Peptic ulcer disease

Peptic ulcer disease is an open sore in our stomach lining or duodenum (the top of our small intestine). It is a condition that causes ulcers on the lining of our digestive tract and usually affects our stomach and duodenum because the gastric juices are most active here.

Origin of the word peptic 

It is derived from the word pepsin. Pepsin is related to digestion and it is the major digestive enzyme produced by our stomach. Pepsin helps to chemically break down food for digestion. This enzyme is highly corrosive.

Occurrence rate

Peptic ulcer disease is found in 5% to 10% of people worldwide in their lifetimes.

It is seen more commonly in middle-aged adults.

Types of peptic ulcers

The two common types of peptic ulcers are -

1. Duodenal ulcers - 80% of peptic ulcers
2. Stomach ulcers - 20% of peptic ulcers

Under unusual circumstances other than ulcers in the stomach and duodenum, we also can have -

1. Esophageal ulcers - which occur due to chronic acid reflux
2. Jejunal ulcers - occur as a side effect of surgery connecting the stomach to jejunum ( i.e, gastrojejunostomy) [jejunum is the middle part of the small intestine]

Also known as stomal ulcers, marginal ulcers, or anastomotic ulcers.

Causes of peptic ulcer disease

The gastrointestinal tract is covered or laminated with a mucous lining which helps to hold it together against the digestive acids and enzymes. Peptic ulcer disease happens if there is increased discharge of acid or decreased mucus secretion. Hence, peptic ulcer disease occurs when something interferes with the natural defences of the gastrointestinal tract.²

Main causes: 

1. H. pylori infection:
   • Helicobacter pylori is a gram negative, flagellated (thread-like projection to aid in movement), helical (spiral shaped), and microaerophilic (grow best in lower oxygen environments) bacterium
   • Previously known as Campylobacter pylori
   •  H.pylori is so common that it has taken up residence in the stomach and duodenum of half of the world's population
   • It does not usually cause trouble, but if its number increases it leads to an imbalance of the microbes lining the stomach and/or duodenum causing chronic inflammation
   • Hence, the chronic and persistent inflammation leads to open sores known as peptic ulcer disease
2. Overuse of NSAIDs
   • Non-steroidal anti-inflammatory drugs (NSAIDs) are a common over-the-counter drug, usually taken for pain relief
   • NSAIDs include Aspirin and Ibuprofen
   • Continued consumption of NSAIDs can cause a natural imbalance in the gastrointestinal tract leading to peptic ulcer disease³

Other uncommon origins of peptic ulcer disease are:

1. Ischemia (i.e, loss of blood supply)
2. Other infections
3. Stress
4. Chemotherapy/ radiation therapy
5. Zollinger-Ellison Syndrome
   1. It is a syndrome characterized by excess secretion of a hormone called Gastrin
   2. Gastrin when secreted in normal levels helps in the breakdown and digestion of food but when it is secreted in abnormal levels can cause the formation of peptic ulcers
6. Crohn's disease
   1. Crohn’s disease is an autoimmune condition characterized by inflammation of the gastrointestinal tract (also known as inflammatory bowel disease)
   2. Any inflammation in the digestive tract can lead to ulcer development
7. Stomach cancer
8. Gastric bypass surgery
   1. It is a surgery where the stomach is directly attached to the jejunum (the middle part of the small intestine)
   2. This leads to a new duodenum without protective mucosal lining (jejunum is deprived of a natural mucosal lining)
9. Chronic esophagitis - a condition in which the lining of the oesophagus is inflamed²

Risk factors

1. Smoking habit - the nicotine present in tobacco is a highly active factor which disturbs the normal epithelial lining of the gastrointestinal tract. It causes increased secretion of acids in the stomach resulting in irritation and gastro-oesophageal reflux. Smoking also decreases the mucous secretion which leads to less blood absorption and leaves you more prone to infection and inflammation¹
2. Alcohol consumption - intake of alcohol can cause erosion of the mucosal lining of the gastrointestinal tract leading to gastritis. Gastritis is a condition in which the mucosal lining is inflamed and becomes red. If there is excess intake of alcohol then gastritis will in turn lead to peptic ulcer disease
3. Physiological stress - stress is a part of every individual's life. Stress and anxiety are both contributing factors for developing peptic ulcers. Stress causes hormonal disruption or hormonal irregularity, disturbed sleeping patterns, and stress eating which eventually give rise to peptic ulcer formation. These kinds of ulcers are termed as stress ulcers in the stomach. Physiological stress is related to a medical condition (i.e. when a patient has undergone surgery due to a serious infection or has had a critical injury, particularly to the head) and can lead to peptic ulcers
4. Consumption of spicy foods - there is no relation between the consumption of spicy food and peptic ulcers. Spicy foods are just an additional contributing factor that worsens the already present peptic ulcer

All these risk factors individually do not cause ulcers, but they combine with H.pylori and/or NSAIDs and worsen the condition of ulcers.

Symptoms of peptic ulcer disease

1. Most of the time ulcers show no symptoms
2. Some people with ulcers have belly pain
3. Central upper abdominal pain, also known as epigastric pain
4. Indigestion
5. Gnawing sensation - it is the feeling of burning in which stomach acids and enzymes start eating the gastrointestinal lining
6. Bloated stomach
7. Burping/ belching
8. Loss of appetite
9. Nausea and vomiting²

Symptoms of gastric ulcers, duodenal ulcers, and esophageal ulcers

Complications

1. Ulcers will start to bleed if they are not treated for a long time. Symptoms may include:
   • Blood in stool (poop)
   • Black, tarry stool
   • Coffee ground vomitus
   • Dizziness or faintness
   • Paleness
   • Rapid heart rate
2. Long-standing ulcers start to erode the gastrointestinal tract and make a hole, showing symptoms like:
   • Sudden, sharp, severe abdominal pain
   • Abdominal swelling and tenderness to touch
   • Fever and chills
3. Gastrointestinal obstruction- a condition in which the gastrointestinal tract will slow down or stop food from moving through due to continuous scarring and/or swelling from untreated ulcers. Symptoms include:
   • Abdominal bloating, swelling, and pain
   • Nausea and vomiting
   • Loss of appetite
   • Weight loss
   • Constipation²

FAQs

What is peptic ulcer disease?

Peptic ulcer disease is a condition in which ulcers are formed in the stomach and duodenal lining of the gastrointestinal tract.

What causes peptic ulcer disease?

There are two major causes for the peptic ulcer formation. They are –

1. H. pylori infection
2. Long term use of NSAIDs

There are many other causative factors such as – alcohol and smoking habit, medical conditions like Zollinger-Ellison Disease, and physiological stress.

What are the symptoms of peptic ulcers?

Symptoms include indigestion, heartburn, burping, abdominal pain, loss of appetite, and gastro-oesophageal reflux.

When can one visit a gastroenterologist?

When the condition becomes severe and there is bleeding from the stools and bloody vomiting or intense abdomen pain after meals.

How is peptic ulcer disease diagnosed?

Diagnosis is done by proper history taking, physical examination, endoscopy, stool examination for H. pylori presence, and a breath test.

What is the treatment for peptic ulcer disease?

Treatment includes medications – proton pump inhibitors and/or histamine blockers to reduce the acid secretion.³

Antibiotics to treat the bacterial infection.

Surgical option for the long-standing peptic ulcers.

Summary

Peptic ulcer disease is a condition which causes ulcers in the stomach and duodenum. It is commonly caused due to H. pylori infection and overuse of NSAIDs. Duodenal ulcers and stomach ulcers are the two most common types. Peptic ulcer disease shows symptoms like abdominal pain, heartburn, indigestion, gnawing sensations, and burping. The long-standing ulcers will start to bleed and will erode the stomach and/or duodenum as a complication.