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Ulcers

Definition

An ulcer is any area of skin or mucous membrane that erodes, causing the tissue to degenerate. In common use, ulcers refer to disorders such as these that occur in the upper digestive tract. They may be called gastric ulcers, peptic ulcers, or simply ulcers.

Description

Gastric ulcers refer to those that occur in the lining of the stomach. Peptic ulcers also can develop in the lower part of the esophagus, the stomach, the first part of the small intestine (duodenum), and the second part of the small intestine (jejunum).

Duodenal and gastric ulcers are the most common types. About 80% of all ulcers occur in the digestive tract and are called duodenal ulcers. Gastric ulcers account for about 16% of peptic ulcers. While it was once believed that stress and eating spicy foods caused ulcers, it was later discovered that most ulcers are caused by a bacterial infection. Some foods can aggravate ulcer symptoms.

The body makes strong acids to digest food. A thin lining protects the stomach and intestines from these acids. But if something damages the lining, the acids can reach the stomach and duodenal walls. Ulcers can get larger and cause bleeding.

Demographics

One in 10 Americans will develop an ulcer at some time in their lives. The American Gastroenterological Association estimates that four million Americans have peptic ulcer disease. Ulcers can occur at any age, but are more common as people get older, particularly in people over age 60. In fact, as many as one-half of people over age 60 may have an ulcer. At least two-thirds of ulcers are believed to be caused by bacteria and most of the remaining ulcers are caused by use of non-steroidal anti-inflammatory drugs (NSAIDS). Many people are infected with the bacterium that causes ulcers although ulcers may not actually develop from the bacterium.

Causes and symptoms

The bacterium that causes peptic ulcers is called Helicobacter pylori, or H. pylori. Although the discovery that H. pylori was the major cause of ulcers only occurred in the 1990s, it is believed that the bacterium has been around in humans’ digestive tracts for at least 60,000 years. The exact source of H. pylori and the way in which it is transmitted from one person to another is not known. Theories include transmission through water, saliva, and person-to-person contact. Researchers also do not yet know why some people with the infection develop ulcers while others do not. They believe it may be due to characteristics of the infected person, the type of H. pylori, and other possible factors.

Use of NSAIDs is the second most common cause of ulcers. These drugs include aspirin, ibuprofen, and naproxen. Frequent and long-term use of these drugs to reduce pain and inflammation may lead to ulcers, as these drugs also weaken the lining of digestive walls. Many older people use these drugs frequently to help relieve pain and inflammation from arthritis, which may help explain the higher number of older adults with peptic ulcers.

The most common symptom of a peptic ulcer is a burning sensation that occurs in the stomach between the breastbone and belly button. Although the pain can occur at any time, it often is worse between meals when the stomach is more likely to be empty. The pain often is described as a dull ache and it may be severe enough to cause waking during the night. The pain may last minutes or several hours and may come and go. Sometimes, the pain goes away after eating.

Other symptoms of ulcers include a feeling of fullness more quickly than normal during a meal, general loss of

appetite, a bloating or heavy feeling in the stomach, upset stomach or nausea and vomiting, weight loss, and blood in the stool. In some cases, blood is the first and only symptom of an ulcer.

Once an ulcer bleeds and continues bleeding without proper treatment, a person may become anemic and weak.

Diagnosis

The physician will note symptoms and history and will perform one or more of several tests available to detect peptic ulcer disease.

H. pylori breath test

This is a safe and simple laboratory test that is used to detect active H. pylori infection. It involves breathing into a balloon-like bag, then drinking a small amount of a clear solution and breathing into the bag again 20 to 30 minutes later. The air that is breathed into the bag the second time is tested for an increase in carbon dioxide. The test involves some preparation, such as avoiding antibiotics and acid-relieving medications for weeks before the test. No eating or drinking is allowed one hour before the test, but the procedure lasts only about 30 minutes and normal diet can be resumed immediately following the test. This test also is effective at monitoring treatment, since a patient can be retested to determine if H. pylori antibodies are still present a month or more later.

Fecal occult blood test

The fecal occult blood test is used to detect tiny or invisible blood in the stool, or feces. It may be used to

KEY TERMS

Anemia, anemic—Anemia is the condition in which the blood’s hemoglobin, which is the part of the blood rich in iron, decreases.

Antibodies—Proteins in the immune system that help fight disease.

Peptic—A description that relates to digestion.

detect ulcers, screen for colorectal cancer, or a number of other diseases. The test requires collection of three stool samples that should be taken one day apart. The samples are returned to the physician’s office or a laboratory and are examined under a microscope for signs of blood. Certain foods and medicines affect test results and should not be eaten or used about two to three days before beginning the test.

Upper GI series

An upper gastrointestinal (GI) series is an x-ray examination that helps diagnose problems in the esophagus, stomach, and duodenum. It may be the first test a physician orders to detect an ulcer. Clearly showing the inside lining of these organs requires drinking a thick, white liquid called barium. The barium coats the linking and as it moves through the digestive system, the radiologist can follow the milkshake-like liquid on images, using a machine called a fluoroscope. The resulting images detect some ulcers, but not all of them. The procedure takes one to two hours or longer if imaging the small intestine as well. No food or drink is allowed after midnight the night before the examination so the stomach will be empty for the procedure. The barium can cause constipation and a white-colored stool for a few days following the procedure.

Upper GI endoscopy

Upper GI endoscopy uses a thin, flexible, lighted tube to help see inside the esophagus, stomach, and duodenum. In some cases, the endoscopy may follow the upper GI series. In other cases, the physician may perform the endoscopy first. The physician sprays the throat with a numbing agent before inserting the tube to help prevent gagging. Pain medication and sedatives also help patients relax during the procedures. The camera at the end of the tube transmits pictures that allow the physician to carefully examine the lining of the organs. The scope also has a device that blows a small amount of air, which can open folds of tissue so the physician can more easily examine the stomach lining and look for ulcers. No eating or drinking will be allowed for eight to 10 hours before the procedure.

Treatment

The treatment of H. pylori infection is called ‘‘triple therapy’’, since a combination approach is used. Two antibiotics, often clarithromycin and amoxicillin, are prescribed for about two weeks. In addition, use of bismuth subsalicylate (a common brand name is Pepto Bismol) will be used along with the antibiotics. Follow-up tests should be ordered to be certain that the H. pylori has cleared up.

Other medicines help treat ulcers and their symptoms. Acid blockers and proton pump inhibitors reduce the amount of acid made in the stomach. This helps relieve pain and promotes healing of ulcers. These drugs are available by prescription or over=the-counter and are sold as ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet), and nizatidine (Axid).

If an ulcer has erupted to the point that it has bled, treatment of anemia may require iron supplements. An ulcer that has caused a perforation or obstruction in the stomach to develop may require surgery. The surgery will remove the ulcer or the ulcer can be covered with tissue from another part of the intestine. Other options may be to tie off the bleeding vessel or to cut off the nerve supply to the base of the stomach.

Nutrition/Dietetic concerns

The old school of though about spicy foods causing ulcers has been shown tobe untrue. But those who have ulcers may still need to watch what they eat to relieve symptoms of peptic ulcer disease. The effect of diet on ulcers varies for everyone, but certain foods and drinks can worsen pain. Drinking coffee can increase pain, whether it contains caffeine or is decaffeinated. Tea, chocolate, chili powder, mustard seed, meat extracts, black pepper, and nutmeg are other foods and spices that may cause discomfort for those with ulcers. With proper use of medications, dietary restrictions should not be necessary, except to ease symptoms.

People with ulcers should avoid alcoholic beverages. Eating a balanced diet is advised. Avoiding large meals in one setting may help relieve feelings of bloating and fullness. It is best to eat small, frequent meals when having ulcer pain. The American Gastroentero-logical Association recommends eating food that has been properly prepared and only drinking water from clean, safe sources to help prevent ulcers.

Prognosis

The prognosis for recovery from ulcers is good for most patients. Very few ulcers fail to respond to current treatments, particularly since discovery of H. pylori. If the bacterium is eliminated, an individual most likely will not have ulcer recurrence. Most patients who develop complications such as perforation will recover without problems, even if emergency surgery is necessary.

Prevention

Until more is learned about the transmission of H. pylori, it is unlikely that individuals can totally prevent infection with the bacterium. Careful hand washing after using the restroom and before eating may help prevent infection. Other prevention techniques are to eat only properly prepared food and to drink water from clean, safe sources. Restricting use of NSAIDs or discussing appropriate use of these medicines with a physician may help lessen risk of ulcers. Smoking and drinking alcohol damage the lining of the digestive tract, so eliminating these behaviors also will help prevent peptic ulcers. Cigarette smoking also increases risk of ulcer bleeding and stomach perforation and can cause some medications to fail. Avoiding certain foods such as coffee and various spices may help ease ulcer symptoms. But will not prevent ulcers.

ORGANIZATIONS

American College of Gastroenterology. P.O. Box 342260, Bethesda, MD 20827. (301) 263-9000. <http://www.acg.gi.org>

American Gastroenterological Association. 4930 Del Ray Ave., Bethesda, MD 20814. (301) 654-2055. <http://www.gastro.org>

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892. (800) 891-5389. <http://digestive.niddk.nih.gov>

Teresa G. Odle


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