Peptic Ulcer Disease — Causes, Symptoms and Treatment

One of the most common complaints I hear in clinic is a burning pain in the upper abdomen that has been going on for weeks. Often the patient has already been taking antacids on their own. In many of these cases, the real problem is a peptic ulcer.

What is peptic ulcer disease?

A peptic ulcer is an open sore in the lining of the stomach (gastric ulcer) or the first part of the small intestine (duodenal ulcer). It develops when the protective mucus layer weakens and stomach acid and pepsin damage the tissue underneath.

Main causes

Two causes account for the vast majority of ulcers:

• H. pylori infection. This spiral-shaped bacterium lives in the stomach lining and causes chronic inflammation. It is the leading cause of peptic ulcers worldwide and is especially common where it is acquired in childhood.
• NSAIDs. Ibuprofen, diclofenac, naproxen and aspirin block prostaglandins, which the stomach needs to protect itself. Long-term or high-dose use, older age, and combining NSAIDs with steroids or blood thinners all raise the risk.

Smoking, heavy alcohol use, and severe physiological stress can contribute, while rarer causes include Zollinger-Ellison syndrome. Spicy food and stress alone do not cause ulcers, though they can aggravate symptoms.

Symptoms

The classic symptom is gnawing or burning epigastric pain. Pain from a duodenal ulcer often improves after eating but may wake the patient at night, whereas gastric ulcer pain tends to worsen with meals. Other symptoms include bloating, nausea, early satiety, and belching.

Some patients, particularly those on NSAIDs, have no pain at all and first present with bleeding.

How is it diagnosed?

Every patient with suspected ulcer disease should be tested for H. pylori. Options include the urea breath test, stool antigen test, and biopsy taken during endoscopy. Blood antibody tests only show past exposure and cannot confirm an active infection. Because PPIs can cause false-negative results, they should be stopped about two weeks before breath or stool testing.

Endoscopy allows direct visualization of the ulcer and biopsy. It is recommended for patients over about 55 and for anyone with alarm features: weight loss, difficulty swallowing, persistent vomiting, anemia, or black stools. Gastric ulcers are usually biopsied to exclude cancer.

Treatment

Acid suppression. Proton pump inhibitors (PPIs) such as omeprazole or esomeprazole are the mainstay, usually given for 4 to 8 weeks to allow healing.

Eradication therapy. If H. pylori is present, it must be treated. Current American College of Gastroenterology guidance favors 14 days of bismuth quadruple therapy (a PPI, bismuth, tetracycline, and metronidazole) as first-line treatment, since clarithromycin-based triple therapy fails more often in areas with higher resistance. Eradication should be confirmed with a repeat test at least four weeks after finishing antibiotics.

NSAID-related ulcers. Stop the NSAID whenever possible. If it cannot be avoided, a PPI should be taken alongside it, and a COX-2 selective drug may be considered in high-risk patients.

Complications

Untreated ulcers can lead to serious problems:

• GI bleeding, the most common complication, presenting as vomiting blood or black, tarry stools
• Perforation, a surgical emergency causing sudden severe pain
• Gastric outlet obstruction from scarring, causing repeated vomiting

Go to the emergency department immediately if you notice blood in vomit, black stools, fainting, or sudden severe abdominal pain.