Peptic Ulcer Disease

Peptic ulcer disease (gastric ulcer and duodenal ulcer) is a common health problem. Approximately 20 million Americans will suffer from an ulcer once in their lifetime.

An ulcer is a break in the lining of the stomach or in the first part of the small intestine (the duodenum), a result of erosion caused by the stomach’s natural acids.

Causes

Peptic ulcer disease was once thought of simply as a problem of too much acid and stress. However, it is now clear that an ulcer is the end result of an imbalance between digestive fluids (hydrochloric acid and pepsin) in the stomach and duodenum. Much of that imbalance is clearly related to infection with the bacteria Helicobacter pylori (H. pylori). The other major risk factor for the development of ulcers is ingestion of nonsteroidal antiinflammatory drugs (NSAIDs) such as aspirin, buffered aspirin, naproxen (Aleve, Anaprox, Naprosyn, etc.) and ibuprofen (Motrin, Advil, Midol, etc.).

The risk of NSAID-induced ulceration is dose-related and increases with:

• age – more likely over age 60
• gender – will occur more often in women than men
• use of corticosteroids and NSAIDs together
• length of time taking NSAIDs
• a history of ulcer disease

The following serious complications associated with patients taking NSAIDs occur without warning:

• bleeding
• perforation (a hole through the lining of the stomach)
• gastric outlet obstruction (scarring that blocks the passageway leading from the stomach to the small intestine)

Risk factors for developing these serious complications are:

• age – 60 years or older
• a history of peptic ulcer disease, bleeding ulcers or cardiovascular disease

A number of myths are clearly not associated with the development of ulcers. Stress, personality, occupation, alcohol consumption, and diet all have no relationship to the development of peptic ulcers.

Symptoms

Gnawing, burning, upper abdominal pain relieved by antacids that often awakens the patient at night is classically associated with peptic ulcer disease. Other causes of this discomfort include: gastroesophageal reflux disease (commonly known as heartburn), stomach cancer, slow stomach emptying, and a sensitive stomach. Ulcers may produce no symptoms, especially in patients that ingest NSAIDs.

Diagnosis

An ulcer cannot be diagnosed simply by talking to your doctor. There are several ways your doctor can confirm if you have a peptic ulcer:

• A short trial of an acid blocking medication (Tagamet®, Zantac®, Pepcid®, Prilosec®, Axid®, Prevacid®, Protonix®, Nexium®, Aciphex®) to see if symptoms improve.
• Perform diagnostic tests to see if there is an ulcer:

• ~ Upper endoscopy, which involves inserting a small lighted tube into the stomach to look for abnormalities. A small sample of tissue (biopsy) is removed and analyzed to confirm diagnosis.

• ~ Testing for H. pylori infection by either a stool sample or by obtaining a breath sample. If the test is positive, the patient is treated with antibiotics. If negative, the focus of the evaluation will be on the other causes of peptic ulcer disease, such as NSAID consumption.

Treatment

A number of excellent treatment options are available for healing peptic ulcers:

Antacids are highly effective agents for healing ulcers and controlling symptoms. However, from a practical perspective, the inconvenient dosing frequency and adverse effects of therapy limit the use of antacids to symptom control only.

H2-receptor antagonists (Tagamet®, Zantac®, Pepcid®, Axid®) decrease acid production by the stomach and heal almost all duodenal and gastric ulcers after 8 weeks of treatment.

Proton pump inhibitors (Prilosec®, Prevacid®, Nexium®, Protonix®, Aciphex®) are better at stopping the production of stomach acid and heal almost all duodenal ulcers in 4 weeks and gastric ulcers in 8 weeks.

Peptic ulcer disease is a chronic disorder and almost all patients develop another ulcer within one year after being treated. This relapse rate was once reduced by taking chronic low dose (1/2 strength) maintenance therapy with any of the H2-blockers. However, treatment of H. pylori infection has revolutionized the treatment of peptic ulcer disease and cures ulcer disease completely in many patients.

H. pylori is treated with a combination of antibiotics (clarithromycin, amoxicillin, etc.) medications plus a proton pump inhibitor. This treatment should be attempted on all patients with evidence of infection and a current or past documented history of peptic ulcer disease.

However, treatment of H. pylori infection is not simple. None of the antibiotic regimens used to treat H. pylori are 100% effective and there is no agreement on a single best regimen. The medications may cause side effects such as an upset stomach, diarrhea and taste disturbance. This makes completion of treatment difficult and completion of the two week course of therapy is essential for success.