An "ulcer" is an open sore. The word "peptic" means that the cause of the
problem is due to acid. Most of the time when a gastroenterologist is referring
to an "ulcer" the doctor means a peptic ulcer.The two most common types of
peptic ulcer are called "gastric ulcers" and "duodenal ulcers". These names
refer to the location where the ulcer is found. Gastric ulcers are located in
the stomach (see Figure 1). Duodenal ulcers are found at the beginning of the
small intestine (also called the small bowel) known as the duodenum. A person
may have both gastric and duodenal ulcers at the same time.
Symptoms
Many people with ulcers have no symptoms at all. Some people with an ulcer have
belly pain. This pain is often in the upper abdomen. Sometimes food makes the
pain better, and sometimes it makes it worse. Other symptoms include nausea,
vomiting, or feeling bloated or full. It is important to know that there are
many causes of abdominal pain, so not all pain in the abdomen is an "ulcer".The
most important symptoms that ulcers cause are related to bleeding. Bleeding from
an ulcer can be slow and go unnoticed or can cause life-threatening hemorrhage.
Ulcers that bleed slowly might not produce the symptoms until the person becomes
anemic. Symptoms of anemia include fatigue, shortness of breath with exercise
and pale skin color.Bleeding that occurs more rapidly might show up as melena -
jet black, very sticky stool (often compared to "roof tar") - or even a large
amount of dark red or maroon blood in the stool. People with bleeding ulcers may
also vomit. This vomit may be red blood or may look like "coffee grounds". Other
symptoms might include "passing out" or feeling lightheaded. Symptoms of rapid
bleeding represent a medical emergency. If this occurs, immediate medical
attention is needed. People with these symptoms should dial 911 or go to the
nearest emergency room.
Causes/Risk Factors
The two most important causes of ulcers are infection with Helicobacter pylori
and a group of medications known as NSAIDs.Helicobacter pylori (also called H.
pylori or "HP) is a bacterium that lives in the stomach of infected people. The
understanding that H. pylori can cause ulcers was one of the most important
medical discoveries of the late 20th century. In fact, Dr. Barry Marshall and
Dr. J. Robin Warren were awarded the 2005 Nobel Prize in Medicine for this
discovery. People infected with H. pylori are at increased risk of developing
peptic ulcers. When a person is diagnosed with an ulcer, testing for H. pylori
is often done. There are a number of tests to diagnose H. pylori and the type of
test used depends on the situation.People with ulcers. who are infected with H.
pylori. should have their infection treated. Treatment usually consists of
taking either three or four drugs. The drug therapy will use acid suppression
therapy with a proton pump inhibitor (PPI) along with antibiotic therapy and
perhaps a bismuth containing agent such as Pepto-Bismol. H. pylori can be very
difficult to cure; so it is very important that people being treated for this
infection take their entire course of antibiotics as prescribed.NSAIDs
(Non-Steroidal Anti-Inflammatory Drugs) are a group of medications typically
used to treat pain. There are many drugs in this group. A few of these include:
aspirin (Bayer®), ibuprofen (Motrin®, Advil®), naproxen (Aleve®, Naprosyn®),
ketorolac (Toradol®) and oxaprozin (Daypro®). NSAIDs are also included in some
combination medications, such as Alka-Seltzer®, Goody's Powder® and BC
Powder®.Acetaminophen (Tylenol®) is NOT an NSAID and is therefore the preferred
non-prescription treatment for pain in patients at risk for peptic ulcer
disease.NSAID use is very common because many are available over the counter
without a prescriptionand therefore they are a very common cause of peptic
ulcers. NSAIDs cause ulcers by interrupting the natural ability of the stomach
and the duodenum to protect themselves from stomach acid. NSAIDs also can
interfere with blood clotting, which has obvious importance when ulcers
bleed.People who take NSAIDs for a long time and/or at high doses, have a higher
risk of developing ulcers. These people should discuss the various options for
preventing ulcers with their physician. Some people are given an acid
suppressing PPI. These drugs can prevent or significantly reduce the risk of an
ulcer being caused by NSAIDs.There are many myths about peptic ulcers. Ulcers
are not caused by emotional "stress" or by worrying. They are not caused by
spicy foods or a rich diet. Certain foods might irritate an ulcer that is
already there, however, the food is not the cause of the ulcer. People diagnosed
with ulcers do not need to follow a specific diet. The days of ulcer patients
surviving on a bland diet are a thing of the past.
Diagnosis
The most typical way for ulcers to be diagnosed is by a procedure called an EGD.
EGD stands for EsophagoGastroDuodenoscopy. An EGD (also called "upper
endoscopy") is performed by inserting a special lighted camera on a flexible
tube into the person's mouth to look directly into the stomach and the beginning
of the small bowel. This flexible camera carefully inspects the most likely
areas for ulcers to be located. Ulcers identified during an EGD may be
photographed, biopsied and even treated, if bleeding is present.Another way
ulcers were diagnosed in the past was with an x-ray test called an "upper GI
series". An upper GI series involves drinking a white chalky substance called
barium, and then taking a number of x-rays to look at the lining of the stomach.
Doctors can see the ulcers on the x-rays when they have barium in them. Today,
the preferred method for diagnosing ulcers is with an EGD given the flexible
camera is better able to detect even small ulcers and because it allows for
potential treatment at that time if the ulcer is bleeding. An upper GI series
can miss small ulcers and also does not allow direct treatment of an ulcer.
Treatment
The way that ulcers are treated depends on a number of features. Nearly all
peptic ulcers will be treated with a proton pump inhibitor (PPI). PPIs are
powerful acid blocking drugs that can be taken as a pill or given in an IV.
Often, the potent IV form is used if a patient is hospitalized with a bleeding
ulcer. There are six PPIs available in the United States. These are omeprazole
(Prilosec®, Zegerid®), lansoprazole (Prevacid®), pantoprazole (Protonix®),
rabeprazole (Aciphex®), esomeprazole (Nexium®), and dexlansoprazole (Dexilant®).
There are very few medical differences between these drugs.PPIs require a meal
to activate them. Patients should eat a meal within 30 minutes to 1 hour after
taking this medication for the acid suppression therapy to work most
effectively. Waiting later than this time can decrease the positive effect of
this medication. This might delay healing or even result in the failure of the
ulcer to heal.Sometimes duodenal ulcers (not gastric ulcers) will be treated
with H2 blockers. H2 blockers are another type of acid reducing medication.
Common H2 blockers are ranitidine (Zantac®), cimetidine (Tagamet®), famotidine
(Pepcid®) and nizatidine (Axid®).An important part in treating ulcers is by
identifying what caused them Patients with ulcers caused by NSAIDs should talk
to their doctor about other medications that can be used to treat pain. If the
person is infected with H. pylori this infection should be treated. Completing
the full dose of antibiotics is very important. Just as important, is making
sure that the infection is gone. There are number of ways to do this. Generally,
a blood test is not a good way to test if the infection is gone. The doctor who
treated the infection can recommend the best way to do the "test of cure". When
someone has an ulcer that has bled significantly, treatment might be done at the
time of EGD. There are a number of techniques that can be performed during an
EGD to control bleeding from an ulcer. The gastroenterologist might inject
medications, use a catheter to cauterize the ulcer (burn a bleeding vessel shut)
or place a small clip to clamp off a bleeding vessel. Not all ulcers need to be
treated this way. The doctor doing the EGD will decide if treatment is indicated
based on the way the ulcer looks. The doctor will usually treat an ulcer that is
actually bleeding when it is seen and will also often treat other ulcers if they
have a certain appearance. These findings are sometimes called "stigmata of
recent hemorrhage" or just "stigmata". Stigmata will usually get treated during
the EGD if they are classified as high-risk. Common high-risk findings include a
"visible vessel" and an "adherent clot".Most ulcers can be treated and will
heal. Often, people with ulcers will have to take PPIs for several weeks to heal
an ulcer. It is also important to correct what caused the ulcer. When possible,
NSAIDs should be stopped. Patients with ulcers caused by NSAIDs should talk to
their doctor about other medications that can be used to treat pain.If the
person is infected with H. pylori, then completing the full dose of antibiotics
is very important. Just as important, is making sure that the infection is gone.
There are number of ways to do this. Generally, a blood test is not a good way
to test if the infection is gone. The doctor who treated the infection can
recommend the best way to do the "test of cure".People with gastric ulcers (only
in the stomach) usually have another EGD several weeks after treatment to make
sure that the ulcer is gone. This is because a very small number of gastric
ulcers might contain cancer. Duodenal ulcers (at the beginning of the small
intestine) usually don't need to be looked at again.
Glossary
Anemia - A low red blood cell count. Symptoms of anemia include feeling tired,
shortness of breath, weakness and poor exercise tolerance.Duodenal - referring
to the beginning of the small intestine or duodenum.EGD -
EsophagoGastroDuodenoscopy, also called "upper endoscopy" is a medical procedure
where a flexible lighted tube with a camera is inserted through the person's
mouth and into the stomach and duodenum to diagnose or treat disease.Erosion - a
very shallow sore, similar to an abrasion or a scrape. These are usually not
very important and very rarely cause symptoms.Gastric - referring to the
stomach.H2 blocker - H2 blockers significantly lower the production of acid in
the stomach. They are sometimes used to treat duodenal (not gastric) ulcers.
They are also often used to treat heartburn and GERD. Common H2 blockers are
ranitidine (Zantac®), cimetidine (Tagamet®), famotidine (Pepcid®) and nizatidine
(Axid®).Helicobacter pylori - sometimes called H. pylori or HP is a bacterium
that causes ulcers. H. pylori is also a risk factor for stomach cancer. If
prescribed, it is very important to complete an entire course of antibiotics for
H. pylori.Melena - black very sticky stool, often compared to roof tar. This is
a common symptom of a bleeding ulcer. Black stool that looks like melena can be
caused by taking iron medications and by drugs like Pepto-Bismol®.NSAIDs -
(Non-Steroidal Anti-Inflammatory Drugs) are a group of medications typically
used to treat pain. There are many drugs in this group. A few of these include:
aspirin (Bayer®), ibuprofen (Motrin®, Advil®), naproxen (Aleve®, Naprosyn®),
ketorolac (Toradol®) and oxaprozin (Daypro®). NSAIDs are also included in some
combination medications, such as Alka-Seltzer®. Acetaminophen (Tylenol®) is NOT
an NSAID and is therefore the preferred non-prescription treatment for pain in
patients at risk for peptic ulcer disease.Peptic - caused by acid.PPIs - Proton
Pump Inhibitors. Powerful acid blocking drugs that can be taken as a pill or
given in an IV. PPIs are frequently used to treat ulcers, and also heartburn and
GERD. There are six PPIs available in the United States. These are omeprazole
(Prilosec®, Zegerid®), lansoprazole (Prevacid®), pantoprazole (Protonix®),
rabeprazole (Aciphex®), esomeprazole (Nexium®) and dexlansoprazole (Dexilant®).
There are very few medical differences between these drugs. It is important to
know that PPIs require a meal to activate them. Patients should eat a meal
within 30 minutes to 1 hour after taking this medication for the acid
suppression therapy to work properly.Stigmata of recent hemorrhage - sometimes
just called "stigmata" are findings during an EGD that indicate a higher risk of
bleeding or re-bleeding. Stigmata are usually treated during the EGD when they
are found. This treatment reduces the chance of bleeding.Ulcer - an open sore.
Ulcers are deeper than erosions.
Author(s) and Publication Date(s)
Sean P. Caufield, MD, Lieutenant Commander, Medical Corps, U.S. Navy,
Gastroenterology Fellow, Naval Medical Center, San Diego, CA, and Theodore W.
Schafer, MD, FACP, FACG, Captain, Medical Corps, U.S. Navy, Associate Professor
of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
- Updated December 2012.Theodore W. Schafer, MD, FACP, Commander, Medical Corps,
U.S. Navy, Uniformed Services University of the Health Sciences, Bethesda, MD -
Published November 2007.Disclaimer: The views expressed in this article are
those of the authors and do not reflect the official policy or position of the
Department of the Navy, Department of Defense, or the United States Government.
IMPORTANT REMINDER:
The preceding information is intended only to provide general information and not as a definitive basis for diagnosis or treatment in any particular case. It is very important that you consult your doctor about your specific condition.