What is a Stomach Ulcer?
Peptic ulcer disease is a medical condition characterized by ulceration in the stomach or small intestine. The most common causes of peptic ulcer disease in the United States are non-steroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori infection. Patients typically present with epigastric abdominal pain during or after meals. This is related to increased gastric acid secretion during digestion of food.
Patients may lose weight due to the fear of eating and epigastric pain. Some patients may develop black “tarry” stool (melena) due to gastrointestinal bleeding. Individuals with severe cases may have hematemesis – vomiting up of bright red blood.
Due to the importance of this condition, it is critical that patients understand its causes, symptoms, and treatment.
What Causes a Stomach Ulcer?
Peptic ulcers are caused by an imbalance between the protective and ulcer-provoking factors in the stomach. Stomach acid does not normally injure the stomach, but too much acid or too little protection against acid promotes the formation of ulcers.
Peptic ulcer disease is typically caused by non-steroidal anti-inflammatory drugs (NSAIDs) or Helicobacter pylori infection. NSAIDS reduce the production of protective prostaglandins in the stomach – low levels of these prostaglandins increase the risk of ulcer formation. H. pylori can also invade the stomach, producing a basic environment around it so it can survive the hostility of the acidic stomach environment – it does this with the enzyme urease. Chronic infection with H. pylori is a risk factor for the development of stomach cancer.
If an ulcer is severe enough, it can perforate the stomach or small intestine, resulting in an abdominal catastrophe – these situations typically require emergency surgery.
Other risk factors for peptic ulcer disease include:
- Alcohol use
- Smoking tobacco
- Physiologic stress – surgery, critical illness
- Corticosteroid use
How Common is Peptic Ulcer Disease?
Peptic ulcer disease is exceedingly common in the United States and responsible for frequent primary care and emergency department visits. The most common causes include non-steroidal anti-inflammatory drugs (NSAIDs) or Helicobacter pylori infection. The condition may require referral to a gastroenterology specialist.
The incidence of uncomplicated peptic ulcer disease is approximately 0.09 to 0.3 percent per patient-year. The incidence of bleeding from a peptic ulcer is 13-fold higher in patients age >70 compared to those age <40. Patients with H. pylori have an ulcer incidence of about 1% per year.
Signs and Symptoms
Symptoms of peptic ulcer disease may include:
- Epigastric pain
- Nausea & Vomiting
- Hematemesis – vomiting blood
- Melena – black “tarry” stool
- Weight loss
The epigastric pain can occur during or after meals. Patients may have associated gastroesophageal reflux symptoms such as heart burn and regurgitation. On physical examination, there is often tenderness on palpation of the epigastric region. Patients with severe ulcers that have perforated can have signs of an acute abdomen such as abdominal rigidity, guarding, and rebound tenderness to palpation. They may also appear toxic and have abnormal vital signs.
The diagnosis of peptic ulcer disease is suggested based on symptoms and physical examination.
Your doctor will typically test you for Helicobacter pylori infection with a stool antigen study. The serum antibody test is no longer recommended as it only informs you of past infection and a positive study may simply represent a prior episode.
If your condition is moderate to severe, your doctor will likely order blood tests that may include a CMP (comprehensive metabolic panel), CBC (complete blood cell count), lipase, and coagulation studies (PT/INR, PTT). They may also order an abdominal ultrasound evaluating the liver, gallbladder, and pancreas. If your doctor is particularly concerned about a perforated ulcer they will likely obtain an upright abdominal x-ray and/or CT scan of the abdomen with oral contrast. This is typically obtained in the emergency department with surgical consultation.
Stomach Ulcer Treatment
Peptic ulcer disease is initially treated by lifestyle and dietary modifications. This includes avoiding alcohol or tobacco use, significant caffeine, spicy foods, and NSAIDs.
Patient are also typically treated with proton-pump inhibitors (PPIs) such as:
These medications work by reducing acid secretion in the stomach. They are generally used for at least 2 weeks in patients with peptic ulcer disease.
Histamine blockers such as Zantac (Ranitidine) and Pepcid (Famotidine) are sometimes used as a substitute to proton pump inhibitors. These medications also work by reducing acid levels but may not be as effective as PPIs.
Patients with a positive H. pylori stool antigen require therapy with antibiotics. This typically includes one or more of the following:
Your doctor may also recommend Pepto-Bismol (Bismuth Subsalicylate) to coat the inner lining of the stomach and intestines.
- Lai KC, Lam SK, Chu KM, et al. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use. N Engl J Med 2002; 346:2033. - https://www.ncbi.nlm.nih.gov/pubmed/12087138
- Li LF, Chan RL, Lu L, et al. Cigarette smoking and gastrointestinal diseases: the causal relationship and underlying molecular mechanisms (review). Int J Mol Med 2014; 34:372. - https://www.ncbi.nlm.nih.gov/pubmed/24859303
- Malfertheiner P, Megraud F, O'Morain CA, et al. Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report. Gut 2012; 61:646. - https://www.ncbi.nlm.nih.gov/pubmed/22491499
The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.