Peptic Ulcer

U.S. Department of Health and Human Services Public Health Service National Institutes of Health
[Editor's Note: This is an OLD one, see ulcers1998.htm for latest stuff.]

What is a Peptic Ulcer? A peptic ulcer is an ulcer of the lining of either the stomach or the first part of the small intestine below the stomach called the duodenum. Peptic ulcers occur only in those regions of the gastrointestinal tract that are bathed by digestive juices secreted by the stomach. These juices contain hydrochloric acid and a digestive enzyme called pepsin - hence the name "peptic" ulcer. Peptic ulcers that appear in the stomach are called gastric ulcers, and those that occur in the duodenum are called duodenal ulcers. In the United States, duodenal ulcers are more common than gastric ulcers. The reverse is true in Japan. Who Gets Ulcers? Approximately 1 out of every 10 Americans will have a peptic ulcer sometime during his or her life. Each year, over 46,000 operations for peptic ulcer disease are performed, and over 7,000 people in the United States die from complications associated with ulcers. Although ulcers can occur at any age, they are rare among children and only slightly more common in teenagers. Duodenal ulcers usually first appear in people during their twenties or thirties, while gastric ulcers are more likely to develop among people who are in their forties or older. Heredity also is a factor in the incidence of peptic ulcer disease. A person's risk for getting an ulcer is increased threefold if any of his or her blood relatives have ulcers. A person has a greater chance of getting a duodenal ulcer if the relative has a duodenal ulcer. Similarly, a gastric ulcer is more likely to occur in a person whose parent or sibling has a gastric ulcer. Contrary to popular beliefs, there is limited evidence to show that a person's occupation or socioeconomic status has any effect on causing ulcers. However, the incidence of duodenal ulcers in men is about twice that in women, while the occurrence of gastric ulcers is about equal in both sexes.

What Causes Ulcers?

In a healthy person, there is a balance between factors that cause ulcers and factors that prevent ulcers. Most important among these factors are (1) the amount of acid and pepsin the stomach secretes, especially the former, and (2) the ability of the lining of the stomach and duodenum to resist the erosive action of the acid and pepsin. Sometimes, however, this balance can be upset and may lead to the development of an ulcer.

Most people with duodenal ulcers and some people with gastric ulcers secrete excess amounts of pepsin and acid. High levels of these digestive juices can overcome the lining defenses of the stomach or the duodenal wall and can cause an ulcer.

On the other hand, some ulcer patients secrete normal amounts of gastric acid. Instead, their ulcer may be caused by a decreased resistance of the lining of the stomach or duodenum. This weakness can leave the lining of the digestive tract unable to tolerate the normal amounts of gastric acid that the stomach secretes.

Environmental Factors

Although a variety of popular beliefs have associated numerous factors with peptic ulcers, only a few have been found to play a role in causing ulcers.

.Smoking. A considerable amount of scientific evidence has shown that cigarette smoking not only double a person's chances of getting an ulcer, but it also tends to slow the healing process of an existing ulcer. In addition, recent research findings indicate that smoking is an important factor in causing ulcer recurrence. People who stop smoking have a lower rate of recurrent ulcers regardless of what medication they may take. In fact, recent research has shown that the chances of an ulcer healing and staying healed are better if a patient quits smoking and takes no medication than if the patient continues to smoke and receives drug treatment.

.Aspirin. Persons who use aspirin regularly over long periods of time, such as some arthritis patients, have an increased chance of developing a gastric ulcer. Researchers have found that aspirin and similar drugs inhibit the stomach's production of a substance called prostaglandins. Prostaglandins may act to protect the lining of the stomach from injury by a wide variety of chemical agents, including the stomach's own acid secretions. In most cases, however, these ulcers disappear once the damaging drugs are stopped.

.Caffeine. Coffee, tea, cola drinks, and other foods that contain caffeine can stimulate acid secretion in the digestive tract and, in turn, may aggravate the pain of an existing ulcer. However, the role of caffeine products in contributing to the development of ulcers is unknown. The level of acid secretion induced by decaffeinated coffee is the same as with regular coffee. Therefore, substances other than caffeine are present in coffee that stimulate gastric activity.

.Diet. No convincing evidence shows that certain diets can cause ulcers or that certain diets can heal ulcers and keep them healed. A diet may help to relieve the pain or indigestion of an existing ulcer, but it will not prevent an ulcer from forming. Many foods that initially neutralize acid in the stomach also may stimulate additional acid secretion. In fact, research has shown that milk, which was a mainstay in the diets of ulcer patients, actually can be a potent stimulant of gastric acid secretion.

.Alcohol. One of the most popular myths about peptic ulcers is that people who drink alcohol are more likely to get an ulcer. The truth is that even those people who are moderate to heavy users of alcohol do not have an increased chance of developing an ulcer. Although alcohol often was though to be a stimulant of stomach acid secretion, numerous studies have failed to establish such a relationship between acid secretion and concentrated alcoholic drinks.

Can Stress Cause Ulcers?

Although stress may aggravate the pain or indigestion associated with an ulcer, scientists have not yet been able to determine whether stress is an important factor in causing ulcers. Stress is difficult to measure, because people react differently to similar circumstances. A situation that may cause stress in one person may have no effect on someone else.

So far, there is no convincing proof that people who have high pressure jobs or who experience a great deal of tension in their lives are more likely to develop ulcers. However, some ulcer patients may be less able to tolerate large amounts of stress or tension. Consequently, these people may believe that their ulcer pain increases or "acts up" when they are confronted with a stressful situation.

Regardless of the level of effect that stress may have on a patient's ulcer, it is a good idea for the patient and his or her physician to work together to identify and then try to reduce or remove stressful factors in the patient's life.

Physical stress, however, is associated with an increase in ulcer incidence. thus burns, surgery, and other trauma often require rigorous treatment of acidity.

What are the Symptoms of an Ulcer?

The most common symptom of a duodena ulcer is a gnawing or burning pain in the abdomen between the navel and lower end of the breastbone. The pain most often occurs between meals and in the early hours of the morning, when the stomach may increase its acid secretion. The pain, which can last a few minutes to a few hours, usually is relieved by eating food or taking antacids. Unfortunately, these symptoms are not always specific enough to diagnose an ulcer. Some people may have an ulcer with little or no pain, while others may have an unrelated disorder that causes similar symptoms. Frequently, a physician will conduct more extensive tests to verify the presence of an ulcer.

How Does a Doctor Diagnose an Ulcer?

When a patient describes symptoms similar to those mentioned above, a physician usually suspects a peptic ulcer. The most common procedure for detecting an ulcer is an X-ray. With this technique, the physician may have the patient swallow a solution containing barium sulfate, a substance that helps to create a sharp silhouette of the digestive tract on x-ray film. If an ulcer is present, a pool of barium liquid may fill the ulcer crater and usually appear in x-ray pictures of the stomach and duodenum.

Sometimes, an ulcer may not be revealed in an x-ray study. If this happens, the doctor can use an alternate method of detecting ulcers with an instrument called a fiber optic endoscope. This device is a flexible tube containing two bundles of flexible glass fibers that can be passed through a patient's mouth and esophagus and into the stomach and duodenum. One small bundle of fibers is used to conduct light, which illuminates the inner surfaces of the digestive tract. The other bundle lets the physician view the lighted area to look for signs of an ulcer.

How are Ulcers Treated?

Most treatments for ulcers attempt to reduce stomach acid concentration to allow an ulcer to heal more quickly.

.Antacids. Antacids are medications that can offer temporary relief from ulcer pain by neutralizing hydrochloric acid in the stomach. There are many commercially available antacids on the market, and a physician usually can find one for a patient that is not unpleasant to take.

.Drugs. Several prescription drugs can successfully relieve pain and promote ulcer healing.

-Cimetidine (Tagamet) reduces the amount of acid the stomach secretes by stopping the stomach's response to histamine. (In addition to hay fever and other allergic reactions, histamine also plays a role in gastric acid secretion.) Cimetidine works by blocking the action of the histamine II receptors in the stomach. These receptors are different in the stomach. These receptors are different from the histamine I receptors that are involved with allergies.

-Ranitidine (Zantac) also inhibits stomach acid secretion by blocking histamine action at the site of the histamine II receptors. However, ranitidine does not have some of the side effects associated with cimetidine.

-Sucralfate (Carafate) has been approved by the Food and Drug Administration (FDA) for short-term (up to 8 weeks) treatment of duodenal ulcers. Unlike cimetidine or ranitidine, sucralfate may act directly on an ulcer site by coating the ulcer and protecting the area from further damage by gastric acid.

What Happens if the Ulcer Won't Heal?

In the vast majority of cases, the drugs mentioned above are successful in healing ulcers. However, some patients may not respond to this type of treatment. In these cases, surgery may be required to correct the problem.

One type of surgery is known as an antrectomy. This operation involves removing a lower portion of the stomach called the antrum. The antrum is the part of the stomach that produces gastrin, which is the hormone that stimulates the stomach to secrete digestive juices. Sometimes a surgeon may also remove an adjacent part of the stomach that actually secretes pepsin and acid.

Another type of operation, called a vagotomy, involves cutting the vagus nerve, which connects the brain to the stomach. There are several variations of a vagotomy, depending on where the vagus nerve is cut. The newest and most refined variation of this operation is called a selective vagotomy. This procedure concentrates on cutting only those parts of the vagus nerve that go to the acid secreting cells in the stomach wall. The operation is designed to avoid those parts of the vagus nerve that influences the motility involved in stomach emptying. This type of surgery has the lowest incidence of side effects, but it is the least effective in keeping ulcers healed.

These operations are usually successful in healing ulcers. However, ulcer surgery sometimes can result in serious complications, which may have long-term effects and which may be more debilitating than the original ulcer disease. Thus, a patient should consult his or her physician and thoroughly consider the possible side effects of an operation before undergoing surgery.

What are the Complications of Ulcers?

In addition to pain, ulcer patients may sometimes experience serious complications if their ulcer is left untreated.

.Bleeding. As an ulcer erodes into the muscular portion of the gastric or duodenal wall, it can erode into blood vessels and cause bleeding into the digestive tract. If the damaged blood vessels are small, the blood may seep out slowly, and over a long period of time, the patient can gradually become anemic. On the other hand, if the damaged blood vessel is large, bleeding into the intestinal tract is more rapid and can be very dangerous. The patient may feel faint, vomit blood, or collapse suddenly. With some bleeding ulcers, the stool may become a tarry black color due to the digested blood it contains. Without prompt medical attention, often including blood transfusions and surgery, the patient may bleed to death.

.Perforation. Sometimes an ulcer will erode all the way through the wall of the stomach or duodenum. If this happens, partially digested food and bacteria from the digestive tract can spill into the sterile abdominal cavity and cause peritonitis, an inflammation of the abdominal cavity and wall. A perforated ulcer, which can cause sudden, severe pain, usually requires hospitalization and corrective surgery.

.Narrowing and Obstruction. Ulcers that occur in the duodenum or in the narrow section where the stomach connects to the duodenum can cause spasms of the adjacent muscles and swelling of surrounding tissue. This swelling can cause the intestinal opening to become narrowed or closed off completely. Such an obstruction can prevent food from leaving the stomach and entering the intestinal tract. A patient may vomit the contents of the stomach and, if the condition continues, lose weight and develop other problems. Again, surgery may be necessary to correct this problem.

Can Ulcers Recur?

Peptic ulcer disease is a chronic relapsing disorder. About 50 percent of ulcer patients experience another episode within 1 to 2 years after the previous ulcer has healed. The longer a person goes without a recurrence, the greater the likelihood that an ulcer will return. The underlying cause of ulcers is still unknown, but researchers believe that peptic ulcer disease is a group of disorders, all of which share the same symptom - an ulceration of the lining of the stomach of duodenum.

The FDA has approved cimetidine (Tagamet) for long-term maintenance therapy to prevent recurrent ulcers. The drug, if taken regularly, can be successful and has exhibited a very low incidence of side effects. It also provides an effective alternative to surgery for those patients with severe cases of peptic ulcers who are at a high risk for surgery or who prefer not to have an operation. However, the protection that the drug gives is lost when the treatment is stopped.

Can an Ulcer Lead to Cancer?

Although there is little evidence that a peptic ulcer ever develops into cancer, there can be ulceration in a stomach cancer. Because stomach cancer can ulcerate or exhibit some symptoms that are similar to those of a peptic ulcer, it is important to establish promptly whether the ulceration is truly a peptic ulcer or an ulcer with cancer. Cancer of the duodenum is very rare so there is little chance of cancer being the cause of a duodenal ulcer.

Are Peptic Ulcers and Ulcerative Colitis Related?

No, they are entirely different diseases. Ulcerative colitis is an inflammatory condition of the colon and rectum, the lowermost portions of the intestines. Although many small ulcers develop in the colon in ulcerative colitis, the basic cause and treatment of these two disorders are very different.

Peptic Ulcer Research

The National Institute of Arthritis, Diabetes, and Digestive and Kidney Diseases (NIADDK), a bureau of the National Institutes of Health, provides a great deal of funding for research on peptic ulcer disease. A variety of projects funded by NIADDK are under way that are aimed at helping scientists understand the cause of ulcers and the mechanisms that control gastric acid secretion.

For example, NIADDK-funded scientists have been looking for possible significance of the fact that certain hormones have been found both in the stomach and in the brain. They also have been examining the role of these hormones, along with the central nervous system, in controlling gastric acid secretion.

Other institute-supported researchers have been studying how the stomach can repair itself after damage inflicted by a variety of chemicals. Aspirin is one chemical that has long been known to cause ulcers in arthritis patients who take large doses of the drug to fight the joint inflammation of the disease. Findings from these studies may help scientists understand the mechanisms that cause an ulcer, and, in turn, how to induce the injured stomach to repair itself once an ulcer has occurred. An understanding of the mechanism by which the stomach manufactures acid, by activity of an enzyme called HK ATPase, has led to possibly significant new drugs.

Some of NIADDK's own scientists at the National Institutes of Health in Bethesda, Maryland, have been testing promising new drugs for treating ulcers, particularly for long-term therapy. One drug, omeprazole, also holds hope for the long-term treatment of Zollinger-Ellison syndrome. This condition is marked by severe recurrent ulcers due to the production of several times the normal amounts of stomach acid.

The Institute also provides funding for the Center for Ulcer Research and Education (CURE) located at the University of California in Los Angeles. The center's two main goals are (1) to investigate the cause, treatment, diagnosis, and prevention of peptic ulcers and (2) to disseminate the knowledge gained from this research to health professionals and the general public.

For additional information on peptic ulcers, contact:

CURE Foundation Suite 304 11661 San Vincente Boulevard Los Angeles, California 90049

Prepared by the Office of Health Research Reports National Institute of Arthritis, Diabetes, and Digestive and Kidney Diseases

NIH Publication No. 85-38 September 1985 ?? /book35.htm

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