Introduction

Peptic ulcer disease and gastritis are conditions that affect the digestive system, which is responsible for the breakdown and absorption of food in the body. In peptic ulcer disease, open sores form in the lining of the stomach and parts of the upper small intestine this can be extremely painful, and can lead to severe bleeding and perforation of the intestine. In gastritis, the stomach becomes inflamed and irritated this can be either acute (occurs suddenly) or chronic (long-term).

How does the digestive system work?

The digestive system

The digestive system is a vital organ system in the body, responsible for breaking down food into smaller, simpler molecules, are used for energy, growth and repair. The stomach churns the food and mechanically breaks it down into smaller pieces. Acid and enzymes inside the stomach chemically digest the food, after which the contents are emptied into the small intestine.¹ The small intestine helps to further digest food after it has left the stomach and also absorbs nutrients, proteins, fats and carbohydrates from the food. The small intestine has three different sections, called the duodenum, jejunum and ileum.¹ Food then passes through the large intestine, rectum and anus, to be passed out of the body in the form of faeces.¹

How does the stomach protect itself from acids and enzymes?

The specialised lining of the stomach, called the gastric mucosa², protects the stomach from being damaged by acid and digestive enzymes. The gastric mucosa has four layers: the innermost layer is called the mucosa, which acts as a protective barrier; the second layer is called the submucosa; the third layer is a muscle layer, and the outermost layer is the serosa.² The stomach also produces mucus and bicarbonate, which provide another layer of protection to the stomach.³ The gastric mucosa and mucus-bicarbonate barrier are referred to as the ‘mucosal defence’, as they defend the stomach from damage.³ The inside of the stomach is a very harsh environment, and mucosal defence is important in helping the stomach to withstand these harsh conditions.² 

Production of enzymes and stomach acid

The stomach produces a large volume of acid and enzymes, which are important in the digestion of food. Stomach acid lowers the pH inside the stomach and makes it more acidic, which helps to break down food molecules and kills bacteria.² Digestive enzymes help to speed up the breakdown of proteins into smaller building blocks. Even though stomach acid and digestive enzymes are vital for healthy digestion, they have the potential to cause can cause damage and injury to the stomach itself. The mucosal defence is important in protecting the stomach from acid and digestive enzymes.² When this goes wrong and too much damage occurs to the gastric mucosa, it can lead to peptic ulcer disease and gastritis.

Peptic ulcer disease can affect both the stomach and the duodenum.

Causes and risk factors

Peptic ulcer disease

In peptic ulcer disease, ulcers form in the lining of the stomach. There is a break in the epithelium (lining) of the stomach, which extends through the mucosa and submucosa. Ulcers develop when excessive damage occurs to the stomach lining, as acid and digestive enzymes erode the epithelium. This can also occur in the duodenum, which is the first part of the small intestine. 

Peptic ulcer disease has a variety of different causes, including infection from a bacteria called Helicobacter pylori (H. pylori), use of certain drugs called nonsteroidal anti-inflammatory drugs (NSAIDs), smoking, stress, and excessive alcohol intake.

Gastritis

Gastritis occurs when the lining of the stomach (gastric mucosa) gets irritated and inflamed. It can be acute or chronic. Acute gastritis usually comes on suddenly, and lasts a short time. On the other hand, chronic gastritis occurs when the stomach lining is damaged over a long period, leading to persistent inflammation and irritation. Chronic gastritis tends to develop gradually.

Gastritis is commonly caused by:

• Helicobacter pylori infection 
• Certain drugs (NSAIDs)
• Extreme stress, such as major surgery
• Autoimmune conditions in which the body attacks its own cells, causing inflammation and thinning of the stomach lining

Stress, anxiety and alcohol consumption also increase the risk of developing acute gastritis. 

Helicobacter pylori

Helicobacter pylori (H. pylori) is a common bacteria that infects the stomach and damages the stomach mucosa, leading to gastritis and peptic ulcer disease. Around 50% of the global population is infected with H. pylori⁴, but most will never show any signs or symptoms.

H. pylori damages the stomach by attacking and the stomach mucosa. It makes an enzyme called urease, which converts urea, a substance produced during the breakdown of proteins, into carbon dioxide and ammonia.⁵ This helps H. pylori to protect itself, by making the stomach less acidic and forming a protective ammonia barrier, so it survives longer. The urease enzymes also weaken the stomach lining, making it more susceptible to damage. Other enzymes produced by H. pylori degrade and damage the gastric mucosa, causing injury to the mucosal cells.⁵

Through these methods, H. pylori can damage the gastric mucosa and lead to the development of gastritis, peptic ulcer disease and even certain cancers. 

NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a type of medicine that are commonly used to treat pain, inflammation and fever.⁶ Some well-known NSAIDs include ibuprofen, naproxen and aspirin⁶ and although they are very effective at reducing inflammation, they can cause many harmful side effects, particularly in the digestive system.⁶ Taking NSAIDs regularly can damage the stomach, liver and small intestine. They do this by interfering with the function of prostaglandins.

Prostaglandins are a group of specialised fats with lots of different roles in the body. In the stomach, they are responsible for mucosal defence and keeping the gastric mucosa healthy. 

NSAIDs inhibit prostaglandins and stop them from functioning properly. The protective functions of prostaglandins are inhibited, so, in the event of damage to the stomach lining, it is harder for the mucosa to repair itself. Therefore, NSAIDs increase the risk of developing certain gastrointestinal conditions, including peptic ulcer disease and gastritis.

Symptoms of gastric ulcers and gastritis

Peptic ulcer disease

Symptoms of peptic ulcer disease include:

• Burning pain in the middle of the abdomen⁷ 
• Indigestion (discomfort and pain in the upper abdomen)⁷
• Heartburn and acid reflux (burning feeling in the chest due to stomach acid moving up the oesophagus)⁷
• Feeling sick and nausea⁷

Various complications can arise from peptic ulcer disease, such as perforation of the ulcer, bleeding and obstruction. Perforation occurs when the stomach lining around the ulcer splits open, creating a hole in the stomach lining.⁷ Obstruction is where the ulcer blocks and obstructs the stomach, so food cannot pass through to the small intestine.⁷

Gastritis

Symptoms of gastritis include:

• Abdominal pain
• Indigestion
• Bloating (feeling full)
• Nausea (feeling sick) and vomiting
• Reduced appetite and not feeling as hungry as usual⁸

If left untreated, gastritis can lead to peptic ulcer disease, bleeding in the digestive system and certain types of anaemia.⁹ Certain types of gastritis can also increase the risk of stomach cancer.⁹

Diagnosis

If your doctor suspects you may have peptic ulcer disease or gastritis, they may consider further diagnostic tests. These tests may include an endoscopy, biopsy, urea breath tests, blood tests and imaging such as CT scans.

An endoscopy uses a thin tube with a camera to take pictures of your digestive system. The tube is passed directly into the body, allowing accurate pictures to be taken from the inside of the organs. In a biopsy, small pieces of tissues are removed from the body and sent to a lab for further testing. Urea breath tests analyse your breath after you consume a special drink containing urea- this test checks for infection with H. pylori in the stomach.

The results of these tests, confirms whether you may have gastritis or peptic ulcer disease.

Treatment of peptic ulcers and gastritis

Treatment for ulcers and gastritis can vary depending on the specific cause and how severity of the condition. Common treatments include medications and lifestyle/dietary modifications, but specific treatments may differ from person to person. Severe cases that do not respond to treatment may require surgery.

Medications

• Antibiotics are often prescribed if there is an infection with H. pylori. This helps to eradicate the infection. Common antibiotics prescribed include amoxicillin and clarithromycin⁷
• Proton pump inhibitors (PPIs) may be prescribed to reduce the production of stomach acid. Lansoprazole and omeprazole are examples of commonly used PPIs
• H2 receptor blockers reduce the amount of acid produced by the stomach overnight
• Antacids are not the primary treatment for ulcers and gastritis, but they may be prescribed to help neutralise stomach acid. Antacids can also be purchased over the counter

Lifestyle and dietary changes

Lifestyle and dietary modifications are important in treating gastritis and peptic ulcer disease, as well as preventing them again in the future. Avoiding NSAIDs, alcohol, and other irritants helps the stomach to recover and heal, and stress management is also important in the long-term treatment of these conditions. Eating a healthy, balanced diet and making dietary modifications can help the stomach to heal and reduce discomfort.

Summary

Peptic ulcer disease and gastritis are both common, but extremely painful conditions. Treatment is important for getting these conditions under control, relieving the pain, as well as preventing further complications in the future. Lifestyle modifications, as well as medications, can help in the treatment of these conditions, but prevention is just as important- eating a healthy, balanced diet, not drinking excess alcohol, avoiding NSAIDs and managing stress all help prevent these conditions from developing in the first place.