Peptic ulcer

What are peptic ulcers?
Peptic ulcers are breaks or wounds in the lining of the parts of the upper gut that are exposed to stomach acid. They occur in the stomach (gastric ulcer) or the first part of the small intestine (duodenal ulcer), and in the oesophagus (gullet). About 10% of people in the developed world will have an ulcer at some time in their life.

What causes peptic ulceration?
The two most important causes of duodenal and gastric ulcers are

• Helicobacter pylori, a germ that lives in the stomach
  70 – 80% of patients with peptic ulceration are infected with Helicobacter pylori. This germ, which is caught in childhood, lives in the stomach and causes inflammation, resulting in increased acid production. Most people with the infection are unaware of the infection and only about 1 in 5 will develop an ulcer.
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs).
  NSAIDs are a group of pain killing medications commonly taken for headaches, joint pains and period pains. They include aspirin, ibuprofen and diclofenac amongst many others, but do not include paracetamol which is not associated with peptic ulceration. NSAIDs cause both inflammation and ulceration, particularly if taken in high doses over a long period of time, and more so in the elderly.

Peptic ulcers are more common in cigarette smokers. Stress and spicy foods may make ulcer symptoms worse but we now know they do not cause ulcers.

Peptic oesophageal ulcers are due to severe reflux of acid gastric juice into the oesophagus due to a failure of the lower oesophageal sphincter mechanism, usually associated with a hiatus hernia. (MAKE LINK TO HIATUS HERNIA)

Do I have peptic ulceration?
Although some gastric and duodenal ulcers give no symptoms, the most common problem is abdominal pain. Typical ulcer pain is felt in the centre or left upper abdomen and sometimes in the back. The pain does not always conform to a pattern but is usually made worse or relieved by eating and improved with antacid medicines. However, many people have symptoms just like an ulcer, but do not have one – this is called ‘non-ulcer dyspepsia’.
Oesophageal ulcers cause heartburn and often difficulty and pain on swallowing.

The only secure way to diagnose or exclude an ulcer is by gastroscopy. If gastroscopy is not possible, a barium meal x-ray can detect an ulcer, but cannot sample the gut to check for Helicobacter or stop bleeding.

Ulcers can bleed, which can be very serious. Bleeding ulcers cause vomiting of blood or passage of black tarry stools, known as ‘melaena’. If you have either, you should call an ambulance and be taken to the nearest Accident & Emergency Department.

If blood loss is slow it may not be seen in the stool but can cause a reduction in the amount of blood in your circulation, called anaemia. Anaemia makes you look pale and feel tired or lethargic or short of breath.

What is the treatment for peptic ulceration?
Helicobacter pylori infection is treated with a combination of antibiotics and an acid suppressing drug, usually a PPI (MAKE LINK).
Eradication of helicobacter cures the ulcer long-term. It is important that the success of the treatment is confirmed 6-8 weeks later with either a stool test, a breath test or a repeat gastroscopy.

If the ulcer is related to NSAIDs, they should be stopped and if possible avoided in the future. If they cannot be withdrawn, taking a PPI as well gives quite good protection against ulcers.

Proton pump inhibitors (PPIs) reduce the amount of acid produced by the stomach more effectively than any other drug.
The available PPIs are omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole; all of these are marketed under proprietary names. They are usually given as tablets, but are also available as injections for severe problems such as bleeding.
PPI tablets will often stop the symptoms of an ulcer and may heal it temporarily, but the ulcer almost always returns when the PPI is stopped. They are the most effective treatment for oesophageal ulcers.
These days, surgery is very rarely required for gastric or duodenal ulcers. Oesophageal ulcers associated with severe reflux may sometimes require treatment with a surgical anti-reflux procedure.

Am I infected with Helicobacter pylori?
Helicobacter pylori can be detected in several ways:

• Breath testing is one of the most common techniques.
  It takes about half an hour. The person being tested swallows a small amount of radio-labelled (but not radio-active) urea. Helicobacter in the stomach metabolises the labelled urea to labelled carbon dioxide. Levels of the label in the carbon dioxide in the breath are measured. High levels indicate the presence of Helicobacter pylori.
• Stool tests are becoming increasingly accurate and are likely to be the best way of detecting the presence of the bacteria in the future. A single small sample of stool is needed.
• Blood tests are not accurate enough for use in individuals, though they have been used in population studies.
• Helicobacter can be detected at gastroscopy by sampling the lining of the stomach.

Will my ulcer come back?
If Helicobacter pylori has been successfully eradicated and NSAIDs are avoided, it is very unlikely that a gastric or duodenal ulcer will recur. Although it is rare for stomach ulcers to be malignant, it is routine to repeat a gastroscopy 6-8 weeks after the diagnosis of a gastric (stomach) ulcer, to make sure there is no underlying cancer. Follow-up gastroscopy is not routinely performed for duodenal ulcers, because they are so rarely malignant.
Oesophageal ulcers usually require long-term PPI treatment, unless surgical treatment is chosen.