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Peptic ulcer facts**Peptic ulcer disease facts medically edited by: Jay W. Marks, MD

Peptic ulcers are sores in the lining of the stomach or duodenum. Peptic ulcer formation is related to H. pylori bacteriain the stomach andnonsteroidal antiinflammatory medications(NSAIDs) in 50% of patients. For the remaining 50% there are miscellaneous or unknown causes. Ulcer pain may not correlate with the presence or severity of ulceration. The main symptom of peptic ulcer is upper abdominal pain which can be dull, sharp, or burning. (Bloatingand burping are not symptoms of peptic ulcer, and vomiting, poor appetite, and nausea are uncommon symptoms of peptic ulcer.) Diagnosis of ulcer is made with upper GI series orendoscopy. Treatment of ulcers involves antibiotic combinations along with stomach acid suppression to eradicate H. pylori, eliminating precipitating factors such as NSAIDs and stomach acid suppression with medications alone . Complications of ulcers include bleeding, perforation, and blockage of the stomach (gastric obstruction). If a person with peptic ulcers smokes or take NSAIDs, the ulcers may recur after treatment.

What is a peptic ulcer?A peptic ulcer is a sore in the lining of your stomach or duodenum. The duodenum is the first part of your small intestine. A peptic ulcer in the stomach is called a gastric ulcer. One that is in the duodenum is called a duodenal ulcer. A peptic ulcer also may develop just above your stomach in the esophagus, the tube that connects the mouth to the stomach. But most peptic ulcers develop in the stomach or duodenum. Many people have peptic ulcers. You can have both gastric and duodenal ulcers at the same time and you also can have more than one ulcer in your lifetime. Peptic ulcers can be treated successfully. Seeing your doctor is the first step.

What causes of peptic ulcers?Most peptic ulcers are caused by

Helicobacter pyloricus (H. pylori) a germ that causes infection nonsteroidal anti-inflammatory drugs NSAIDs), such as aspirin andibuprofen

H. pylori is the most common cause of peptic ulcers. Doctors think H. pylorimay be spread through unclean food or water or by mouth-to-mouth contact, such as kissing. Even though many people have an H. pylori infection, most of them never develop an ulcer.

Use of NSAIDs is the second most common cause of peptic ulcers. But not everyone who takes NSAIDs gets a peptic ulcer. Ulcers caused by NSAIDs are more often found in people who

are age 60 or older are female have taken NSAIDs for a long time have had an ulcer before

Other causes of peptic ulcers are rare. One rare cause is Zollinger-Ellison syndrome - a disease that makes the body produce too much stomach acid, which harms the lining of the stomach or duodenum. Stress or spicy food does not cause peptic ulcers, but either can make ulcer symptoms worse.

What are symptoms of peptic ulcers?A dull or burning pain in your stomach is the most common symptom of peptic ulcers. You may feel the pain anywhere between your belly button and breastbone. The pain often

starts between meals or during the night briefly stops if you eat or take antacids lasts for minutes to hours comes and goes for several days or weeks.

Other symptoms of peptic ulcers may include

weight loss poor appetite

bloating burping vomiting feeling sick to your stomach

Even if your symptoms are mild, you may have peptic ulcers. You should see your doctor to talk about your symptoms. Peptic ulcers can get worse if they aren't treated. Call your doctor right away if you have

sudden or sharp pain that doesn't go away black or bloody stools bloody vomit or vomit that looks like coffee grounds

These symptoms could be signs that an ulcer has

broken a blood vessel gone through, or perforated, your stomach or duodenal wall stopped food from moving from you stomach into the duodenum

These symptoms must be treated quickly. You may need surgery.

How are peptic ulcers diagnosed?Tell your doctor about your symptoms and which medicines you take. Be sure to mention those you get without a prescription, such as Bayer, Motrin, Advil, or Aleve. These medicines are all NSAIDs. To see if you have an H. pylori infection, your doctor will test your blood, breath, or stool. About half of all people who develop an ulcer from NSAIDs also have an H. pylori infection. Your doctor also may want to look inside your stomach and duodenum by doing an endoscopy or an upper gastrointestinal (GI) series - a type of X-ray. Both procedures are painless. For an endoscopy, you will be given medicine to relax you. Then the doctor will pass an endoscope a thin, lighted tube with a tiny camera - through your mouth to your stomach and duodenum. Your doctor also may take a small piece of tissue - no bigger than a match head-to look at through a microscope. This process is called a biopsy. For an upper GI series, you will drink a liquid called barium. The barium will make your stomach and duodenum show up clearly on the X-rays.

What is the treatment for peptic ulcers?If you have peptic ulcers, they can be cured. Depending on what caused your ulcers, your doctor may prescribe one or more of the following medicines:

a proton pump inhibitor (PPI) or histamine receptor blocker (H2 blocker) to reduce stomach acid and protect the lining of your stomach and duodenum one or more antibiotics to kill an H. pylori infection a medicine that contains bismuth subsalicylate, such as Pepto-Bismol, to coat the ulcers and protect them from stomach acid

These medicines will stop the pain and help heal the ulcers. If an NSAID caused your peptic ulcers, your doctor may tell you to

stop taking the NSAID reduce how much of the NSAID you take take a PPI or H2 blocker with the NSAID switch to another medicine that won't cause ulcers You should take only the medicines your doctor tells you to take all medicines exactly as your doctor tells you to, even if your pain stops

Tell your doctor if the medicines make you feel sick or dizzy or causediarrhea or headaches. Your doctor can change your medicines. And if you smoke, quit. You also should avoid alcohol. Smoking and drinking alcohol slow the healing of ulcers and can make them worse.

Can antacids or milk help peptic ulcers heal?Neither antacids - such as Tums - nor milk can heal peptic ulcers, although each may make you feel better briefly. Check with your doctor before taking antacids or drinking milk while your ulcers are healing. Some of the antibiotics used for H. pylori infection may not work as well if you take antacids. And while antacids may make ulcer pain go away for a while, they won't kill the H. pylori germ. Only antibiotics can do that. Many people used to think that drinking milk helped peptic ulcers heal. But doctors know now that while milk may make ulcers feel better briefly, it also increases stomach acid. Too much stomach acid makes ulcers worse.

What if peptic ulcers don't heal?In many cases, medicines heal ulcers. If anH. pylori infection caused your ulcers, you must finish all antibiotics and take any other medicines your doctor prescribes. The infection and ulcers will only heal if you take all medicines as prescribed. When you have finished your medicines, your doctor will do a breath or stool test to be sure the H. pylori infection is gone. Sometimes, the H. pylori germ is still there, even after a person has taken all

the medicines correctly. If that happens, your doctor will prescribe different antibiotics to get rid of the infection and cure your ulcers. Rarely, surgery is needed to help ulcers heal. You may need surgery if your ulcers

don't heal keep coming back bleed perforate the stomach or duodenal wall block food from moving out of the stomach

Surgery can

remove the ulcers reduce the amount of acid in your stomach

Can peptic ulcers come back?Yes. If you smoke or take NSAIDs, your ulcers may come back. If you need to take an NSAID, your doctor may switch you to a different medicine or add medicines to help prevent ulcers.

What can I do to prevent peptic ulcers?To help prevent ulcers caused by H. pylori,

wash your hands with soap and water after using the bathroom and before eating eat food that has been washed well and cooked properly drink water from a clean, safe source

To help prevent ulcers caused by NSAIDs,

stop using NSAIDs, if possible take NSAIDs with a meal, if you still need NSAIDs use a lower dose of NSAIDs ask your doctor about medicines to protect your stomach and duodenum while taking NSAIDs ask your doctor about switching to a medicine that won't cause ulcers

Peptic ulcer is basically a lesion located at the level of the stomach, duodenum or esophagus. Ulcer tends to affect the entire gastrointestinal tract, starting from the lining of the mouth and ending with the rectal region. Peptic ulcer suggests the involvement of hydrochloric acid and pepsin in the development of the disorder. When gastric acid is produced in excess, the mucosal membrane that protects the stomach and internal organs from danger is damaged, enabling the bacteria Helicobacter pylori to penetrate the barrier and cause internal infections. Therefore, in the case of peptic ulcer, both gastric acid and bacteria are responsible for the development of the disorder. Peptic ulcer located in the stomach is called gastric ulcer; peptic ulcer located at the level of the duodenum is called duodenal ulcer and peptic ulcer developed at the level of the esophagus is called esophageal ulcer. Peptic ulcer is very common, millions of Americans being diagnosed with different forms of the disorder each year. The advance of modern medicine has allowed scientists to find out more valuable information about these disorders, enabling them to develop new medical treatments. Although in the past peptic ulcer was known to affect mostly male persons, more and more women suffer from forms of peptic ulcer nowadays. Statistics indicate that the predominance of smoking among women has determined an increase of peptic ulcer incidence with the female gender. Peptic ulcers can sometimes develop into more serious disorders. As a result of complications, peptic ulcer may lead to perforate or bleeding ulcer. These two forms of ulcer are considered to be very dangerous, research results indicating a high probability of death due to such complications. Perforate ulcer involves severe tearing of the mucosal membrane, causing acute pain and sourness at the abdominal level. Bleeding ulcer involves internal hemorrhages and it needs immediate medical intervention. Most forms of perforate and bleeding ulcer require surgery due to their gravity. If the bleeding is severe, the medical intervention is primarily focused on stopping the hemorrhage and resuscitating the patient. The patient requires blood transfusions to compensate for the loss of blood and needs to be kept under constant monitoring until recovered. The most common symptoms of bleeding ulcer are: nausea, fever, vomiting blood, presence of blood in the feces, black feces, dehydration, fatigue and body weakness. Due to loss of blood, such forms of ulcer may lead to anemia. Some peptic ulcers are therefore more difficult to treat than others. When dealing with peptic ulcer, it is very important too keep away from alcohol, caffeine, cigarettes and cola, as these may all aggravate the symptoms of the disorder. You should try to respect a healthy diet and follow the medical treatment prescribed by your physician. If you respect these directions, your ulcer symptoms will most likely ameliorate within the first week of treatment, ensuring the remission of the disorder.

Peptic Ulcers OverviewIn the digestive system, an ulcer is an area where tissue has been destroyed by gastric juices and stomach acid. Peptic ulcer disease is a general term for ulcers that occur in the stomach or duodenum (upper part of the small intestine). A peptic ulcer is an erosion or sore in the wall of the gastrointestinal tract. The mucous membrane lining the digestive tract erodes and causes a gradual breakdown of tissue. This breakdown causes a gnawing or burning pain in the upper middle part of the belly (abdomen). Although most peptic ulcers are small, they can cause a considerable amount of discomfort. Peptic ulcers are a very common condition in the United States and throughout the world. In the United States, about 10% of the population will develop a duodenal ulcer at some point in their lives. Peptic ulcer disease affects about 4.6 million people annually. The occurrence of peptic ulcer disease is similar in men and women. Approximately 11%-14% of men and 8%-11% of women will develop peptic ulcer disease in their lifetime. The mortality rate for peptic ulcer disease is approximately one death per 10,000 cases. The mortality rate due to ulcer hemorrhage is approximately 5%. Ulcers can occur at any age, although they are rare in children and teenagers. The good news is that we have learned a lot about ulcers in the past 20 years and effective therapies are now available.

Peptic Ulcers CausesWhen you eat, your stomach produces hydrochloric acid and an enzyme called pepsin to digest the food. The food is partially digested in the stomach and then moves on to the duodenum to continue the process. Peptic ulcers occur when the acid and enzyme overcome the defense mechanisms of the gastrointestinal tract and erode the mucosal wall. In the past it was throught that ulcers were caused by lifestyle factors such as eating habits, cigarette smoking, and stress. Now it is understood that people with ulcers had an imbalance between acid and pepsin coupled with the digestive tract's inability to protect itself from these harsh substances. Research done in the 1980s showed that ulcers are caused by infection with a bacterium named Helicobacter pylori, usually called H pylori. Not everyone who gets an ulcer is infected with H pylori. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) can cause ulcers if taken regularly.

Some types of medical therapy can contribute to ulcer formation. The following factors can weaken the protective mucosal barrier of the stomach increasing the chances of getting an ulcer and slows healing of existing ulcers. Aspirin, nonsteroidal anti-inflammatory drugs (such as ibuprofen andnaproxen), and newer antiinflammatory medications (such as celecoxib[Celebrex]) Alcohol Stress: physical (severe injuries or burns, major surgery) or emotional Caffeine Cigarette smoking Radiation therapy:-used for diseases such as cancer People who take aspirin or other anti-inflammatory medication are at increased risk even if they do not have H pylori infection. Elderly people with conditions such as arthritis are especially vulnerable. People who have had prior ulcers or intestinal bleeding are at higher-than-normal risk. If a person takes these medications regularly, alternatives should be discussed with a health care professional. This is especially true if the affected individual has an upset stomach or heartburn after taking these medications. H pylori bacteria spread through the stools (feces) of an infected person. The stool contaminates food or water (usually through poor personal hygiene). The bacteria in the stool make their way into the digestive tracts of people who consume this food or water. This is called fecal-oral transmission and is a common way for infections to spread. The bacteria are found in the stomach, where they are able to penetrate and damage the lining of the stomach and duodenum. Many people who are exposed to the bacteria never develop ulcers. People who are newly infected usually develop symptoms within a few weeks. Researchers are trying to discover what is different about the people who develop ulcers. Infection with H pylori occurs in all ages, races, and socioeconomic classes. It is more common in older adults, although it is thought that many people are infected in childhood and carry the bacteria throughout their lifetimes. It is also more common in lower socioeconomic classes because these households tend to have more people living together, sharing bathrooms and kitchen facilities. African Americans and Hispanic Americans are more likely to have the bacteria than whites and Asian Americans. It is important to distinguish between ulcers caused by H pylori and those caused by medications only, because the treatment is completely different.

Ulcers can be linked with other medical conditions. People who worry excessively are usually thought to have a condition calledgeneralized anxiety disorder. This disorder has been linked with peptic ulcers. A rare condition called Zollinger-Ellison syndrome causes peptic ulcers as well as tumors in the pancreas and duodenum.

Peptic Ulcer SymptomsUlcers do not always cause symptoms. Sometimes, a serious complication such as bleeding is the first sign of an ulcer. The most common symptom of peptic ulcers isabdominal pain. The pain is usually in the upper middle part of the abdomen, above the belly button (navel) and below the breastbone. The pain can feel like burning or gnawing, and it may go through to the back. Pain often comes several hours after a meal when the stomach is empty. The pain is often worse at night and early morning. It can last anywhere from a few minutes to several hours. The pain may be relieved by food, antacids, or vomiting. Other symptoms of peptic ulcers include the following: Nausea Vomiting Loss of appetite Loss of weight Severe ulcers may cause bleeding in the stomach or duodenum. Bleeding is sometimes the only symptom of an ulcer. This bleeding can be fast or slow. Fast bleeding reveals itself in one of the following ways: Vomiting of blood or dark material that looks something like coffee grounds: This is an emergency and warrants an immediate visit to an emergency department. Blood in the stool or black, tarry, sticky-looking stools Slow bleeding is often more difficult to detect, because it has no dramatic symptoms. The usual result is low blood cell count (anemia). The symptoms of anemia are tiredness (fatigue), lack of energy (lethargy), weakness, rapid heartbeat (tachycardia), and pales skin (pallor).

When to Seek Medical Care

If you have burning pain in your upper stomach that is relieved by eating or taking antacids, call a health care professional for an appointment. Don't assume you have an ulcer. Certain other conditions can cause similar symptoms. If you vomit blood or have other signs ofgastrointestinal bleeding, go to an emergency department right away. Peptic ulcers can cause massive bleeding, which requires blood transfusion or surgery. Severe abdominal pain suggests perforation or tearing of an ulcer. This is an emergency that may require surgery to fix a hole in your stomach. Vomiting and abdominal pain also can be a sign of an obstruction, another complication of peptic ulcers. This also may require emergency surgery.

Peptic Ulcer PreventionPeptic ulcers can be prevented by avoiding things that break down the stomach's protective barrier and increase stomach acid secretion. These include alcohol, smoking, aspirin, nonsteroidal anti-inflammatory drugs, and caffeine. Preventing infection with H pylori is a matter of avoiding contaminated food and water and adhering to strict standards of personal hygiene. Wash hands carefully with warm water and soap every time the bathroom is used, diaper changed, and before and after preparing food. If you need the pain relief and anti-inflammatory action of aspirin or an NSAID, you can reduce your risk of ulcers by trying the following: Try a different NSAID, one that is easier on the stomach. Reduce the dose or the number of times you take the medication. Substitute another medication, such as acetaminophen (Tylenol). Talk to your health care professional about how you can protect yourself. Following the treatment recommendations of your health care professional can help prevent recurrence of ulcers. This includes taking all medications as prescribed, especially if you have H pylori infection.

What Is Peptic Ulcer Disease?Peptic ulcer disease refers to painful sores or ulcers in the lining of the stomach or first part of the small intestine, called the duodenum. What Causes Ulcers? No single cause has been found for ulcers. However, it is now clear that an ulcer is the end result of an imbalance between digestive fluids in the stomach and duodenum. Ulcers can be caused by: Infection with a type of bacteria called Helicobacter pylori (H. pylori) Use of painkillers called nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, naproxen (Aleve, Anaprox, Naprosyn, and others), ibuprofen (Motrin, Advil, Midol, and others), and many others available by prescription. Even aspirin coated with a special substance can still cause ulcers. Excess acid production from gastrinomas, tumors of the acid producing cells of the stomach that increases acid output; seen in Zollinger-Ellison syndrome. What Are the Symptoms of an Ulcer?

An ulcer may or may not have symptoms. When symptoms occur, they include: A gnawing or burning pain in the middle or upper stomach between meals or at night Bloating Heartburn Nausea or vomiting In severe cases, symptoms can include: Dark or black stool (due to bleeding) Vomiting blood (can have a "coffee-grounds" appearance) Weight loss Severe pain in the mid to upper abdomen How Serious Is an Ulcer? Though ulcers often heal on their own, you shouldn't ignore their warning signs. If not properly treated, ulcers can lead to serious health problems, including: Bleeding Perforation (a hole through the wall of the stomach) Gastric outlet obstruction from swelling or scarring that blocks the passageway leading from the stomach to the small intestine. Taking NSAIDs can cause any of the above without warning. The risk is especially concerning for the elderly and for those with a prior history of having peptic ulcer disease. Who Is More Likely to Get Ulcers? You may be more likely to develop ulcers if you: Are infected with the H. pylori bacterium Take NSAIDs such as aspirin, ibuprofen, naproxen, and many others Have a family history of ulcers Have another illness, such as liver, kidney, or lung disease Drink alcohol regularly Are 50 years old or older

How Are Ulcers Diagnosed? Your doctor may be able to make an ulcer diagnosis just by talking with you about your symptoms. However, to confirm the diagnosis one of several tests should be taken. First, your doctor may ask you to take an acid-blocking medication such as those used to treat heartburn for a short period of time to see if your symptoms improve. If needed, your doctor may recommend a procedure called an upper endoscopy. It involves inserting a small, lighted tube (endoscope) through the throat and into the stomach to look for abnormalities. This procedure is usually given if you are having severe symptoms of ulcers.

Often, doctors will frequently treat without confirming the diagnosis using endoscopy. If the cause is not likely to be from NSAIDs, then it is very likely to be from H. pylori. Most doctors will now test for H. pylori and will treat specifically for that in addition to giving medications to reduce the symptoms.

What Is Peptic Ulcer Disease?(continued)How Are Ulcers Treated? Though ulcers often heal on their own, you shouldn't ignore their warning signs. If not properly treated, ulcers can lead to serious health problems. There are several ways in which ulcers can be treated, including making changes to ones lifestyle, taking medication, and/or undergoing surgery. Lifestyle Changes to Treat an Ulcer To treat an ulcer, first eliminate substances that can be causing the ulcers. If you smoke or drink alcohol, stop. If the ulcer is believed to be caused by the use of NSAIDs, they need to be stopped. Ulcer Medications Ulcer medications can include: Proton pump medications (PPI). Proton pump medications reduce acid levels and allow the ulcer to heal. They include Prilosec, Prevacid, Aciphex, Protonix, Kapidex, Zegerid, and Nexium. Antibiotics. If you have H. pylori infection, then antibiotics are used. There are multiple combinations of antibiotics that are taken for one to two weeks along with a PPI. Some doctors also recommend taking Pepto-Bismol. Upper Endoscopy . Some bleeding ulcers can be treated through the endoscope. Surgery. Sometimes an operation is needed if the ulcer has created a hole in the wall of the stomach or if there is serious bleeding. Will Drinking Milk Help Cure an Ulcer? No. Milk can make your ulcer worse. Milk provides brief relief of ulcer pain because it coats the stomach lining. But milk can also stimulate your stomach to produce more acid and digestive juices, which can aggravate ulcers. How Can I Prevent Ulcers? To try and prevent ulcers from developing: Don't smoke. Avoid alcohol. Don't overuse aspirin and/or NSAIDs. If you have symptoms of an ulcer, contact your doctor. peptic ulcer, also known as PUD or peptic ulcer disease,[1]

is the most common ulcer of an area of

thegastrointestinal tract that is usually acidic and thus extremely painful. It is defined as mucosal erosions

equal to or greater than 0.5 cm. As many as 7090% of such ulcers are associated with Helicobacter pylori, a spiral-shaped bacterium that lives in the acidic environment of the stomach; however, only 40% of those cases go to a doctor. Ulcers can also be caused or worsened by drugs such as aspirin, ibuprofen, and other NSAIDs. Four times as many peptic ulcers arise in the duodenumthe first part of the small intestine, just after the stomachas in the stomach itself. About 4% of gastric ulcers are caused by a malignant tumor, so multiple biopsies are needed to exclude cancer. Duodenal ulcers are generally benign.Contents [hide]

1 Classification 2 Signs and symptoms


2.1 Complications

3 Cause


3.1 Stress

4 Diagnosis

o o o

4.1 Macroscopic appearance 4.2 Microscopic appearance 4.3 Differential diagnosis

5 Treatment 6 Epidemiology 7 History 8 Notes 9 References 10 External links 11 Notes

[edit]Classification By Region/Location Duodenum (called duodenal ulcer) Oesophagus (called esophageal ulcer) Stomach (called gastric ulcer) Meckel's diverticulum (called Meckel's diverticulum ulcer; is very tender with palpation)

Modified Johnson Classification of peptic ulcers:

Type I: Ulcer along the body of the stomach, most often along the lesser curve at incisura angularis along the locus minoris resistantiae. Type II: Ulcer in the body in combination with duodenal ulcers. Associated with acid oversecretion. Type III: In the pyloric channel within 3 cm of pylorus. Associated with acid oversecretion. Type IV: Proximal gastroesophageal ulcer Type V: Can occur throughout the stomach. Associated with chronic NSAID use (such as aspirin).


and symptoms

Symptoms of a peptic ulcer can be abdominal pain, classically epigastric with severity relating to mealtimes, after around three hours of taking a meal (duodenal ulcers are classically relieved by food, while gastric ulcers are exacerbated by it); bloating and abdominal fullness; waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus - although this is more associated with gastroesophageal reflux disease); nausea, and copious vomiting; loss of appetite and weight loss; hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or from damage to the esophagus from severe/continuing vomiting. melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin); rarely, an ulcer can lead to a gastric or duodenal perforation, which leads to acute peritonitis. This is extremely painful and requires immediate surgery.

A history of heartburn, gastroesophageal reflux disease (GERD) and use of certain forms of medication can raise the suspicion for peptic ulcer. Medicines associated with peptic ulcer include NSAID (nonsteroid anti-inflammatory drugs) that inhibit cyclooxygenase, and most glucocorticoids (e.g. dexamethasone andprednisolone). In patients over 45 with more than two weeks of the above symptoms, the odds for peptic ulceration are high enough to warrant rapid investigation byesophagogastroduodenoscopy. The timing of the symptoms in relation to the meal may differentiate between gastric and duodenal ulcers: A gastric ulcer would give epigastric pain during the meal, as gastric acid production is increased as food enters the stomach. Symptoms of duodenal ulcers would initially be relieved by a meal, as the pyloric sphincter closes to concentrate the stomach contents, therefore acid is not reaching the duodenum. Duodenal ulcer pain would manifest mostly 23 hours after the meal, when the stomach begins to release digested food and acid into the duodenum. Also, the symptoms of peptic ulcers may vary with the location of the ulcer and the patient's age. Furthermore, typical ulcers tend to heal and recur and as a result the pain may occur for few days and weeks and then wane or disappear. unless complications have arisen.[2]

Usually, children and the elderly do not develop any symptoms

Burning or gnawing feeling in the stomach area lasting between 30 minutes and 3 hours commonly accompanies ulcers. This pain can be misinterpreted ashunger, indigestion or heartburn. Pain is usually caused by the ulcer but it may be aggravated by the stomach acid when it comes into contact with the ulcerated area. The pain caused by peptic ulcers can be felt anywhere from the navel up to the sternum, it may last from few minutes to several hours and it may be worse when the stomach is empty. Also, sometimes the pain may flare at night and it can commonly be temporarily relieved by eating foods that buffer stomach acid or by taking anti-acid medication. different for every sufferer. [edit]Complications Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be lifethreatening. artery. [5] [4] [3]

However, peptic ulcer disease symptoms may be

It occurs when the ulcer erodes one of the blood vessels, such as the gastroduodenal

Perforation (a hole in the wall) often leads to catastrophic consequences. Erosion of the gastrointestinal wall by the ulcer leads to spillage of stomach or intestinal content into the abdominal cavity. Perforation at the anterior surface of the stomach leads to acute peritonitis, initially chemical and later bacterial peritonitis. The first sign is often sudden intense abdominal pain. Posterior wall perforation leads to bleeding due to involvement of gastroduodenal artery that lies posterior to the 1st part of duodenum.

Penetration is when the ulcer continues into adjacent organs such as the liver and pancreas.


Scarring and swelling due to ulcers causes narrowing in the duodenum and gastric outlet obstruction. Patient often presents with severe vomiting. Cancer is included in the differential diagnosis (elucidated by biopsy), Helicobacter pylori as the [2] etiological factor making it 3 to 6 times more likely to develop stomach cancer from the ulcer.

[edit]Cause A major causative factor (60% of gastric and up to 90% of duodenal ulcers) is chronic inflammation due [citation needed] to Helicobacter pylori that colonizes the antralmucosa . The immune system is unable to clear the infection, despite the appearance of antibodies. Thus, the bacterium can cause a chronic activegastritis (type B gastritis), resulting in a defect in the regulation of gastrin production by that part of the stomach, and gastrin secretion can either be increased, or as in most cases, decreased, resulting in hypo- or achlorhydria. Gastrin stimulates the production of gastric acid by parietal cells and, in H. pylori colonization responses that increase gastrin, the increase in acid can contribute to the erosion of the mucosa and therefore ulcer formation. Another major cause is the use of NSAIDs (see above). The gastric mucosa protects itself from gastric acid with a layer of mucus, the secretion of which is stimulated by certain prostaglandins. NSAIDs block the function of cyclooxygenase 1 (cox-1), which is essential for the production of these prostaglandins. COX-2 selective anti-inflammatories (such as celecoxib or the since withdrawn rofecoxib) preferentially inhibit cox-2, which is less essential in the gastric mucosa, and roughly halve the risk of NSAID-related gastric ulceration. As the prevalence of H. pylori-caused ulceration declines in the Western world due to increased medical treatment, a greater proportion of ulcers will be due to increasing NSAID use among individuals with pain syndromes as well as the growth of aging populations that develop arthritis.

The incidence of duodenal ulcers has dropped significantly during the last 30 years, while the incidence of gastric ulcers has shown a small increase, mainly caused by the widespread use of NSAIDs. The drop in incidence is considered to be a cohort-phenomenon independent of the progress in treatment of the disease. The cohort-phenomenon is probably explained by improved standards of living which has [6] lowered the incidence of H. pylori infections. Although some studies have found correlations between smoking and ulcer formation,[7]

others have been

more specific in exploring the risks involved and have found that smoking by itself may not be much of a [8][9][10][nb 1] risk factor unless associated with H. pylori infection. Some suggested risk factors such as diet,spice consumption and blood type, were hypothesized as ulcerogens (helping cause ulcers) until late in the 20th century, but have been shown to be of relatively minor importance in the development of peptic ulcers. Similarly, while studies have found that alcohol consumption increases risk when associated with H. pylori infection, it does not seem to independently increase risk, and even when coupled with H. pylori infection, the increase is modest in comparison to the primary risk factor.[8][12][nb 2] [11]

Gastrinomas (Zollinger Ellison syndrome), rare gastrin-secreting tumors, also cause multiple and difficultto-heal ulcers. [edit]Stress Researchers also continue to look at stress as a possible cause, or at least complication, in the development of ulcers. There is debate as to whether psychological stress can influence the development of peptic ulcers. Burns and head trauma, however, can lead to physiologic stress ulcers, which are reported in many patients who are on mechanical ventilation. An expert panel convened by the Academy of Behavioral Medicine Research concluded that ulcers are not purely an infectious disease and that psychological factors do play a significant role. Researchers are examining how stress might promote H. pylori infection. For example, Helicobacter pylori thrives in an acidic environment, and stress has been demonstrated to cause the production of excess stomach acid. This was supported by a study on mice showing that both long-term water-immersion-restraint stress [13] and H. pylori infection were independently associated with the development of peptic ulcers. A study of peptic ulcer patients in a Thai hospital showed that chronic stress was strongly associated with an increased risk of peptic ulcer, and a combination of chronic stress and irregular mealtimes was a significant risk factor.[14] [1]


Endoscopic image of gastric ulcer, biopsy proven to be gastric cancer.

The diagnosis is mainly established based on the characteristic symptoms. Stomach pain is usually the first signal of a peptic ulcer. In some cases, doctors may treat ulcers without diagnosing them with specific tests and observe whether the symptoms resolve, this indicating that their primary diagnosis was accurate. Confirmation of the diagnosis is made with the help of tests such as endoscopies or barium contrast xrays. The tests are typically ordered if the symptoms do not resolve after a few weeks of treatment, or when they first appear in a person who is over age 45 or who has other symptoms such as weight loss, because stomach cancer can cause similar symptoms. Also, when severe ulcers resist treatment, particularly if a person has several ulcers or the ulcers are in unusual places, a doctor may suspect an underlying condition that causes the stomach to overproduce acid.[2]

An esophagogastroduodenoscopy (EGD), a form of endoscopy, also known as a gastroscopy, is carried out on patients in whom a peptic ulcer is suspected. By direct visual identification, the location and severity of an ulcer can be described. Moreover, if no ulcer is present, EGD can often provide an alternative diagnosis. One of the reasons that blood tests are not reliable for accurate peptic ulcer diagnosis on their own is their inability to differentiate between past exposure to the bacteria and current infection. Additionally, a false negative result is possible with a blood test if the patient has recently been taking certain drugs, such as antibiotics or proton pump inhibitors.[15]

The diagnosis of Helicobacter pylori can be made by: Urea breath test (noninvasive and does not require EGD); Direct culture from an EGD biopsy specimen; this is difficult to do, and can be expensive. Most labs are not set up to perform H. pylori cultures; Direct detection of urease activity in a biopsy specimen by rapid urease test;

Measurement of antibody levels in blood (does not require EGD). It is still somewhat controversial whether a positive antibody without EGD is enough to warrant eradication therapy; Stool antigen test; Histological examination and staining of an EGD biopsy.[16]

The breath test uses radioactive carbon atom to detect H. pylori.

To perform this exam the patient will

be asked to drink a tasteless liquid which contains the carbon as part of the substance that the bacteria breaks down. After an hour, the patient will be asked to blow into a bag that is sealed. If the patient is infected with H. pylori, the breath sample will contain radioactive carbon dioxide. This test provides the advantage of being able to monitor the response to treatment used to kill the bacteria. The possibility of other causes of ulcers, notably malignancy (gastric cancer) needs to be kept in mind. This is especially true in ulcers of the greater (large) curvature of the stomach; most are also a consequence of chronic H. pylori infection. If a peptic ulcer perforates, air will leak from the inside of the gastrointestinal tract (which always contains some air) to the peritoneal cavity (which normally never contains air). This leads to "free gas" within the peritoneal cavity. If the patient stands erect, as when having a chest X-ray, the gas will float to a position underneath the diaphragm. Therefore, gas in the peritoneal cavity, shown on an erect chest X-ray or supine lateral abdominal X-ray, is an omen of perforated peptic ulcer disease. [edit]Macroscopic


A benign gastric ulcer (from the antrum) of a gastrectomy specimen.

Gastric ulcers are most often localized on the lesser curvature of the stomach. The ulcer is a round to oval parietal defect ("hole"), 2 to 4 cm diameter, with a smooth base and perpendicular borders. These borders are not elevated or irregular in the acute form of peptic ulcer, regular but with elevated borders and inflammatory surrounding in the chronic form. In the ulcerative form of gastric cancer the borders are irregular. Surrounding mucosa may present radial folds, as a consequence of the parietal scarring. [edit]Microscopic


A gastric peptic ulcer is a mucosal defect which penetrates the muscularis mucosae and muscularis propria, produced by acid-pepsin aggression. Ulcer margins are perpendicular and present chronic gastritis. During the active phase, the base of the ulcer shows 4 zones: inflammatory exudate, fibrinoid necrosis, granulation tissue and fibrous tissue. The fibrous base of the ulcer may contain vessels with thickened wall or with thrombosis. [edit]Differential Peptic ulcer Gastritis Stomach cancer Gastroesophageal reflux disease Pancreatitis Hepatic congestion Cholecystitis Biliary colic Inferior myocardial infarction Referred pain (pleurisy, pericarditis) Superior mesenteric artery syndrome[17]


[edit]Treatment Younger patients with ulcer-like symptoms are often treated with antacids or H2 antagonists before EGD [citation needed] is undertaken. Bismuth compounds may actually reduce or even clear organisms , though the warning labels of some bismuth subsalicylate products indicate that the product should not be used by someone with an ulcer.[18]

Patients who are taking nonsteroidal anti-inflammatories (NSAIDs) may also be prescribed a prostaglandin analogue (Misoprostol) in order to help prevent peptic ulcers, which may be a sideeffect of the NSAIDs. When H. pylori infection is present, the most effective treatments are combinations of 2 antibiotics (e.g. Clarithromycin, Amoxicillin, Tetracycline, Metronidazole) and 1 proton pump inhibitor (PPI), sometimes together with a bismuth compound. In complicated, treatment-resistant cases, 3 antibiotics (e.g. amoxicillin + clarithromycin + metronidazole) may be used together with a PPI and sometimes with bismuth compound. An effective first-line therapy for uncomplicated cases would be Amoxicillin + Metronidazole + Pantoprazole (a PPI). In the absence of H. pylori, long-term higher dose PPIs are often used. Treatment of H. pylori usually leads to clearing of infection, relief of symptoms and eventual healing of ulcers. Recurrence of infection can occur and retreatment may be required, if necessary with other antibiotics. Since the widespread use of PPI's in the 1990s, surgical procedures (like "highly selective vagotomy") for uncomplicated peptic ulcers became obsolete.

Perforated peptic ulcer is a surgical emergency and requires surgical repair of the perforation. Most bleeding ulcers require endoscopy urgently to stop bleeding with cautery, injection, or clipping. Ranitidine provides relief of peptic ulcers, heartburn, indigestion and excess stomach acid and prevention of these symptoms associated with excessive consumption of food and drink. Ranitidine is available over the counter from a pharmacy and works by decreasing the amount of acid the stomach produces allowing healing of ulcers. Zantac tablets contain Ranitidine 150 mg as the active ingredient which can also be bought generically.[19] [20]

Sucralfate, (Carafate) has also been a successful treatment of peptic ulcers. [edit]Epidemiology

Disability-adjusted life year for peptic ulcer disease per 100,000 inhabitants in 2004. no data less than 20 2040 4060 6080 80100 100120 120140 140160 160180 180200 200220 more than 220


The lifetime risk for developing a peptic ulcer is approximately 10%.


In Western countries the prevalence of Helicobacter pylori infections roughly matches age (i.e., 20% at age 20, 30% at age 30, 80% at age 80 etc.). Prevalence is higher in third world countries. Transmission is by food, contaminated groundwater, and through human saliva (such as from kissing or sharing food utensils).[23]

A minority of cases of H. pylori infection will eventually lead to an ulcer and a larger proportion of people will get non-specific discomfort, abdominal pain or gastritis. Peptic ulcer disease had a tremendous effect on morbidity and mortality until the last decades of the 20th century, when epidemiological trends started to point to an impressive fall in its incidence.[24]

The reason

that the rates of peptic ulcer disease decreased is thought to be the development of new effective medication and acid suppressants and the discovery of the cause of the condition, H. pylori. In the United States about 4 million people have active peptic ulcers and about 350,000 new cases are diagnosed each year. Four times as many duodenal ulcers as gastric ulcers are diagnosed. Approximately 3,000 deaths per year in the United States are due to duodenal ulcer and 3,000 to gastric ulcer.[25]

[edit]History See also: Timeline of peptic ulcer disease and Helicobacter pylori John Lykoudis, a general practitioner in Greece, treated patients for peptic ulcer disease with antibiotics, beginning in 1958, long before it was commonly recognized that bacteria were a dominant cause for the disease.[26]

Helicobacter pylori was rediscovered in 1982 by two Australian scientists, Robin Warren and Barry J. Marshall as a causative factor for ulcers. food as had been assumed before.[28] [29] [27]

In their original paper, Warren and Marshall contended that

most gastric ulcers and gastritis were caused by colonization with this bacterium, not by stress or spicy

The H. pylori hypothesis was poorly received,

so in an act of self-experimentation Marshall drank

a Petri dish containing a culture of organisms extracted from a patient and five days later developed gastritis. His symptoms disappeared after two weeks, but he took antibiotics to kill the remaining bacteria at the urging of his wife, since halitosis is one of the symptoms of infection.[30]

This experiment was

published in 1984 in the Australian Medical Journal and is among the most cited articles from the journal. In 1997, the Centers for Disease Control and Prevention, with other government agencies, academic institutions, and industry, launched a national education campaign to inform health care providers and consumers about the link between H. pylori and ulcers. This campaign reinforced the news that ulcers are a curable infection, and that health can be greatly improved and money saved by disseminating [31] information about H. pylori. In 2005, the Karolinska Institute in Stockholm awarded the Nobel Prize in Physiology or Medicine to Dr. Marshall and his long-time collaborator Dr. Warren "for their discovery of the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease." Professor Marshall continues research related to H. pyloriand runs a molecular biology lab at UWA in Perth, Western Australia.

Some believed that mastic gum, a tree resin extract, actively eliminates the H. pylori bacteria.



multiple subsequent studies have found no effect of using mastic gum on reducing H. pylori levels.