Peptic ulcers are craterlike erosions in the lining of the stomach, the duodenum (the part of the small intestine just past the stomach), and rarely, the esophagus. Duodenal ulcers are about three times more common than stomach (gastric) ulcers.

Normally, glands in the stomach secrete acid and the enzyme pepsin (hence the name peptic ulcer) that help to break down foods in the digestive process. The stomach and duodenum meanwhile secrete mucus to protect them against harm from pepsin and gastric acid. In peptic ulcer disease the digestive tract’s defensive mechanisms break down, often as a result of infection with the bacterium Helicobacter pylori. Consequently, even small amounts of stomach acid can cause corrosion.

Each year, about 1 percent of Americans develop peptic ulcers, and overall, up to 10 percent of the population will have a peptic ulcer at some point during their lives. All ages may be affected (including children), although peptic ulcers most often affect those over 30.

Peptic ulcers commonly recur: even after a peptic ulcer has healed, new peptic ulcers often arise throughout the patient’s lifetime, either in the original location or elsewhere. Therefore, current drugs for peptic ulcers, which mostly act to reduce levels of stomach acids, must often be taken on a long-term basis. The development of newer, short-term drug regimens directed against H. pylori may significantly lower the high rate of peptic ulcer recurrence.

Although peptic ulcers are rarely a major health threat, they sometimes lead to serious complications, such as bleeding, obstruction of the digestive tract due to scarring, or the creation of a hole or tear (perforation) in the digestive tract, which can lead to severe, life-threatening infection of the abdominal cavity (peritonitis). In addition, in a small percentage of cases a persistent stomach ulcer may be cancerous. The same is not true for duodenal ulcers.

For most peptic ulcers, treatment is highly effective in controlling symptoms and preventing serious complications.

Symptoms of Peptic Ulcer

• No symptoms in some patients.

• Gnawing pain in the upper stomach area several hours after a meal (duodenal ulcer) or dull, aching pain, often right after a meal (gastric ulcer). Pain may radiate to the back or behind the breastbone, resembling heartburn.

• Indigestion, nausea, vomiting, and weight loss.

• Emergency symptoms: black, tarry, or bloody stools; vomiting of blood or material resembling coffee grounds (signs of potentially serious bleeding). Searing abdominal pain could indicate that an ulcer has eroded completely through the digestive tract (perforation).

What Causes Peptic Ulcer?

• At least 80 percent of peptic ulcers are believed to be caused by infection of the digestive tract with H. pylori bacteria. It’s not known how the infection spreads, although it may be transmitted orally. H. pylori infests about 60 percent of Americans by age 60, but most of those infected do not develop peptic ulcers. Rather, the bacteria merely increase the chances of developing a peptic ulcer by weakening the stomach’s protective mechanisms and making the lining of the digestive tract susceptible to erosion by stomach acids. Once a peptic ulcer has developed, various secondary factors can aggravate it, including alcohol, caffeine, dietary factors, smoking, and stress.

• In the past, excessive production of stomach acid was thought to be the primary cause of peptic ulcers. It is now recognized that many people with peptic ulcers actually have normal or even slightly less-than-normal amounts of stomach acid. However, because mechanisms that protect the digestive tract lining are weakened, even small amounts of stomach acid can cause (or delay the healing of) peptic ulcers. The exception is ulcers caused by certain kinds of pancreatic or duodenal tumors, which secrete the hormone gastrin and cause massive amounts of acid secretion (Zollinger-Ellison syndrome).

• Long-term use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, can lead to ulcers primarily in the stomach by irritating its lining.

• Hereditary factors also appear to play a role.

Prevention of Peptic Ulcer

• Avoid long-term use of aspirin or nonsteroidal anti-inflammatory drugs if possible. Anyone who must take these drugs on a long-term basis, such as those with arthritis, may benefit from the prescription drug misoprostol.

• Taking ulcer medications as prescribed, and avoiding smoking and foods or drinks that have aggravated ulcers in the past, can help prevent ulcer recurrence.

Diagnosis of Peptic Ulcer

• Patient history and physical examination are needed.

• An upper GI series (which involves swallowing a solution containing barium to create a clear image of the digestive tract on x-ray) may show active peptic ulcers or scarring caused by past ulcers.

• Endoscopy (in which a flexible scope is guided down the throat and into the stomach and duodenum) allows peptic ulcers to be viewed directly. Endoscopy also allows the doctor to take a small sample of the ulcer (biopsy); this sample is then tested for cancer.

• Biopsies can also detect the presence of H. pylori, but this method is invasive and expensive. Quick office tests for the detection of this bacterium are becoming available.

How To Treat Peptic Ulcer

• For those with mild disease (one or two periods of symptoms a year), drugs that reduce secretion of stomach acid (cimetidine, ranitidine, famotidine, nizatidine, or omeprazole) or that coat the lining of the stomach (sucralfate) usually relieve pain within a week, although ulcers take about eight weeks to heal.

• Antacids may also help, although they may interfere with the actions of acid-reducing drugs if both are taken in close succession.

• Antibiotics directed against H. pylori bacteria are generally reserved for those with more serious disease who do not respond to other ulcer medications, as the long-term effectiveness and side effects of this approach are still being evaluated. A combination of two antibiotics (usually metronidazole and tetracycline) is usually taken for at least two weeks, along with a bismuth-containing antacid (such as Pepto-Bismol). Antacids or medications that reduce acid secretion may also be given. Combination antibiotic regimens prevent ulcer recurrences in about 90 percent of cases.

• Surgery may be needed for bleeding, obstruction or perforation of the digestive tract, or intractable pain from peptic ulcers.

• Eat a well-balanced diet rich in fiber. Many dietary measures advocated in the past—such as eating bland foods, eating many small meals a day, or drinking milk—do not appear to help. Indeed, milk may actually increase stomach acid production, although one or two glasses a day is usually not harmful. Coffee, tea, and caffeinated sodas can increase acid secretion. Avoid excessive alcohol consumption.

When To Call A Doctor

• Call a doctor for symptoms of peptic ulcer disease.

• Emergency: For those with ulcers, any signs of bleeding or perforation (including vomiting blood; black, tarry stools; or severe abdominal pain) require immediate emergency medical attention.

For more information on peptic ulcers and other digestive disorders, click on this link -- Johns Hopkins Health Alerts: Digestive Disorders

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