We look at what peptic ulcers are and how to treat them.

A peptic ulcer is an area of damage to either the lining of the stomach or the wall of the small intestine.  

Peptic ulcers can occur at any age and can even occur in children, but they usually affect middle-aged people. Small intestine (duodenal) ulcers are more common than stomach ulcers.

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. Ulcers often heal and then recur, so the pain may last for weeks then disappear, only to re-occur weeks or months later. If you have a stomach ulcer, eating may make the pain worse or better. If you have a duodenal ulcer, the pain will usually come on two to three hours after a meal. The pain may also wake you at night.

Other symptoms may include:

• heartburn
• feeling sick or vomiting
• inability to tolerate fatty foods
• feeling full or belching
• symptoms of anaemia (e.g. tiredness, shortness of breath). 

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

• difficulty swallowing food or pain on swallowing
• lost weight without dieting 
• blood in your vomit or bowel movements 
• sudden, intense and persistent pain in the abdomen or back
• recurrent vomiting.

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

Causes of peptic ulcers 

The most common cause of peptic ulcers is a stomach infection caused by a bacterium called Helicobacter pylori (H. pylori), which is usually acquired during childhood. This infection is quite common – about half of the world's population is infected at some point 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. When the inflammation is sustained over time, it causes more acid to be released in the stomach. The acid injures the layer of mucus that usually protects the stomach and small intestine from acid and causes an ulcer. In the small intestine, it may also interfere with the mechanisms that the small intestine uses to neutralise stomach acid.

Another common cause of peptic ulcers is pain-relieving medicines 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 or have certain risk factors, these medicines can damage the mucus lining in your stomach and cause a peptic ulcer. These risk factors include: 

• being age 65 years or older
• history of peptic ulcers
• having heart disease
• concurrent use of antiplatelet, corticosteroid or anticoagulant medications.

If you're in doubt about which painkillers are appropriate for you to take, ask your pharmacist.

Recent evidence suggests taking NSAIDS when you have H. Pylori infection further increases your risk of a peptic ulcer as these factors work together to enhance the mechanisms that lead to ulceration. Your GP may test you for H. Pylori before starting you on NSAID therapy for any length of time if they think you are at risk of getting a peptic ulcer.

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

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 (the oxygen carrier of your red blood cells).

Perforation

Rarely, the ulcer may eat very deeply into the wall of your stomach or small intestine making a hole into your abdomen. This is called perforation – it causes severe pain and you will need emergency surgery. Similarly, ulcers may perforate right through the stomach or small intestine wall into nearby organs, such as the pancreas, causing intense, persistent pain. The pain may be felt in another part of the torso than the abdomen. If medicines don’t heal the ulcer, surgery may be needed.

However, because treatment with medicine is usually successful, it's very unlikely that you will need surgery for a peptic ulcer.

Obstruction 
In some cases, the inflammation or scarring from a peptic ulcer can block the passage of food through your digestive system. This can cause you to become full easily and feel full or bloated for longer periods of time, have repeated episodes of vomiting (especially of undigested food), and to lose weight. 

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.

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

Alternatively, 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.

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 the following.

• Cutting back or not having food and drink that give you more severe symptoms
• Stopping smoking, as this slows down the ulcer healing process and increases your chances of them recurring. 
• Avoiding NSAID painkillers that are likely to cause ulcers – your GP or pharmacist can give you advice on other medicines you may be able to take instead. If you have to take NSAIDs, your GP will undertake measures to minimise your chances of getting an ulcer while taking these therapies. This may include using the lowest dose of NSAID for the shortest time possible, eradicating H. pylori if you have it, or giving you acid-supressing drugs like a proton pump inhibitor to take as well.

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 if you have H. pylori and it hasn’t 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, but it is important to take the medicines exactly as directed. If you don’t, you may fail to eradicate the bacterium. Your GP will do tests again after treatment to make sure it has been successful in getting rid of H. pylori. If you still test positive for H. pylori, you will need further treatment to eradicate it.

Further information 

Gastroenterological Society of Australia: www.gesa.org.au