Peptic Ulcer Disease (PUD) is a disease in which open sores form in the lining of the digestive tract. They are most commonly found in the stomach (gastric ulcer) or in the upper part of the intestines, known as the duodenum (duodenal ulcer). They can produce a gnawing and often intense type of pain that can be quite distressing. 

Helicobacter pylori or H.pylori is a bacteria which can cause an infection mostly affecting the stomach. At times, you might not even realise you are infected by it as there can be no obvious symptoms. 

H.pylori is one of the leading causes of PUD. If you have been diagnosed with PUD, you will also be tested for the presence of this bacteria.

Causes and risk factors

H.pylori infection: As stated above, H.pylori is one of the most common causes of PUD and this bacteria accounts for 90% of gastric ulcers and 70% of duodenal ulcers.¹ Surprisingly, many people have the presence of this bacteria in their stomach without any symptoms, so they might not even be aware of its presence. It is often acquired in childhood and can persist in the gut for a long time before it is treated. If this bacteria grows too much in the stomach, it can upset the balance of healthy microbes found in the gut. It can adhere to the lining of the stomach and secrete various substances that cause inflammation and destroy the lining of the stomach, known as the mucosa. The destruction of the mucosal layer leads to the formation of PUD.  

Non-steroidal anti-inflammatory drugs (NSAIDs): these are a widely used type of medicine which can relieve pain and fever. One common example is ibuprofen which is also available over the counter. They can be very effective but taking excess NSAIDS can lead to the development of PUD. 

Pathophysiology 

Normally, our digestive tracts are lined by a layer of protective soft tissue, known as mucosa. This layer is necessary because our stomach produces various digestive enzymes and acids in order to break down the food we eat to help with proper absorption. These acids and enzymes are naturally corrosive and the mucosa helps to protect our gut from being eroded and damaged by them. H.pylori and NSAIDs are two common causes of eroding the mucosa leading to the formation of ulcers. 

H.pylori: this bacteria can adhere to the stomach lining and invoke an inflammatory response. ² This response causes white blood cells, plasma cells, and macrophages to invade the mucosa which can lead to its damage. The inner lining of the stomach is now exposed to digestive enzymes and stomach acid which are corrosive in nature and can cause significant stomach pain. 

NSAIDS: Although NSAIDs are very widely used to relieve pain and fever, 25% of people who use NSAIDs will go on to develop ulcers.² This is quite a high risk of developing ulcers and NSAIDs have several factors that cause ulcers to develop in the gut lining. NSAIDS are mildly acidic and when they enter the acidic environment of the stomach they undergo chemical changes which cause them to enter the cells lining the stomach. The NSAIDs are trapped within the cells and cause damage to them through a series of events including cellular injury, bleeding, and erosion which eventually lead to an ulcer formation. NSAIDs also inhibit a substance which is responsible for maintaining the mucosal integrity.  In addition, they also decrease the blood flow to the mucosa in the stomach lining which can cause cell death, erosion and ulcer formation.³

Clinical presentation

At times, ulcers might be silent which means they do not cause any obvious symptoms. When symptoms start presenting they might not be continuous but may come and go and some of these include: 

• Upper abdominal pain which might be burning in nature and might radiate to the back
• Pain which is worse after eating (may be indicative of a gastric ulcer)
• Pain which is relieved by eating (may be indicative of a duodenal ulcer)
• Nausea
• Indigestion 
• Bloating 
• Loss of appetite 

If left untreated, an ulcer might develop further complications. They may begin to bleed or perforate through the digestive tract or cause an obstruction in the digestive tract.⁴ These complications require urgent medical attention and may present as: 

• Blood in your stool or tarry stool
• Vomit which resembles coffee grounds 
• Feeling pale and/or dizzy
• Tachycardia (fast heart rate)
• Severe abdominal pain and swelling 
• Fever with or without chills 

Diagnosis 

The first step in diagnosing an ulcer is a detailed medical history that your doctor will obtain from you by asking you a series of questions about your symptoms. This may lead to a physical examination. 

After these initial steps, your doctor will want to examine your digestive tract for any erosions and test you for H.Pylori infection. The ulcer can be visualised by upper GI (gastrointestinal) endoscopy which is a procedure during which a small flexible tube with a camera on one end is inserted into the upper part of the digestive tract, through your mouth. You will be given a mild sedative and a local anaesthetic (numbing agent) will be sprayed onto the back of your throat, to make you more comfortable. Your doctor will then be able to properly diagnose any ulcers, if present. They might even take a small sample of tissue from the ulcer in order to test for the presence of H.pylori. 

There are several tests which can be conducted to test for H.pylori infection. ⁵ These include: 

• Urea breath test: H.pylori can break down urea into a gas called carbon dioxide. During the test, you will be given a drink which contains urea and your breath will be tested after for the presence of excess amounts of this gas
• Stool antigen test: This test assesses the stool sample for the presence of H.pylori
• Blood test: The blood sample is tested for the presence of H.pylori. One downside to this test is that it cannot differentiate between an active/current and an old infection you may have previously had. 

You may be asked to stop taking certain medications such as proton pump inhibitors or antibiotics two weeks prior to these tests and you may also be asked to fast before these tests. 

Treatment 

The first step in managing ulcers would be managing the pain. In order to manage pain, the mucosal lining needs to be allowed to repair itself and thus, stomach acid being secreted needs to be reduced and reducing this acid will also help to lower pain. Medications which are used to reduce stomach acids are called histamine receptor blockers (H2 blockers) and proton pump inhibitors (PPIs).⁶ 

PPIs can also form a protective layer over your stomach lining by coating it, which can help to enhance mucosal repair. There are also other medications known as cytoprotective agents which can be used to coat your stomach lining such as bismuth subsalicylate (which are easily available over the counter one example would be Pepto-Bismol) and sucralfate. It is also highly advisable to avoid alcohol, smoking, and spicy food while the ulcer is healing.

Treatment also depends largely on the cause of the ulcers. If they were caused by NSAIDs, they need to be stopped immediately and alternative pain relief medications need to be considered. If the ulcers were caused by H.pylori infection, they need to be treated with antibiotics. 

If the ulcers were caused by h.pylori, a triple regimen of medications are initiated which consist of a PPI and two antibiotics, such as clarithromycin or metronidazole. These medications need to be taken regularly for 7 -14 days. If this regime fails, a quadruple therapy is initiated which consists of a different combination of antibiotics. 

If the ulcer still fails to heal after medication or if there is a complication such as bleeding, obstruction, or perforation, surgical intervention may be required. Some complicated ulcers can be treated during the upper GI endoscopy examination. The doctor will treat the erosion through stitches, injections or cauterisation. Rarely, if an obstruction has occurred, surgery may be required to reopen and explore the digestive tract. 

Prevention 

There are several ways you can prevent or reduce the risk of formation of ulcers: 

• A simple urea breath test can be done to determine an infection and get it treated before it can cause an ulcer
• Try not to over-use NSAIDs and only use as directed by your doctor
• Control your stress levels
• Avoid or limit smoking or alcohol 

Conclusion 

PUD is a condition in which open sores develop in the digestive tract. These sores are called ulcers and they most commonly occur either in the stomach or in the upper part of the duodenum. 

Ulcers form when the mucosal layer which lines and protects the stomach lining is damaged and eroded and the acids and enzymes secreted by the stomach cause further irritation and prevent healing of this sore. The two main factors which damage the mucosal lining are NSAIDs and H.pylori infection. H.pylori infections are very common and most people may not be aware of themselves being infected. 

There are various different ways to test for the presence of h.pylori infection in the body and these are quite simple and painless tests. If these tests are positive you will be prescribed a combination of different medications to help treat this infection and to help heal your ulcer. 

Ulcers are commonly found among individuals and their prognosis is quite good. They can be effectively treated but they carry a high rate of recurrence so good care needs to be taken in order to prevent its recurrence.