Heartburn

Peptic Ulcer Symptoms, Diagnosis, and Treatment

An Overview of Peptic Ulcer Disease

Peptic ulcer disease is a common digestive disorder that not only can make life very uncomfortable, but can also have some severe consequences. Recent developments—especially new knowledge about its causes and treatments—have revolutionized the care of peptic ulcer disease. If you or a loved one have peptic ulcer disease, you need to make sure you’re aware of the latest information on this common problem.

What Is a Peptic Ulcer?

A peptic ulcer is an erosion of the lining of the stomach or duodenum (the first part of the small intestine). These ulcers are called “peptic” ulcers because they are related to the activity of acid and pepsin (an important digestive enzyme) on the cells that line the stomach and duodenum. 

A peptic ulcer located in the stomach is called a gastric ulcer. If it is in the duodenum it is called a duodenal ulcer.

Symptoms may vary somewhat between these two types of peptic ulcers and your doctor may treat them a little differently. Doctors see people with peptic ulcers very frequently. At any given time, up to one percent of people worldwide will have a peptic ulcer.

The symptoms of a peptic ulcer can become quite distressing. Worse, these ulcers can lead to significant, possibly life-threatening consequences. Fortunately, in most people they can be healed and severe complications can be avoided with appropriate medical therapy and with measures to prevent recurrent ulcers.

Symptoms

The chief symptom of a peptic ulcer is abdominal pain.

Most people will describe a gnawing or burning pain usually located in the pit of the stomach or just below the ribs on either the right or left side.

The pattern of abdominal pain may depend on the location of the ulcer. With gastric ulcers, the pain is often made worse by a meal and, occasionally, a person with a gastric ulcer may (possibly subconsciously) cut back on eating and even lose some weight.

In contrast, duodenal ulcers tend to produce pain in between meals when the stomach is empty—the pain is often relieved by eating something. People with a duodenal ulcer seldom lose weight and may actually gain weight.

If a peptic ulcer becomes large enough, it may erode into a blood vessel and produce bleeding. Doctors call this an “upper GI bleed” since the site of bleeding is in the upper part of the gastrointestinal system. The symptoms of an upper GI bleed may be quite dramatic and impossible to ignore, such as vomiting bright red blood.

On the other hand, if the bleeding is slow, symptoms may be much more subtle and may include the gradual onset of weakness (from anemia), dizzinesspalpitations (from a rapid heart rate), abdominal cramping (caused by blood moving through, and irritating, the intestines), and melena or tarry stool (caused by the digestive process acting on blood in the intestinal tract).

A peptic ulcer located at the junction of the stomach and the duodenum (a location called the pyloric channel) may cause enough swelling in the stomach lining to produce a partial obstruction. If so, symptoms may include bloating, severe indigestion, nausea, vomiting, and weight loss. People with peptic ulcers also have a relatively high chance of developing gastroesophageal reflux disease (GERD) and the symptoms associated with it, especially heartburn

While a peptic ulcer obviously creates a potential for many different symptoms, a surprising proportion of people with peptic ulcers (perhaps up to 50 percent) may not notice any particular symptoms. Unfortunately, even peptic ulcers that do not directly produce symptoms may ultimately cause significant complications.

Read more about the symptoms of peptic ulcers.

Complications

If the only thing peptic ulcers did was to cause abdominal pain, they might not be considered such a significant problem. But, as we have already seen, they can do much more than that!

 The major complications of peptic ulcer disease Include:

  • Bleeding. This is the most common complication of peptic ulcer disease. The bleeding can be slow and rather subtle or it can be massive and immediately life-threatening. Notably, a slowly bleeding ulcer that may have gone unnoticed can eventually become an acute medical emergency—if it further erodes into a blood vessel. 
  • Gastric outlet obstruction. This condition—a blockage at the junction of the stomach and duodenum—can be caused by an active peptic ulcer or by chronic scarring due to a prior peptic ulcer. If the obstruction is severe, or if a moderate obstruction is not resolved after a reasonable period of medical therapy, surgical therapy may become necessary.
  • Perforation. If a peptic ulcer erodes entirely through the wall of the stomach or duodenum, it may cause perforation. A perforation may allow stomach acid to leak into the abdominal cavity, causing severe generalized abdominal pain and sometimes shock. Perforation of a peptic ulcer is a life-threatening condition. Treatment requires surgical therapy.
  • Fistula. A peptic ulcer may also perforate into an adjacent abdominal organ and form a fistula (that is, a connection) between the stomach or duodenum and an adjacent structure. Fistulas may form with the colon, biliary tree, pancreas, or a major blood vessel. Depending on which organ is involved, symptoms may vary from vomiting feculent material to acute, massive, or fatal hemorrhages. Similar to perforation, surgical therapy is required for treatment.

Read more on the complications of peptic ulcers.

Causes

In the large majority of cases, peptic ulcers are caused by one of two things:

  1. An infection with a bacterium called Helicobacter pylori (H. pylori)
  2. The chronic use of non-steroidal anti-inflammatory drugs (NSAIDS)

The realization that H. pylori infections are responsible for much if not most peptic ulcer disease is one of the greatest medical advances of the last few decades. Chronic infection with H. pylori is extremely common. Estimates are that at least 50 percent of all humans have H. pylori in their upper gastrointestinal tracts. And it is believed that this has been the case throughout human history.

Research indicates that H. pylori may predispose people to peptic ulcers by several different mechanisms, including:

  • Increasing the secretion of stomach acid
  • Causing inflammation
  • Diminishing the defense mechanisms of the stomach lining
  • Causing gastric cells (which secrete acid and pepsin) to grow in the lining of the duodenum

An H. pylori infection is extremely common in people who have peptic ulcer disease. About 75 percent of peptic ulcers in the U.S. are associated with this infection—and the proportion is higher in the undeveloped world. Eradicating H. pylori is an important component of therapy for peptic ulcer disease.

The chronic use of NSAIDs, including aspirin, increases the risk of peptic ulcers by 20-fold. NSAID users who also have H. pylori (a group that, again, includes more than half of all people) have a 60-fold increase in peptic ulcer disease.

NSAIDs are thought to increase the risk of peptic ulcers by inhibiting the COX-1 receptor in the upper gastrointestinal tract. Inhibition of COX-1 reduces the production of various prostaglandins that function to protect the lining of the stomach and duodenum. (NSAIDs that do not inhibit the COX-1 receptor have been developed, but these have received a bad reputation because of an apparent increase in cardiovascular problems.) 

Read more about NSAIDs and the heart.

People without H. pylori can develop peptic ulcers, especially if they use NSAIDs. People who do not use NSAIDs can develop peptic ulcers, especially if they have H. pylori. But people who have both of these factors have an especially high risk of peptic ulcer disease.

While H. pylori and NSAIDs account for most peptic ulcer disease, there are many other potential causes as well. These include:

Despite what you may have heard all your life, there is really no evidence that eating any kind of specific foods, like spicy dishes, causes peptic ulcer disease. You may find that, in your own case, eating particular foods can bring on heartburn, indigestion, or other gastrointestinal symptoms—and if so, you should avoid them. But you’re avoiding them in order to feel better, not to prevent peptic ulcer disease.

Similarly, experts now discount the idea that ulcers are caused by either acute or chronic emotional stress, like dealing with an annoying boss, unless the stress leads you to smoke, drink, or pop lots of Advil.

Read more about the causes of peptic ulcers.

Diagnosis

Diagnostic testing for peptic ulcer disease has two distinct goals:

  1. Establishing the presence or absence of a peptic ulcer
  2. Assessing the cause of an ulcer, if present

If your symptoms are mild, your doctor may simply put you on a course of therapy to block stomach acid. If your symptoms go away and do not return after this simple measure, that may be all there is to it. However, if your symptoms are moderately severe, or if your symptoms return after a short course of therapy, it is usually a good idea to make a definitive diagnosis. Today, this is done most efficiently and most accurately with an endoscopy procedure.

With endoscopy, a flexible tube containing a fiberoptic system is passed down the esophagus and into the stomach—and the lining of the stomach and duodenum is directly visualized. Endoscopy is quick and accurate. In addition, if an ulcer is present, its general severity can be assessed and it can be examined for any signs of malignancy—in which case a biopsy can be taken. A biopsy is also very helpful in detecting whether H. pylori is present.

Upper GI x-ray studies, using swallowed barium to create contrast, can also be used to diagnose peptic ulcers. However, this test is far less accurate than endoscopy, takes longer, and does not provide an opportunity for biopsies to check for potential malignancy or H. pylori. It also involves radiation exposure. For these reasons, x-rays are no longer used very often to diagnose ulcer disease.

If a peptic ulcer is diagnosed, it is important to assess whether an infection with H. pylori is present and whether NSAIDs may be a factor. This information is very important in deciding on appropriate treatment.

The best way to detect H. pylori is with a biopsy obtained during endoscopy. Alternatively, a urea breath test may be used. H. pylori secretes the enzyme urease that results in excess urea—which can be detected in the breath. Blood testing and stool testing may also be used to detect H. pylori.

Because NSAIDs (and sometimes other medications) often play a prominent role in the development of peptic ulcers, it is important to give your doctor a full account of all the medications you have been using, prescription or over-the-counter.

If you have a peptic ulcer and do not have either an H. pylori infection or NSAID usage, your doctor may need to perform further medical evaluation, looking for other potential underlying causes. In the large majority of people with peptic ulcer disease, however, this is not necessary.

Read more about diagnosing peptic ulcers.

Treatment

In most cases, peptic ulcers can be successfully treated with medical therapy. In general, medical therapy consists of three things: 

  1. Eradicating H. pylori 
  2. Giving a course of proton pump inhibitor (PPI) therapy
  3. Withdrawing factors that contribute to peptic ulcers

If testing is positive for H. pylori, the key to successfully treating peptic ulcer disease is to get rid of the infection with a course of antibiotics. Generally, two different antibiotics are used for seven to 14 days—most often clarithromycin, metronidazole, and/or amoxicillin.

It is important to repeat testing for H. pylori after the course of antibiotics to document that the infection is gone. If it is not, another treatment course, using different drugs or different dosages, will be needed. Failure to heal the ulcer, and recurrent ulcers, are much more likely in people whose H. pylori infections are not adequately treated.

Ulcer healing can also be promoted by inhibiting the secretion of stomach acid. When a peptic ulcer is present, this is best accomplished by using a PPI, such as esomeprazole (Nexium), pantoprazole (Prevacid), omeprazole (Prilosec), or rabeprazole (AcipHex). Reducing the acid in the stomach not only helps the ulcer to heal but also makes antibiotics more effective against H. pylori. PPI therapy is usually continued for eight to 12 weeks in people with peptic ulcer disease.

In addition to avoiding all NSAIDs, anyone with a peptic ulcer should stop smoking and limit alcohol to no more than one drink per day (if that). 

After antibiotics have been taken, the H. pylori eradicated, eight to 12 weeks of PPI therapy, and eliminating offending agents like NSAIDs, the chances of completely healing a peptic ulcer are excellent—generally above 90-95 percent. Furthermore, the risk of a recurrent ulcer is quite low.

However, if H. pylori is not eradicated—or if you continue (or begin) using NSAIDS, smoking, or consuming higher amounts of alcohol—there is a very good chance the ulcer will fail to heal or will return.

Most experts recommend repeating an endoscopy after treatment of a gastric ulcer to assure that healing is complete. Gastric ulcers occasionally form at the site of gastric cancer—so it can be important to visualize the area after treatment to make sure the healed site is normal. It is usually not necessary to repeat the endoscopy after treatment of a duodenal ulcer.

A peptic ulcer that does not heal after 12 weeks of PPI therapy is called a “refractory” ulcer. If you have a refractory ulcer on top of another 12-week course of PPI therapy:

  • You are likely to have another endoscopy with more biopsies, looking for a residual H. pylori infection, and to make sure there is no sign of a malignancy.
  • You might have to undergo a more extensive medical workup looking for unusual underlying causes for peptic ulcer disease. 
  • You should expect your doctor to undertake a more extensive interrogation of your habits regarding NSAID usage, smoking, drinking, and any other drug usage.

All this is necessary. Finding a way to treat a refractory ulcer is critical, since people with refractory ulcers are more likely to develop one of the nasty complications of peptic ulcer disease. 

In the past, surgical treatment for peptic ulcer disease was quite common. However, since H. pylori was discovered to be an important and frequent underlying cause—and since powerful PPI drugs were developed—surgery has become only rarely necessary.

Surgery is now needed mainly for ulcers that prove utterly refractory to medical treatment, are suspected to harbor a malignancy, or as treatment of the complications of peptic ulcer disease, like severe bleeding, obstruction, perforation, or fistula formation. 

Read more about treating peptic ulcers.

A Word From Verywell

While a peptic ulcer is a significant medical problem that can have dire consequences, advances in medical care over the past few decades have utterly changed the treatment of this condition and the prognosis of the people who have it.

If you are diagnosed with peptic ulcer disease, as long as you work with your doctor to establish an underlying cause, faithfully follow the two to three month regimen of medical therapy that likely will be prescribed, and avoid the medications—and habits—you are supposed to avoid, there is an excellent chance that your ulcer will heal completely and will never come back.

Sources:

Lau JY, Sung J, Hill C, et al. Systematic Review of the Epidemiology of Complicated Peptic Ulcer Disease: Incidence, Recurrence, Risk Factors and Mortality. Digestion 2011; 84:102.

Leodolter A, Kulig M, Brasch H, et al. A Meta-analysis Comparing Eradication, Healing and Relapse Rates in Patients with Helicobacter pylori-associated Gastric or Duodenal ulcer. Aliment Pharmacol Ther 2001; 15:1949.

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.

Malfertheiner P, Megraud F, O'Morain CA, et al. Management of Helicobacter Pylori Infection--the Maastricht IV/ Florence Consensus Report. Gut 2012; 61:646.

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