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Peptic ulcers

A peptic ulcer is an area of damage to either the lining of the stomach or the wall of the small intestine. They are more common in women than men.

Your stomach produces acid to help you digest food. The lining of your stomach and the first part of your small intestine (duodenum) have a layer of mucus that protects them from the acid. If this protection mechanism doesn't work properly, the acid can eat into your stomach lining and cause an ulcer.

Digestive system

Stomach (gastric) ulcers usually affect people between the ages of 40 and 80 while small intestine (duodenal) ulcers affect people between the ages of 20 and 60. Duodenal ulcers are more common. Collectively, these are known as peptic ulcers. The size of peptic ulcers can vary from one millimetre to several centimetres across. They look similar to mouth ulcers.

Symptoms of peptic ulcers 

You may not have any symptoms at all. However, many people have pain in their abdomen (tummy), usually just below the sternum (breastbone). This pain is often described as burning or gnawing and may extend to your back. If you have a stomach ulcer, the pain usually comes on about 15 to 20 minutes after eating. If you have a duodenal ulcer, the pain will usually come on one to three hours after a meal. The pain may also wake you at night.

Other symptoms may include:

  • heartburn
  • a bitter taste in your mouth
  • feeling sick or vomiting
  • regurgitating food.

It's important to see your GP if you have:

  • difficulty swallowing food
  • lost weight without dieting
  • seen blood in your vomit or bowel movements
  • experienced sudden, very painful abdominal pain.

These symptoms may be caused by problems other than a peptic ulcer. If you have any of them, visit your GP for advice.

Complications of peptic ulcers 

Complications aren’t very common but they can include the following.

Bleeding

Occasionally ulcers can cause the lining of your stomach or small intestine to bleed. If this happens suddenly, symptoms may include:

  • vomiting blood – it may be bright red or like coffee grains (dark brown bits of clotted blood)
  • dark faeces that look black or like tar – this is because the blood from the bleeding ulcer will have been partially broken down as it makes its way through the bowel.

If you have any of these symptoms, see your GP immediately.

Anaemia

If the bleeding from the ulcer is slow, you might not see blood in your vomit or faeces. However, you may develop anaemia. Anaemia is when there are too few red blood cells or not enough haemoglobin in the blood.

Perforation

Rarely, the ulcer may eat very deeply into the wall of your stomach or small bowel making a hole into your abdomen. This is called perforation – it causes severe pain and you will need emergency surgery. However, because treatment with medicine is usually successful, it's very unlikely that you will need surgery for a peptic ulcer.

Pyloric stenosis

Pyloric stenosis can result if you have a peptic ulcer that causes long-term inflammation in the lining of your stomach or small bowel. This is a narrowing of the small passage called the pylorus that links your stomach and the first part of your small bowel. The main symptom of pyloric stenosis is vomiting.

Causes of peptic ulcers 

The most common cause of peptic ulcers is a stomach infection caused by a bacterium called Helicobacter pylori (H. pylori). This infection is quite common – about half of the world's population is infected with the bacterium but it doesn't always cause illness.

H. Pylori can cause inflammation in the lining of the stomach. Inflammation is when part of the body reacts to an infection or injury causing it to become swollen, hot, red and/or painful. The inflammation reduces the layer of mucus that protects the stomach and small bowel from the stomach acid and causes an ulcer. If the H. Pylori infection is in the upper part of your stomach, it can cause more acid to be produced. This can overload the protective layer of mucus and cause an ulcer.

The second most common cause of peptic ulcers is a type of medicine called non-steroidal anti-inflammatory drugs (NSAIDs). Examples of these medicines include aspirin, ibuprofen, naproxen and diclofenac. Most people can take these safely as directed but for some people, if you take NSAIDs over a long period of time, they can damage the mucus lining in your stomach and cause a peptic ulcer. If you're in doubt about which painkillers are appropriate for you to take, ask your pharmacist.

You're more likely to get peptic ulcers if you smoke. You may also be more at risk if other people in your family have had ulcers.

It used to be thought that stress could cause a peptic ulcer. However, stress is now only considered to be important if it's a result of a major operation or trauma.

Diagnosis of peptic ulcers 

Your GP will ask about your symptoms and examine you. He or she may also ask you about your medical history. If your GP thinks you may have a peptic ulcer, he or she may recommend some of the following tests to diagnose you and decide what treatment will suit you best.

H. pylori test

As H. pylori is the most common cause of a peptic ulcer, your GP may test you for the bacterium and, if necessary, prescribe medicines to treat the infection.

H. pylori can be detected in a urea breath test. You will be asked to swallow a liquid containing a substance called urea that is broken down by H. pylori to produce water and carbon dioxide. Your breath will then be tested using a machine for the amount of carbon dioxide in it. If the carbon dioxide is over a certain level, H. pylori is present.

Alternatively a sample of your blood or your faeces will be sent to a laboratory to test for H. pylori.

Endoscopy

If you have a suspected peptic ulcer, your GP may arrange a gastrointestinal endoscopy (also called a gastroscopy). Not everyone who has abdominal pain needs one, so your GP may use one of the other tests first. However, endoscopy is the only way to be certain whether or not you have a peptic ulcer.

An endoscopy is a procedure that allows a doctor to look at the inside of your body. The test is done using a narrow, flexible, tube-like telescopic camera called an endoscope that is passed through your mouth and into your stomach. The procedure usually lasts a few minutes.

Your doctor will be able to see the lining of your stomach and can take a sample of your stomach lining at the same time. This sample is either sent to a laboratory and examined under a microscope, or directly tested for H. pylori.

Treatment of peptic ulcers 

Self-help

There are lifestyle changes that you can make to help your ulcers heal and prevent them coming back. These include:

  • cutting back or not having food and drink that give you more severe symptoms
  • stopping smoking
  • not taking painkillers that are likely to cause ulcers in the future – your GP or pharmacist can give you advice on other medicines you can take instead.

Medicines

There are two main groups of medicines available to treat symptoms of peptic ulcers.

These are:

  • proton pump inhibitors, such as omeprazole and lansoprazole
  • H2-blockers, such as ranitidine and famotidine.

Both types of medicine reduce acid production in the stomach, allowing your ulcer to heal.

These medicines will relieve your symptoms and within a few weeks your ulcer will heal. However, once you stop taking the medicine, your ulcer may come back unless the H. pylori has been treated and removed.

Treating H. pylori infection 

If tests confirm that you have H. pylori, you will be prescribed medicines to treat it. This is usually a seven-day course of a proton pump inhibitor combined with two antibiotics. Treating the H. pylori infection should allow your ulcer to heal and prevent it from coming back. Your GP will do the tests again after treatment to make sure it has been successful in getting rid of H. pylori.

Further information 

Gastroenterological Society of Australia
www.gesa.org.au

Sources 

Clinical Knowledge Summaries. Dyspepsia – proven peptic ulcer. [online] London: National Institutes for Health and Clinical Excellence. 2008 [last updated Jul 2009, accessed 6 Jul 2011] Available from: http://www.cks.nhs.uk/dyspepsia_proven_peptic_ulcer

Digestive Health Foundation (DHF). Facts about Helicobacter pylori. [online] Sydney, NSW: Gastroenterological Society of Australia. 2003 [accessed 5 Jul 2011] Available from: http://www.gesa.org.au/

Festi D Scaioli E Baldi F et al. Body weight, lifestyle, dietary habits and gastro esophageal reflux disease. World J Gastroenterol. 2009; 15(14): 1690-1701.

Gastrointestinal Expert Group. Therapeutic guidelines: gastrointestinal. Version 4. Melbourne: Therapeutic Guidelines Limited. 2006.

Kaltenbach T Crockett S Gerson LB. Are Lifestyle Measures Effective in Patients with Gastroesophageal Reflux Disease? An Evidence-Based Approach. Arch Intern Med. 2006; 166: 965–971.

Leontiadis GI Ford AC Moayyedi P. Helicobacter pylori infection. BMJ Clinical Evidence. 2009.

myDr. Peptic ulcers explained. [online] St Leonards, NSW: UBM Medica Australia. c2000-2011 [Last reviewed Jul 2009, accessed 6 Jul 2011] Available from: http://www.mydr.com.au

National Institute for Health and Clinical Excellence (NICE). Dyspepsia: managing dyspepsia in adults in primary care. [online] Aug 2004 [accessed 6 Jul 2011] Available from: http://guidance.nice.org.uk/CG17

National Prescribing Service (NPS). NPS Prescribing Practice Review 45: Proton pump inhibitors: step-down to symptom control [online]. 2009. NSW: NPS [accessed 25 Nov 2010] Available from: http://www.nps.org.au/health_professionals/publications/prescribing_practice_review/current/nps_prescribing_practice_review_45

Rossi S (ed). Australian Medicines Handbook. Adelaide: Australian Medicines Handbook. 2011.

Stanghellini V. Relationship between upper gastrointestinal symptoms and lifestyle, psychosocial factors and comorbidity in the general population: results from the Domestic/International Gastroenterology Surveillance Study (DIGEST). Scand J Gastroenterol. 1999; Suppl 231: 29–37.

World Health Organization (WHO). Helicobacter pylori. [online] Geneva, Switzerland: WHO. c2011 [accessed 5 Jul 2011] Available from: http://www.who.int/vaccine_research/documents/Helicobacter_pylori/en/

Last published: 30 July 2011

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