About 15 million Americans have been diagnosed with ulcers that affect the digestive system. Gastric ulcers are deep, nonhealing mucosal defects in the stomach, usually in the antrum. Duodenal ulcers are nonhealing defects in the mucosal lining of the duodenum, usually in the duodenal bulb. This type of ulcer tends to affect young people, especially males, and has a prolonged clinical course with periodic relapses. The term “peptic ulcers” refers to both types of ulcers.
Peptic ulcers occur when the lining of the stomach or duodenum becomes damaged, usually by acid. Between 70% and 80% of gastric ulcers and nearly all duodenal ulcers are associated with chronic infection from a small bacterium, H. pylori. The presence of H. pylori leads to overproduction of gastric acid, which predisposes a person to the development of peptic ulcers. NSAIDs and the osteoporosis drug Fosamax (alendronate) also can damage the lining of the stomach, increasing the risk of gastric ulcers.
Symptoms and Complications of Ulcers
People with gastric ulcers experience pain soon (15 to 30 minutes) after eating, are frequently afraid to eat, and often lose weight. Pain rarely occurs at night and when fasting.
People with duodenal ulcers often complain of pain in the upper abdomen (the epigastrium) and indigestion. Pain frequently occurs two to three hours after meals, when the stomach is empty. It can awaken the person at night and is relieved by eating.
If not treated, peptic ulcers can lead to bleeding, perforation, or penetration. Bleeding occurs when the ulcer causes a blood vessel to rupture in the lining of the stomach or duodenum. Perforation occurs when an ulcer erodes through the entire depth of the gastric or duodenal wall into the abdominal cavity, leading to infection and inflammation of the cavity (peritonitis). And penetration occurs when an ulcer erodes through the duodenal or gastric wall into adjacent organs, such as the liver, pancreas, or colon (the large intestine).
Less frequently, the inflammatory changes around the ulcer can deform the stomach or duodenum and produce obstruction (blockage) of the gastric outlet or duodenum. People with this problem develop nausea and intractable vomiting; they require endoscopy with dilation or surgical treatment to restore the normal passage of food.
Drug Therapy for Peptic Ulcers
Peptic ulcers can be healed temporarily by suppressing gastric acid secretion. The ulcer medications most commonly used to suppress gastric acid production are H2-blockers and proton pump inhibitors. Ulcers usually return if acid suppression is not maintained.
On the other hand, if H. pylori is eradicated from the stomach, gastric secretion returns to normal levels and peptic ulcers are usually cured. The treatment regimen to eradicate H. pylori includes antibiotics and acid-reducing medications. Usually doctors first prescribe triple therapy, which consists of a proton pump inhibitor and two antibiotics. This approach cures ulcers in 84% to 94% of cases.
If initial triple therapy to eradicate the H. pylori infection does not produce a cure, a second triple therapy—containing a proton pump inhibitor (for example, Nexium) and a different combination of two antibiotics—may be tried. Alternatively, doctors may prescribe quadruple therapy containing bismuth subsalicylate (Bismatrol, Pepto-Bismol), two antibiotics, and a proton pump inhibitor or H2-blocker. If the H. pylori infection is not eradicated, the recurrence rate of peptic ulcers is high. Continued use of NSAIDs lowers the success rate in the healing of gastric ulcers.
Triple and quadruple therapies for ulcers are complicated regimens, and many people find them difficult to follow. But if you have an ulcer it is essential to follow the regimens carefully and for the recommended period of time to prevent antibiotic resistance and ensure eradication of the H. pylori infection.
To make the drug regimens easier to take, some companies sell them prepackaged rather than as separate medications. Although they are more convenient, these prepackaged drug regimens are more expensive than buying the medications in the regimen individually. Adverse reactions vary depending on the specific medications used but are typically minor; they include rash, diarrhea, nausea, taste disturbance, and black stools.
Ulcers were once commonly treated with surgery: either partial gastrectomy or vagotomy. Partial gastrectomy involves removing the acid-producing portion of the stomach, while vagotomy involves cutting the vagal nerve to decrease production of acid in response to acetylcholine from the vagal nerve. Now that proton pump inhibitors are available and the role of H. pylori is understood, surgery is rarely used for people with uncomplicated peptic ulcers. Surgery is still used for complicated ulcers, however, to stop bleeding, close perforations, or open up the gastric outlet if an ulcer is blocking it.
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