Digestive Problems
Diseases: Stomach and Duodenum: Peptic Ulcer Disease
The term peptic ulcer refers to a break in the surface lining of the stomach which is deep enough to produce a shallow crater (ulcer) in the wall of the duodenum or, less commonly, the stomach. Rarely peptic ulcers can be found in the lower esophagus or small intestine. Duodenal ulcers are more common in men, whereas gastric ulcers affect men and women more or less equally. Ulcers are found at all ages but are more common with increasing age. They may appear acutely or develop slowly and chronically. Up to 1 in 10 of all adults may suffer from peptic ulcer disease at some time in their lives.
It is now known that over 90% of duodenal ulcers are the result of infection with Helicobacter pylori (HP). It is not known for certain how this bacteria is transmitted but infection is more common in areas of poverty, poor sanitation and overcrowding. The vast majority of infected people remain healthy and asymptomatic but, for unknown reasons, a small percentage develop peptic ulcer disease. After infection the bacteria lives close to the surface lining of the stomach, underneath the layer of mucus, where it is protected from acid. It causes inflammation of the lower part of the stomach (antrum) and chronic gastritis. As a result, acid secretion in response to a meal increases and it is thought that this excessive amount of acid damages the duodenum and leads to ulcer development. HP is also thought to be responsible for 60 - 70% of gastric ulcers. Other gastric ulcers usually occur in patients taking aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs). Duodenal ulcers are always benign but gastric ulcers can be benign or malignant and require careful investigation and follow up to ensure that they heal completely with treatment.
Aspirin and NSAIDs damage the lining of the stomach and make it more susceptible to damage from acid and enzymes. These drugs, however, only play a small role in causing ulcers in the duodenum but may flare up existing ulcers. Not everybody is at risk of the side effects of aspirin and NSAIDs. People at higher risk of complications include those over the age of sixty, those taking high doses and those with a past history of peptic ulcer or complications from these drugs. Some NSAIDs are safer than others and if prescribed one of these medications you should check with your doctor that it is safe to take it.
There is often afamily history of peptic ulcer disease but reasons for this are unclear and peptic ulcers are not strictly a "genetic" disease.
Smoking also carries an increased risk of ulcers. Complications of ulcers, including delayed healing, are more common in smokers than in non-smokers. Lastly, ulcers may very rarely be the result of a hormone-producing tumor ("gastrinoma") which leads to massive acid production. Ulcers in this condition are often multiple, aggressive and resistant to therapy. This condition is rare and accounts for only approximately 1% of all ulcers.
Can peptic ulcers be prevented ?
This is discussed under health maintenance. At present there is no good evidence that widespread antibiotic therapy to eradicate HP in the population will prevent ulcer disease. This is the subject on ongoing debate by specialists and may change in the future. Careful use of aspirin and NSAIDs and their avoidance by people at high risk of complications is also recommended. Stopping smoking may also reduce the chances of developing and ulcer.
What are the symptoms and signs of an ulcer?
Peptic ulcers are usually chronic and may come and go over a period of many years, even without treatment. The most common symptom is abdominal pain, usually located in the upper central abdomen and which may also be felt in the back. Pain may be worse when the stomach is empty and can be relieved by eating but this is not always the case. Pain which wakes a patient from sleep is also suggestive of an ulcer. Other important symptoms include dyspepsia, vomiting and anemia. In a few patients an ulcer may be silent until it erodes completely through the gut wall, causing perforation or erodes into blood vessel and causes bleeding. These complications are serious and usually present as an emergency.
How are peptic ulcers diagnosed ?
In most cases the diagnosis is made by endoscopy, at which time the ulcer is usually seen and can be biopsied if it appears suspicious for malignancy. Biopsies of the stomach can also be taken to look for the presence of HP organisms. A further advantage of endoscopy is that treatment can be carried out at the same time if the ulcer is bleeding (see below). The majority of ulcers can also be diagnosed by careful barium meal examination and this is an alternative for patients who cannot or do not wish to have endoscopy. Because of the ability to take biopsies and perform endoscopic treatment, endoscopy is the perferred method of investigation.
Although biopsies of the stomach are the "gold standard" for diagnosing HP infection it is possible in some centers to diagnose the infection by using a simple breath test. A number of blood tests for the infection are also available but these are less accurate.
Routine blood tests are usually normal in patients with ulcers apart from those where bleeding has resulted in anemia.
How are peptic ulcers treated ?
The goals of treatment are to relieve symptoms quickly, make the ulcer heal, and prevent it from recurring in the future. Treatment of HP infection is now recognized as the most important aspect of treatment and all ulcer patients who are infected with bacteria should be offered antibiotic therapy. Usually this requires a combination of drugs and many different combinations are available. Usually an acid suppressing drug is necessary, to relieve symptoms and induce ulcer healing, but also to boost the effects of the antibiotics. The most effective acid suppressing medications are Omeprazole ("Prilosec") and Lansoprazole ("Prevacid"). At the same time two antibiotics are usually necessary to ensure successful eradication of the infection. Many different antibiotics are available, including amoxycillin, clarithromycin, and metronizadole. This "triple therapy" (i.e. an acid suppressing medication plus two antibiotics) is usually taken for one to two weeks and is 80 - 90% successful in getting rid of the infection. Symptoms may take longer to disappear completely but, when they do, there is little need to perform further tests to ensure that treatment has worked. Patients who have had serious complications from their ulcer (such as bleeding or perforation) should undergo repeat testing to ensure that the treatment is successful. For patients whose infection persists after antibiotic therapy,"second line" therapy (using a different combination of medicines) is usually given and is successful most of the time. A few patients fail this therapy and require long term acid suppression therapy to prevent ulcer recurrence.
A number of factors are known to influence whether HP eradication therapy is successful:
- Compliance – it is important not to miss doses of treatment and to complete the course, to minimize the chances of the bacteria becoming resistant to the antibiotics.
- Side effects – these are common but usually minor and disappear with continued treatment. The commonest is diarrhea which may affect up to 50% of patients. Nausea, vomiting, abdominal cramps, headache and rash are other reported side effects. Metronidazole may cause a metallic taste in the mouth and can interact with alcohol to cause flushing and vomiting.
- Metronidazole resistance – Some strains of HP are resistant to Metronidazole and this makes treatment less effective. The frequency of this problem varies considerably throughout the country and between countries.
- Cost – The cost of a course of HP therapy varies considerably and you should discuss this with your doctor and your pharmacist when treatment is prescribed.
Other indications for HP eradication are still under study. It is indicated in patients suffering from a rare type of low grade lymphoma affecting the stomach (MALToma). There is currently no evidence that getting rid of the infection helps patients with gastroesophageal reflux disease, non ulcer dyspepsia, or relatives of patients with gastric cancer.
Other important steps in management include stopping smoking, curtailing excessive alcohol intake and avoiding aspirin and NSAIDs if possible. No specific dietary measures are required. Long term treatment with acid suppressing drugs is not usually necessary after successful HP therapy.
Many different medications are available to relieve the symptoms of dyspepsia and for healing peptic ulcers. The most commonly used are:
- Antacids
- These are simple, widely available and helpful in relieving minor symptoms. Many different ones are available and most are based on aluminum, magnesium, or calcium salts. They are generally safe and side effects are uncommon. Calcium and aluminum based antacids may cause constipation, while those containing magnesium may cause loose stools. Some contain large amounts of sodium (salt) and these should be used with caution in patients with heart failure.
- H2 (histamine) antagonists
- These drugs were a major breakthrough in the treatment of ulcers when they were discovered around 25 years ago. The chemical histamine is involved in stimulating acid secretion from the stomach and blocking its effects inhibits acid secretion. There are several different medicines in this category:
- cimetidine (Tagamet)
- ranitidine (Zantac)
- famotidine (Pepcid)
- nizatidine (Axid)
- Proton Pump Inhibitors
- The first drug in this category (omeprazole, Prilosec) became available approximately 10 years ago and more recently Lansoprazole (Prevacid) has become available. These medications are more powerful than H2 antagonists at blocking acid secretion and will lead to faster relief of symptoms and healing of ulcers. They are, in general, very safe drugs but some side effects may occur and you should consult the package insert and your doctor before taking them. These are available only on prescription.
- Bismuth (Pepto-Bismol)
- Bismuth has been used for many years to treat indigestion and related symptoms. During this time its mechanism was not fully understood but it does have activity against HP and this may be the reason why it is useful. In combination with antibiotics it is effective in eradicating the infection and treatment with bismuth alone may provide relief of minor symptoms of indigestion or diarrhea. The success of powerful acid inhibiting drugs and HP therapy in recent years has made routine surgery for peptic ulcer disease rarely necessary. Patients who present as an emergency with perforation of an ulcer require urgent surgery as do those with severe ulcer bleeding which cannot be controlled by doctors using an endoscope.