. Acid blockers — also called histamine (H-2) blockers — reduce the amount of hydrochloric acid released into your digestive tract, which relieves ulcer pain and encourages healing. Acid blockers work by keeping histamine from reaching histamine receptors. Histamine is a substance normally present in your body. When it reacts with histamine receptors, the receptors signal acid-secreting cells in your stomach to release hydrochloric acid. Available by prescription or over-the-counter (OTC), acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet) and nizatidine (Axid).
- Antacids. Your doctor may include an antacid in your drug regimen. An antacid may be taken in addition to an acid blocker or in place of one. Instead of reducing acid secretion, antacids neutralize existing stomach acid and can provide rapid pain relief.
- Proton pump inhibitors. Another way to reduce stomach acid is to shut down the "pumps" within acid-secreting cells. Proton pump inhibitors reduce acid by blocking the action of these tiny pumps. These drugs include the prescription and over-the-counter medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex) and esomeprazole (Nexium). The drug pantoprazole (Protonix) can be taken orally or administered intravenously in the hospital. Doctors frequently prescribe proton pump inhibitors to promote the healing of peptic ulcers. If you're admitted to the hospital with a bleeding ulcer, taking intravenous proton pump inhibitors decreases the chance that bleeding will recur. Proton pump inhibitors also appear to inhibit H. pylori. However, long-term use of proton pump inhibitors, particularly at high doses, may increase your risk of hip fracture. Ask your doctor if you need a calcium supplement while taking these medications.
- Cytoprotective agents. In some cases, your doctor may prescribe these medications that help protect the tissues that line your stomach and small intestine. They include the prescription medications sucralfate (Carafate) and misoprostol (Cytotec). Another nonprescription cytoprotective agent is bismuth subsalicylate (Pepto-Bismol).
If H. pylori isn't identified in your system, then it's likely that your ulcer is due to NSAIDs — which you should stop using, if possible — or acid reflux, which can cause esophageal ulcers. In both cases, your doctor will try to reduce acid levels — through use of acid blockers, antacids or proton pump inhibitors — and may also have you use cytoprotective drugs.
Ulcers that fail to heal
Peptic ulcers that don't heal with treatment are called refractory ulcers. There are many reasons why an ulcer may fail to heal. These reasons may include:
- Not taking medications according to directions.
- The fact that some types of H. pylori are resistant to antibiotics.
- Regular use of tobacco.
- Regular use of alcohol.
- Regular use of nonsteroidal anti-inflammatory drugs (NSAIDs). Sometimes the problem is accidental: People may be unaware that a medication they're taking contains an NSAID.
Less often, refractory ulcers may be a result of:
- Extreme overproduction of stomach acid, such as occurs in Zollinger-Ellison syndrome
- An infection other than H. pylori
- Stomach cancer
- Other diseases, including cirrhosis and chronic obstructive pulmonary disorder (COPD)
Treatment for refractory ulcers generally involves eliminating factors that may interfere with healing, along with stronger doses of ulcer medications. Sometimes, additional medications may be included. Surgery to help heal an ulcer is necessary only when the ulcer doesn't respond to aggressive drug treatment.
Lifestyle and home remedies
Before the discovery of H. pylori, doctors often advised people with ulcers to eat a restricted diet and reduce the amount of stress in their lives. Now that food and stress have been eliminated as direct causes of ulcers, these factors are no longer of as much importance.
However, while an ulcer is healing, it's still advisable to watch what you eat and to control stress. Acidic or spicy foods may increase ulcer pain. The same is true for stress because stress may increase acid. If stress is severe, it may delay the healing of an ulcer.
Your doctor may also give you these helpful suggestions:
- Don't smoke. Smoking may interfere with the protective lining of the stomach, making your stomach more susceptible to the development of an ulcer. Smoking also increases stomach acid.
- Limit or avoid alcohol. Excessive use of alcohol can irritate and erode the mucous lining in your stomach and intestines, causing inflammation and bleeding.
- Avoid nonsteroidal anti-inflammatory drugs (NSAIDs). If you use pain relievers regularly, use acetaminophen (Tylenol, others).
- Control acid reflux. If you have an esophageal ulcer — usually associated with acid reflux — you can take several steps to help manage acid reflux. These include avoiding spicy and fatty foods, avoiding reclining after meals, raising the head of your bed and reducing your weight. Avoiding smoking, alcohol and NSAIDs also may help to control acid reflux.
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