A peptic ulcer is a sore or hole that forms in the lining of the stomach or intestine. The word "peptic" is a general term relating to the digestive tract. An ulcer in the lining of the stomach is more specifically called a gastric ulcer. An ulcer in the first part of the small intestine (the duodenum) is called a duodenal ulcer.

The lining of the stomach is a layer of special cells and mucous. Mucous prevents the stomach and duodenum from being damaged by acid and digestive enzymes. If there is a break in the lining such as an ulcer, the tissue under the lining can be damaged by the enzymes and corrosive acid. If the ulcer is small, there may be few symptoms, and the wound can heal on its own. If the ulcer is deep, it can cause serious pain or bleeding, and rarely, corrosive acids in the digestive juices may eat completely through the stomach or duodenum wall.

Peptic ulcers are very common. It has been estimated that about 10% of Americans will develop an ulcer at some time in their lives. Ulcers can develop in anyone at any age, but they become more common as people age. Duodenal ulcers tend to occur at an earlier age than gastric ulcers. While ulcers used to be more common in men, recent studies show that ulcers now occur at the same rate in men and women.

The bacterium Helicobacter pylori is believed to cause between 70% and 90% of all peptic ulcers. This bacteria type causes inflammation in the stomach lining, and this probably makes the lining vulnerable. But infection is not the whole story, because only about 20% of people infected with H. pylori develop ulcers.

The second most common cause of ulcers is the use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen (Advil, Motrin and others) and naproxen (Aleve, Naprosyn). NSAIDs cause you to make less of the natural chemicals that are named prostaglandins. Prostaglandins have a variety of effects in your body. In your stomach, prostaglandins make the stomach less acidic and they stimulate mucous production. With less prostaglandin, ulcers are more likely to form. Ulcers caused by NSAIDs are particularly common in the elderly.

Several factors can increase your risk of developing a peptic ulcer. Both gastric and duodenal ulcers run in families. Smoking puts you at higher risk for an ulcer, particularly if you are infected with H. pylori. Alcohol may increase the production of acid and damage the lining of the stomach. However, contrary to popular belief, stress and spicy foods do not seem to increase the risk of ulcers.

Most people with ulcers complain of a burning or gnawing pain in the upper abdomen. This typically occurs when the stomach is empty, and may be worse at night or upon waking. However, some people's pain may worsen when they eat. Other symptoms include nausea, vomiting, loss of appetite, bloating, burping and weight loss. Some of these symptoms may be relieved by taking over-the-counter antacids or avoiding spicy or acidic foods. In general, symptoms worsen as an ulcer grows, or if more than one ulcer develops. Some people with mild disease don't have any symptoms.

In more severe cases, ulcers may bleed or extend deep into the wall of the stomach or intestine. Bleeding from large ulcers can be life threatening. Blood may appear in the vomit, which would appear either red or black, or resemble coffee grounds. Blood also may appear in the stools, which would look tarry-black or maroon. Peritonitis, a very serious abdominal infection, may develop if the ulcer eats completely through the wall of the stomach or intestine.

If your health care professional suspects that you have a peptic ulcer, he or she may recommend one of the following tests:

• A blood antibody test for evidence of H. pylori infection. This test is widely available and simple to do, and if the test is positive, treatment might be given without more invasive tests. However, the H. pylori blood test is not always accurate. For example, the test results may remain positive for years after an H. pylori infection has been treated. Another problem is that the test cannot tell whether an H. pylori infection has caused an ulcer. Newer tests that use breath or stool samples may be more accurate, but are not yet widely available.



• An esophagogastroduodenoscopy, better known as an EGD or endoscopy. In this procedure a flexible, lighted tube with a tiny camera on the end is passed through your throat into your stomach and intestines. This allows your doctor to examine the walls of the stomach and duodenum. He or she also may snip off a small piece of the lining of the stomach for a biopsy, which is a close examination of the tissue in a laboratory. A biopsy can show whether there is an ongoing infection with H. Pylori. In people old enough to be at risk for cancer, a biopsy can also check an ulcer to make sure it did not form because of cancer.



• An upper-gastrointestinal (GI) series. This test involves X-rays taken after you drink a chalky liquid that coats the esophagus, stomach and upper part of the intestine. An ulcer will show up on the X-rays as a crater disrupting the smooth silhouette of the stomach and duodenum lining. An upper GI series is sometimes less accurate than endoscopy for diagnosing peptic ulcers, but can be a useful and less invasive test under some circumstances.



• Other tests for H. Pylori. Infection with H. Pylori can be confirmed by way of a biopsy of the stomach or duodenal lining (usually from the edge of an ulcer, at the time of an EGD). Another test to detect the bacteria is called a urea breath test. For this test, you swallow a substance containing carbon (in many cases, a small amount of radioactivity is present in the sample). If bacteria are present in your stomach, the bacteria cause carbon dioxide to be released from this substance into your breath, giving you a positive breath test. Finally, stool samples can be tested for proteins that are associated with the bacteria.

Sometimes, more than one test is needed to diagnose your condition.

Ulcers caused by a medication should begin healing shortly after you stop taking the drug. Anti-acid medicine may be used for two to six weeks to help healing and relieve pain.

Ulcers caused by H. pylori can heal after the bacteria are killed. Typically, you will take antibiotics along with acid-suppressing medicine for two weeks, then may take acid-suppressing medication for another four to eight weeks. Gastric ulcers tend to heal more slowly than duodenal ulcers. Uncomplicated gastric ulcers take up to two or three months to heal completely, while duodenal ulcers take about six weeks. An ulcer can temporarily heal without antibiotics, but it is common for an ulcer to recur or for another ulcer to form nearby, if the bacteria are not killed.

Peptic ulcers are not usually preventable the first time around. Infection with H. Pylori is extremely common. In the United States, about 10% of adults between 18 and 30 years of age are infected, as are 50% of adults older than age 60. Infection is most common for people with lower incomes. It is probably spread from person to person, and crowded living space appears to be a risk factor.

Good hygiene (washing your hands thoroughly before eating and after using the bathroom) may limit the spread of H. Pylori somewhat.

Recurrent ulcers from H. Pylori can usually be prevented if you get appropriate treatment for your first ulcer, including antibiotics that kill the bacteria. You may help to prevent peptic ulcers by avoiding smoking, avoiding excessive alcohol, and limiting the use of NSAIDs for pain.

For ulcers caused by H. pylori, treatment requires a combination of medications. The goals are to kill H. pylori bacteria in the body, reduce the amount of acid in the stomach, and protect the lining of the stomach and intestines. Most patients are treated with "triple therapy," which requires taking two antibiotics and one acid-suppressing medication for one to two weeks. A variety of antibiotics and acid-suppressing medications may be used. Typically, the acid-suppressing medication will be either an H2 blocker, such as ranitidine (Zantac) or cimetidine (Tagamet) or a proton pump inhibitor, such as omeprazole (Prilosec) or lansoprazole (Prevacid). Your doctor will prescribe a specific regimen based on convenience, cost and any allergies you have. Triple therapy requires taking as many as 8 to 12 pills every day, and it can cause side effects such as nausea, vomiting, diarrhea, headache and yeast infection in women. However, the treatment is 80% to 90% effective. Some doctors are in favor of using antibiotics one after another, instead of giving them all during the same two-week period. This plan has also seemed to work, when it has been studied. It might reduce the chance of side effects from the antibiotics.

If your symptoms don't go away completely, your doctor may suggest re-testing for H. pylori after your treatment is completed.

If your ulcer occurred during a time you were using an NSAID, you should stop using medicines in this category. Healing will begin almost immediately. Doctors also may recommend medications to reduce acid damage during healing. These may include antacids to neutralize gastric acids or medications that decrease the amount of acid produced by the stomach, such as an H2 blocker or proton pump inhibitor.

Emergency treatment may be needed if an ulcer causes serious bleeding. Usually, this treatment is done through an endoscope using special clips or probes. Acid-blocking medications may be given intravenously (injected into a vein), and blood transfusions may be necessary if the bleeding is severe. In rare circumstances, surgery may be needed to treat a perforated or bleeding peptic ulcer. Surgery for peptic ulcer disease may involve sewing to close a bleeding artery. Surgery can also prevent recurrence of ulcers by changing the stomach in ways that prevent it from making as much acid. Changes that reduce acid production by the stomach include cutting the vagus nerve in the stomach, or removing a portion of the stomach named the "antrum," where acid is produced. Surgery is rarely needed for peptic ulcer treatment now because treatments for H. pylori infections are so successful.

Call for medical advice if you have continuing abdominal pain or indigestion, or need to take antacids frequently to prevent these symptoms. Seek emergency care if you experience a sudden sharp pain in your upper abdomen, bloody or black vomit, or maroon or black stools.

Before H. pylori was identified, many people had peptic ulcers that caused intermittent symptoms for years. Now, with proper treatment, the outlook for peptic ulcers is excellent. People who have had a peptic ulcer should avoid aspirin, NSAIDs, excessive alcohol and any smoking to prevent ulcers from returning.

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