Stomach Ulcer – Diagnosis, Symptoms, and Treatment

What is a Stomach Ulcer?

Stomach ulcers are erosions in the lining of the stomach and intestines that normally protects the body from its own digestive acid and enzymes. The medical term for this condition is Peptic ulcer disease. 

The most common causes of peptic ulcer disease in the United States is the overuse of 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 with severe peptic ulcer disease 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 bright red blood.

Peptic ulcer disease generally begins with mild symptoms but can progress into a life-threatening condition if left untreated. Due to this, recognizing the early symptoms and identifying appropriate treatments is critical. 

What Causes a Stomach Ulcer?

Peptic ulcer disease is the result of one of two things; loss of the factors that protect the stomach and intestines from gastric acid or excessive production of gastric acid that overwhelms these factors. 

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 lining, 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 both peptic ulcer disease and stomach cancer.

There are other risk factors for peptic ulcer disease. These risk factors generally do not lead to peptic ulcer disease alone but may lead to peptic ulcer disease in those that are genetically predisposed. The most common of these risk factors are:

• Alcohol use
• Smoking tobacco
• Physiologic stress – surgery, critical illness
• Obesity
• Corticosteroid use

How Common is Peptic Ulcer Disease?

Peptic ulcer disease is extremely common both in the United States and worldwide. It is estimated that 5% to 10% of individuals will experience peptic ulcer disease in their lifetime. Not all patients with peptic ulcer disease require medical treatment which complicates this estimate. 

It is known that peptic ulcer disease is much more common in daily users of NSAIDS and in those with Helicobacter pylori infection. More severe ulcers that affect the intestines and lead to severe bleeding are more common in men than women. These severe ulcers are also far more common in those over the age of 70.

Signs and Symptoms

The signs and symptoms of peptic ulcer disease often begin relatively mild and can increase in severity as time progresses. The most common symptoms of peptic ulcer disease are:

• Epigastric pain
• Nausea & Vomiting
• Hematemesis – vomiting blood
• Melena – black “tarry” stool
• Weight loss

The epigastric pain of peptic ulcer disease classically occurs during or after meals.  Patients may have associated gastroesophageal reflux symptoms such as heartburn and regurgitation.  On physical examination, there is often tenderness to 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 severely ill and have abnormal vital signs such as a fast heart rate and low blood pressure.

If an ulcer is severe enough, it can perforate the stomach or small intestine, resulting in intestinal and stomach contents entering the abdominal cavity causing massive inflammation and infection – these situations typically require emergency surgery.

Diagnosis

The diagnosis of peptic ulcer disease begins with a review of your medical history and the time course of your symptoms. The presence of one or two of the symptoms above is generally all that is needed for your physician to consider testing you for peptic ulcer disease due to how common the condition is. 

All patients that are suspected of having peptic ulcer disease will be tested for Helicobacter pylori infection with a stool antigen study. 

If you have mild to moderate disease and present to a doctor’s office you will likely be trialed on medications designed to reduce the acidity of the stomach and encouraged to adopt lifestyle changes to reduce stomach acid secretion. If these changes result in a resolution of your symptoms further testing is generally not needed. 

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 with lifestyle and dietary modifications.  This includes avoiding alcohol or tobacco use, significant amounts of caffeine, spicy foods, and NSAIDs.

Acid reducing medications are used in the majority of patients, the most effective class of acid-reducing medications are proton pump inhibitors (PPIs). The most common PPIs are:

• Prilosec (Omeprazole)
• Protonix (Pantoprazole)
• Prevacid (Lansoprazole)
• Dexilant (Dexlansoprazole)

These medications work by reducing acid secretion in the stomach.  They are generally used for at least 2 weeks in patients suspected of having peptic ulcer disease who are presenting with mild to moderate symptoms. 

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 a combination of the following:

• Moxatag (Amoxicillin)
• Biaxin (Clarithromycin)
• Flagyl (Metronidazole)

Your doctor may also recommend Pepto-Bismol (Bismuth Subsalicylate) to coat the inner lining of the stomach and intestines. This does little to reduce the damage from excessive amounts of acid but can significantly reduce inflammation and resulting abdominal pain.