Peptic ulcer

IntroductionUlcers are sores or holes in the lining of an organ. They look like small, red craters. Peptic ulcer is the collective name for duodenal ulcers or gastric (stomach) ulcers.

During digestion, your stomach makes acid to break down food. The stomach and duodenum (upper part of the small intestine) are protected from this acid by a lining of mucus (sticky fluid). If the lining is damaged, the sensitive tissue underneath can come into contact with the acid. If the acid irritates this delicate wall tissue, it can eventually cause an ulcer to form.

Duodenal ulcers are more common than gastric ulcers and usually occur in people aged 20 to 45, particularly men. Gastric ulcers are more common in people over the age of 50.

Approximately 1 in 8 people in the UK develop a peptic ulcer at some time in their lives.

Helicobacter Pylori (H. Pylori)

About 95% of duodenal ulcers and 80% of gastric ulcers are caused by the bacterium, Helicobacter Pylori (H. Pylori).

H. Pylori is a very common infection in humans and more than a quarter of people in the UK carry it, although few develop ulcers. Scientists are not sure why H. Pylori does not cause ulcers in every person carrying the infection. It is probably linked to the characteristics of the infected person and the specific type of H. Pylori that they are carrying.

H. Pylori spreads through food and water. It is also found in saliva, so may be spread through mouth to mouth contact, such as kissing. Most people pick up the infection during childhood, although it is becoming less common due to better hygiene standards.

H. Pylori lives in the sticky mucus that coats the lining of the stomach and duodenum. It produces an enzyme called urease which neutralises stomach acid (makes it less acidic). To counteract this, the stomach makes more acid, meaning that irritation of the delicate lining is more likely. The bacteria also weakens the protective mucus so that it is less able to protect the lining of the stomach and duodenum.

H. Pylori bacteria can also attach themselves to stomach cells. This further weakens the stomach's defence system and causes inflammation in the affected area. Medical treatment to completely clear H. Pylori from the stomach is needed to stop ulcers coming back.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are medicines for minor aches and pains, such as headaches and period pain. They include aspirin and ibuprofen. In people with peptic ulcers that are not caused by H. Pylori, NSAIDS are often responsible.

Some NSAIDS are can be bought over-the-counter without a prescription. Other types are only available by prescription, for example diclofenac, naproxen and meloxicam, which may be used to treat conditions such as arthritis.

NSAIDs reduce your stomachs ability to make a protective layer of mucus, which makes it more likely to be damaged by acid. NSAIDS can also affect blood flow to your stomach and how well your body is able to repair cells.

Genetic factors

Some people have a family history of peptic ulcers, which suggests that genetic factors may be involved in their development.

Smoking and drinking alcohol

Smoking and drinking can contribute to the development of peptic ulcers because they irritate the stomach lining and reduce mucus production.

Stress

Stress probably does not cause ulcers, but it does worsen the symptoms if an ulcer is present. Stressful situations worsen symptoms because your stomach produces more acid in response to stress.

Some people do not have any symptoms and may not even realise that they have a peptic ulcer. Mild symptoms are sometimes mistaken for indigestion or heartburn.

If you do have symptoms, they may include the following:

- pain or a burning sensation (similar to indigestion) in your upper abdomen and sometimes your lower chest,
- pain that is worse when your stomach is empty, is relieved by eating, but then comes back a few hours later,
- pain that is made worse by eating,
- difficulty in swallowing or regurgitation (bringing up swallowed food into the mouth),
- bloating, retching and feeling sick, particularly after eating,
- vomiting and nausea, and
- loss of appetite and weight loss.

Severe ulcers may be very painful and bleed. If you experience any of the following symptoms, you should consult your GP immediately:

- vomiting blood: if an ulcer bleeds or if the blood is partially digested, the vomit may look like ground coffee,
- black or tar-like stools, which contain blood from a bleeding ulcer, and
- sudden and severe abdominal pains.

These symptoms indicate a serious problem. The ulcer may have burrowed through your stomach or duodenal wall, or it may be blocking the path of food trying to leave your stomach. Sometimes, the stomach acid, or the ulcer itself, breaks a blood vessel in the lining of the stomach or duodenum.

The test used to diagnose a peptic ulcer is an endoscopy. A thin, bendy tube containing a light and a camera lens is passed into your stomach and duodenum, so that the doctor can see the lining more clearly. If a peptic ulcer is found, a biopsy (small sample of cells) is taken. This is analysed under a microscope to look for H. Pylori infection and also to check for cancer, which can cause similar symptoms.

Infection with H. Pylori can also be diagnosed with the following tests:

- Carbon-13 urea breath test
This involves you drinking a special substance that is normally broken down by H. Pylori. If H.Pylori is present, it changes the substance into a chemical that can be detected with a breathalyser.

- Stool antigen test
A pea-sized sample of your faeces is tested for antibodies to H. pylori.

- Blood test
Your body makes antibodies against H.Pylori, which can be detected in your blood. However, it takes six months or more for the blood test to give negative results after infection has cleared.

Helicobacter pylori (H. pylori)

If you are H. pylori positive, getting rid of the bacterium is the first stage of treatment for a peptic ulcer. The treatment is sometimes called triple therapy because it involves three medicines, two high dose antibiotics and a Proton Pump Inhibitor (PPI) which is a drug to stop your stomach making so much acid. All are usually taken for one week.

The antibiotics kill the H. Pylori bacterium. At least two high doses are needed because it is hard to get enough antibiotics into your stomach lining where H.Pylori lives. The PPIs reduce the amount of acid that the stomach makes, allowing the antibiotics to work better.

Examples of Triple Therapy treatments include:

- Amoxicillin 1g, clarithromycin 500mg and PPI all taken twice a day for one week. This is the most commonly used combination.
Metronidazole 400mg, clarithromycin 250mg and PPI taken twice a day for one week. This combination is useful for people who are allergic to penicillin.
Healing peptic ulcer

For most people with H.Pylori, one week of treatment is usually enough to ease symptoms and encourage the peptic ulcer to heal. Other people may need to carry on taking an acid reducing medicine for 2-4 weeks.

If you are H. pylori negative you will only need to take an acid reducing medicine. This usually needs to be taken for 4-8 weeks to ease symptoms.

Proton Pump Inhibitors (PPIs) such as esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole, are commonly used acid reducing medicines, as they are fast acting and extremely effective.

H2 antagonists, such as cimetidine, famotidine, nizatidine and ranitidine, are an older type of acid reducing medicine. It is less common to treat peptic ulcer with these drugs.

Preventing peptic ulcer recurrence

Symptoms of peptic ulcers sometimes come back, despite getting rid of H. pylori. If your symptoms recur regularly, you may need to be referred to a specialist. On demand therapy may be used. This involves taking a Proton Pump Inhibitor (PPI) each time symptoms recur, but just for a few days until they have cleared up again, or for a short 2-4 week course. However, the manufacturers don not recommend using PPIs in this way.

Gastro-protection for Non Steroidal Anti-Inflammatory Drugs (NSAIDs)

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as aspirin and ibuprofen, can cause peptic ulcer if they are taken for a long period of time.

People who need to take an NSAID but are at risk of developing a peptic ulcer, for example, the elderly and those with a history of peptic ulcer, may be offered gastro-protection medicines. They help to prevent the damage caused by stomach acid.

Medicines that can give gastro-protection against NSAIDs include:

- Proton Pump Inhibitors (PPI). These medicines stop your stomach making so much acid and are the most commonly used for gastro-protection.
- Misoprostol encourages your stomach lining to make more protective mucus.
- H2 Antagonists reduce the amount of acid your stomach makes. Although they have often been used in the past, recent studies show they may not be that effective unless taken at double dose.
Surgery

Occasionally, surgery is recommended if medicines are not enough to control the symptoms of a peptic ulcer.

This may include:

- Vagotomy - cutting the vagus nerve that links the stomach to your brain. This reduces acid production.
- Antrectomy - removal of the lower part of your stomach that makes the hormone that causes the stomach to produce digestive juices.
- Pyloroplasty - making the opening into your duodenum and small intestine bigger, to allow the contents of your stomach to move on more freely.
Emergency treatment of peptic ulcer

Severe blood loss from a bleeding or perforated peptic ulcer (one with a hole in) is a medical emergency and requires immediate medical attention.

Cauterisation, a surgical technique using heat, seals any exposed blood vessels around the ulcer to stop bleeding. This may be carried out during an endoscopy.

Alternatively, medicines to stop the bleeding may be injected into the peptic ulcer. If there is a perforated peptic ulcer or very severe bleeding, surgery and a blood transfusion may be necessary.

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Smoking and drinking a lot of alcohol increases your chances of developing an ulcer, or worsening your symptoms if you already have one. Stop smoking and limit your alcohol intake for a healthier lifestyle and to reduce the risk of developing an ulcer.

If you have an ulcer, it may be worth avoiding certain foods that you will know aggravate your symptoms for example, spicy foods. Losing any extra weight will also help relieve your symptoms.

If you are very sensitive to aspirin and other NSAIDs, ask your GP for advice about alternative medicines. NHSDEC07