Peptic Ulcer Disease

What is a peptic ulcer?

A peptic ulcer is a sore in the lining of the stomach or the duodenum that reaches deeper than a surface irritation.

An ulcer in the stomach is called a gastric ulcer; one in the duodenum, which begins immediately after the stomach, is called a duodenal ulcer.

Although the stomach and duodenum meet stomach acid constantly, they normally have strong protective mechanisms. An ulcer may develop when the balance between this protective system and the acid and other damaging factors is upset.

The cause of most peptic ulcers can now be identified, and good results obtained with suitable treatment.

What causes an ulcer?

The two most important causes of peptic ulcer are Helicobacter pylori (H. pylori) infection and certain painkillers.

H. pylori

H. pylori is a bacterium that can settle in the stomach. By causing chronic gastritis it may impair the protective mechanisms of the stomach and duodenum and make an ulcer more likely.

In patients found to have H. pylori it is not enough merely to heal the ulcer. Clearing the bacterium with suitable treatment, and then confirming that it has genuinely gone, matters.

Painkillers

Certain painkillers and anti-inflammatory drugs other than aspirin, known as NSAIDs, may weaken the protective mechanisms of the stomach and duodenum and lead to an ulcer forming or an existing ulcer bleeding.

The risk may be higher in older people, in those who have had an ulcer before, and in those taking high doses or more than one risky drug.

A patient taking aspirin or a blood thinner for cardiovascular disease should, however, not stop these drugs on their own initiative.

Do stress, spice and hot food cause ulcers?

There are many mistaken beliefs about this.

The stress of daily life and hot or spicy foods are not the underlying causes of peptic ulcer.

Some foods may increase pain, burning or indigestion in a person who already has an ulcer. That does not mean that the food created the ulcer.

For this reason a long, strict “ulcer diet” applied to everyone is no longer advised for patients with ulcers.

Are gastric and duodenal ulcers the same?

No.

Both come under peptic ulcer disease, but there are some important differences.

A significant proportion of duodenal ulcers are associated with H. pylori, and it is not expected that a typical duodenal ulcer will be cancer.

With a gastric ulcer the approach is rather more careful. This is because some stomach cancers can look like an ulcer at endoscopy.

The endoscopic appearance of a gastric ulcer is therefore assessed carefully and, where necessary, biopsies are taken to be sure that no malignant disease is present. Where the appearance is suspicious or the ulcer does not heal, repeat endoscopy and biopsy may be needed even if the first biopsies were benign.

What are the symptoms?

A peptic ulcer sometimes causes no symptoms at all.

When there are symptoms, the commonest are:

• Pain or burning in the upper abdomen,
• Pain related to hunger or to meals,
• Stomach pain arising at night,
• Indigestion,
• Bloating,
• Nausea,
• Feeling full early.

But it is not reliable to tell a gastric ulcer from a duodenal ulcer by the character of the pain alone.

In some patients the first sign of an ulcer may be bleeding.

What happens if an ulcer bleeds?

Peptic ulcer is one of the important causes of upper gastrointestinal bleeding.

When bleeding occurs there may be:

• Vomiting of blood,
• Coffee-ground vomiting,
• Black, tarry stools,
• Weakness,
• Dizziness,
• Palpitations or fainting.

These symptoms require emergency medical assessment.

A significant proportion of bleeding ulcers can now be treated during endoscopy with clips, thermal methods or other endoscopic techniques. Current ESGE guidance also recommends endoscopic haemostasis as the mainstay of treatment in high-risk ulcers that are actively bleeding or have a visible vessel.

Can an ulcer perforate?

Yes. This is called perforation and is one of the serious complications of peptic ulcer.

The ulcer may pass through the whole thickness of the stomach or duodenal wall and open into the abdominal cavity.

There is usually sudden, very severe and persistent abdominal pain. The abdomen may become rigid and the patient’s general condition may deteriorate quickly.

This is an emergency and requires rapid assessment in hospital.

Can an ulcer narrow the stomach outlet?

Less commonly, swelling around the ulcer or scar tissue forming over time may narrow the stomach outlet.

In that case there may be:

• Excessive fullness after meals,
• Feeling full early,
• Recurrent vomiting,
• Vomiting food eaten hours earlier,
• Weight loss.

Because of effective H. pylori and acid-suppressing treatments, lasting narrowing caused by an ulcer is seen less often now than in the past.

How is the diagnosis made?

The most important method for assessing a peptic ulcer is gastroscopy.

At endoscopy the gullet, stomach and duodenum are seen directly.

This allows assessment of:

• The site and size of the ulcer,
• Signs of bleeding,
• The appearance of the ulcer,
• Whether there is narrowing at the stomach outlet.

Where necessary, biopsies can be taken and H. pylori looked for.

How is it treated?

Treatment should aim not only at closing the sore but at removing the cause of the ulcer.

If H. pylori is present

Suitable eradication treatment is given for H. pylori.

Because of antibiotic resistance, the choice of treatment now matters. After treatment is completed, clearance of the bacterium should be confirmed with a suitable test.

Acid-suppressing treatment

Proton pump inhibitors (PPIs) strongly reduce stomach acid and help the ulcer to heal.

The duration of treatment may vary with the site, size and cause of the ulcer and with whether there are complications.

Drug-related ulcers

If NSAIDs that could cause an ulcer are being taken, whether the drug is genuinely needed is assessed.

If it can be stopped it may be, or an alternative treatment considered. If it must be continued, protective treatment for the stomach may be needed.

Is every ulcer due to H. pylori or a painkiller?

No.

Although most peptic ulcers can be explained by these two important causes, some patients have no H. pylori and no NSAID use to explain the ulcer.

More detailed assessment may be needed particularly where the ulcer:

• Does not heal despite suitable treatment,
• Recurs frequently,
• Is present in more than one place,
• Arises in an unusual site,
• Is very large,
• Has an atypical endoscopic appearance.

What is looked for in an unhealing or atypical ulcer?

It is necessary first to be sure that H. pylori is genuinely absent and that there is no unrecognised aspirin or NSAID use.

Rarer causes are then assessed.

These may include conditions causing excessive acid production such as Zollinger-Ellison syndrome (gastrinoma), Crohn’s disease, certain infections, circulatory disorders and certain drugs.

In gastric ulcer in particular it is important that the possibility of malignant disease is properly excluded.

The ASGE also recommends re-investigating the cause of peptic ulcers that do not heal despite suitable treatment, and repeat biopsy where needed in gastric ulcers that do not heal or are suspicious.

What is Zollinger-Ellison syndrome?

It is a very rare condition.

A tumour called a gastrinoma produces excessive amounts of the hormone gastrin. The stomach then secretes a great deal of acid.

These patients may develop recurrent, resistant ulcers or ulcers in unusual places. Some also have diarrhoea.

Gastrinoma does not need to be looked for in every recurrent ulcer. Special tests are used when the clinical features raise the suspicion.

Does an ulcer heal completely?

In most patients, yes.

When H. pylori is cleared, ulcer-causing drugs are suitably adjusted and adequate acid-suppressing treatment is given, the great majority of peptic ulcers heal.

But closing the ulcer alone is not enough. If the cause persists, the ulcer may come back.

Is a check endoscopy needed?

The same approach is not applied to every ulcer.

In typical duodenal ulcers without complications that respond to treatment, routine check endoscopy is usually unnecessary.

In gastric ulcers, check endoscopy may be needed according to the initial appearance of the ulcer, the biopsy result, the patient’s risk features and the response to treatment. Re-assessment of gastric ulcers that look suspicious or that do not heal after suitable treatment matters particularly.

When should emergency help be sought?

If a patient with an ulcer develops vomiting of blood, coffee-ground vomiting, black tarry stools, fainting or sudden very severe abdominal pain, nothing should be awaited.

These may be signs of serious complications such as bleeding or perforation.

Outlook

The outlook in peptic ulcer disease is now generally very good.

Recognition of H. pylori, effective acid-suppressing drugs and advanced endoscopic treatment of bleeding mean that ulcer disease is treated far more successfully than in the past.

By contrast, rather than treating a recurrent or unhealing ulcer with the same drugs indefinitely, it is necessary to investigate why it is not healing.

Currency: The information on this page was prepared taking account of current international gastroenterological and endoscopic approaches to peptic ulcer disease, H. pylori infection and the complications of ulcers.

This content is for general information. Diagnosis and treatment should be planned by a doctor according to the patient’s own circumstances.