What Is Peptic Ulcer Disease?

Overview

Belly pain and indigestion are common occurrences in our daily lives. While they subside on their own most of the time, they could also be tell-tale signs of peptic ulcer disease. 

Peptic ulcer disease is a condition characterised by painful, open sores that develop in the stomach lining and the duodenum (first part of the small intestine) caused by direct exposure to stomach acid and other digestive juices.^1,2

Usually, a mucus barrier protects the stomach and the intestines. However, many factors can erode it. This article covers them in detail, along with more information on peptic ulcer disease.

Causes of peptic ulcer disease

There are many causes of peptic ulcer disease. They include –

Most common causes -

• Helicobacter pylori infection:

H. pylorus is a gram-negative bacterium that lives in the stomach. Around 50% of the world’s population is infected with it. However, it only causes ulcers in 10-15% of people due to overgrowth.

It causes ulcers and inflammation by exposing the stomach and duodenal wall to stomach acid by breaking down protective barriers like the mucus lining and bicarbonate secretions. 

Helicobacter pylori infections account for 90% of duodenal ulcers and 70-90% of stomach ulcers. The bacteria are transmissible (mainly during childhood) and prevalent in developing countries and certain ethnic groups.^1,2,3

• Overuse of NSAIDs (Non-steroidal anti-inflammatory drugs): 

It’s the second most common cause of peptic ulcers and accounts for 50% of them. NSAIDs are over-the-counter pain relievers that block prostaglandin synthesis through COX-1 enzyme inhibition. 

Since prostaglandins protect the stomach and duodenal wall (small intestine) by secreting mucus and bicarbonate, peptic ulcers form due to inflammation and exposure to stomach acid. 

Not all NSAID users develop peptic ulcers. Only up to 30% of people who regularly take NSAIDs get them. But aspirin users are twice as likely to get them.^1,2,3,4,5

Additionally, other factors cause peptic ulcers when coupled with NSAID. They include: 

• H. pylori infection
• High NSAID doses
• Prolonged NSAID use
• Age <65
• People AFAB
• Concomitant corticosteroid, antiplatelet, and anticoagulant use
• History of peptic ulcers and heart disease.^1,5

Less common causes -

• Diseases and complications:

Peptic ulcers may develop in cases of serious illnesses and syndromes such as:

• Zollinger-Ellison syndrome
• Crohn’s disease
• Malignancy (Lung, stomach cancer, and lymphomas)
• Vascular insufficiency
• Viral infections.³

• Medications:

Besides NSAIDs, certain medicines like corticosteroids, potassium chloride, bisphosphonates, and fluorouracil also cause peptic ulcers.^1,3

• Stress and diet:

Severe physiological stress caused by severe illness, burns, or injuries causes stress ulcers by increasing stomach acid secretion due to alteration of the body’s pH levels. These ulcers occur instantaneously in response to stress.^1,4

• Spicy foods and coffee do not cause peptic ulcers, but they aggravate them. Skipping meals also irritate stomach ulcers since it exposes the stomach wall to stomach acid, thus intensifying abdominal pain.^2,4

• Smoking and alcohol:

Smoking causes stomach ulcers by triggering stomach lining inflammation through increased free radical secretion. Alcohol consumption causes gastric ulcers by increasing acidity and limiting prostaglandin production.⁴

Peptic ulcers may also develop after radiation therapy, chemotherapy, and surgery.^1,3

Signs and symptoms of peptic ulcer disease

The signs and symptoms of peptic ulcer disease depend on the ulcer's severity and location, the patient's age, and the timing of onset based on meal intake.³ 

The most common symptom is burning and gnawing stomach pain.⁶ Patients with duodenal ulcers experience severe abdominal pain 2-3 hours after meals or at night, while stomach ulcer patients complain of nausea, vomiting, and belly pain.⁷ There are also cases where some ulcer patients are asymptomatic.^1,6

In general, the common symptoms to watch out for are:

• Epigastric pain (Mid to upper abdominal pain) 
• Bloating and abdominal fullness
• Heartburn
• Nausea and vomiting
• Weight loss or weight gain
• Indigestion (particularly intolerance to fatty foods)
• Pain that temporarily subsides after antacid consumption

Severe symptoms of peptic ulcer disease include:

• Hematemesis (Vomiting blood)
• Melena (Black, tarry stools)
• Bloody stools
• Unexplained weight loss
• Dysphagia (Difficulty swallowing) 
• Iron deficiency anaemia
• Severe mid to upper abdominal pain
• Continuous vomiting
• Difficulty breathing
• Paleness and faintness (Signs of blood loss)
• Changes in appetite.^1,2,3,6

These symptoms are warning signs of ulcer complications like bleeding peptic ulcers, stomach cancer-induced ulcers, perforated peptic ulcers, and ulcers that obstruct the small intestine.^1,2,3

Bleeding ulcers, the most common complication of peptic ulcer disease, occur in 15-20% of patients. Upper GI bleeding is an emergency and peptic ulcer disease causes around 40-60% of cases.⁷

Since bleeding ulcers are painless most of the time, watch out for these signs that indicate anaemia: 

• Mild symptoms
  • Dizziness
  • Fatigue
  • Breathlessness
• Severe symptoms (Heavy bleeding)
  • Bloody stools (resembles black tar) and vomit (reddish and coffee granule-like)²

Management and treatment for peptic ulcer disease

The objectives of peptic ulcer disease management include relieving ulcer pain, curing ulcers, preventing ulcer recurrence, reducing ulcer complications, and eliminating H. pylori, if present.⁴

Peptic ulcer disease treatment involves –

• Pharmacological treatment

Medications treat uncomplicated ulcers. They include –

• Antibiotics: They kill H. pylori bacteria. Usually, doctors prescribe a combination of them depending on the severity of the patient’s condition
• Proton pump inhibitors (PPI): They aid in ulcer healing and relieve ulcer symptoms by decreasing stomach acid production and protecting the stomach lining
• Histamine receptor blockers (H2 blockers): They retard stomach acid production by inhibiting histamine, a chemical triggering its secretion
• Antacids: They’re over-the-counter medications that neutralise stomach acid. However, they do not help with ulcer healing and can even interfere with certain antibiotics
• Protective medications: They coat the stomach lining and prevent stomach acid exposure and subsequent inflammation and ulceration^1,2 
• PPIs have replaced H2 blockers due to their better efficacy and ulcer healing capacity. Calcium supplements may be required since prolonged PPI use increases bone fracture risk³

• Surgical treatment
  • Surgery is needed when ulcer patients are unresponsive to medications, are noncompliant, or have complications like bleeding, perforation, and gastrointestinal obstruction
  • Vagotomy and partial gastrectomy are options for persistent peptic ulcers. The causes of these refractory ulcers are continued NSAID use, persistent H. pylori infection, and diseases like stomach cancer that hamper ulcer healing³ 

Treatment of H. pylori-induced peptic ulcers involves a combination of medications in various therapeutic regimes. It includes:

• Standard triple therapy (First-line therapy): It uses two antibiotics and one PPI to eradicate H. pylori. It’s administered for 7-14 days

• Quadruple therapy: It uses a combination of antibiotics and bismuth salts. It’s administered when first-line therapy fails

• Sequential therapy: It’s a quadruple therapy analogue that consists of a 5–day dual therapy (one PPI and antibiotic) and 5–day triple therapy (one PPI and two antibiotics)^3,4

• The efficacy of triple therapy has fallen below 70% in certain countries due to increasing antibiotic resistance⁷

Treatment of NSAID-induced peptic ulcers involves:

• Discontinuing NSAID use or taking a lower dose
• Discontinuing the concomitant use of corticosteroids, anticoagulants, and biphosphates
• Using PPIs, double doses of H2 receptor blockers, and protective medications^3,5

FAQs

How is peptic ulcer disease diagnosed

Peptic ulcers are diagnosed by assessing patients’ symptoms, evaluating NSAID use, determining the history of H. pylori infections, and performing tests that examine the stomach and duodenum for ulceration and abnormalities.^1,7

The various types of diagnostic tests used are –

• Endoscopy/ Upper Endoscopy: It uses an endoscope inserted through the mouth to visualise the stomach and duodenum. Tissue samples may be extracted to check for signs of anaemia, malignancy, H. pylori infection, and mucus damage

• Imaging tests: Upper GI series and CT scans use X-rays to detect duodenal and stomach ulcers. Patients consume a contrast fluid that coats the digestive organs easing their visualisation^1,2 

• Tests for H. pylori

Invasive methods –

• Histology: It uses non-selective and selective stains to detect H. pylori infection in tissue samples obtained from an endoscopy

• Culture: It detects H. pylori in isolated cultivations of the bacteria obtained from biopsy samples. This method also helps in determining antibiotic resistance

• Rapid urease test (RUT): It uses a urea reagent to check the enzymatic activity of  H. pylori. The bacteria’s urease enzyme breaks down the urea to form ammonia, which causes a rise in pH detected by an indicator

Non-invasive methods –

• Urea breath test: It’s a convenient test for H. pylori diagnosis. Patients drink a flavoured solution containing urea. If H. pylori are present, it breaks down the urea into carbon dioxide. The CO2 is then measured when patients breathe into a bag

• Stool antigen test: It determines H. pylori infection by detecting the antigens of the bacteria in stool samples

• Blood test/Serology: It detects H. pylori by checking for antibodies in blood samples. But it isn’t accurate in detecting an active infection^1,2,8 

How can I prevent peptic ulcer disease

Preventive measures for peptic ulcers involve eliminating or reducing triggering factors. They include:

• Moderating NSAID use in consultation with a doctor –
  • Decrease the use of NSAID or use alternatives (Ex: COX-2 selective inhibitors)
  • Reduce NSAID dosage or use medication that protects the stomach lining
  • Take the lowest effective NSAID dose with meals

• Lifestyle changes – 
  • Stop smoking and limit or avoid alcohol consumption
  • Refrain from consuming foods and beverages (Ex: Coffee and spicy foods) that cause indigestion, exuberate peptic ulcer symptoms, and increase stomach acid production
  • Avoid skipping meals to prevent stomach acid from directly eroding the stomach lining
  • Remove psychological stresses or move to a stress-free environment

• Take the H. pylori breath test to check for bacterial overgrowth^1,2,4 

Who are at risk  of peptic ulcer disease

The risk factors that predispose people to develop peptic ulcer disease are: 

• Frequent NSAIDs use
• Family history of ulcers 
• Lung, liver, or kidney diseases
• Habitual smoking and alcohol intake
• Advancing age
• Emigration from a developed nation
• African American/Hispanic ethnicity^1,3

How common is peptic ulcer disease

Peptic ulcer disease occurs globally and has a 5-10% incidence risk. But there’s been a decline in cases worldwide due to improved hygiene and sanitary practices, effective treatment, and careful use of NSAIDs. Duodenal ulcers are four times more common than stomach ulcers. They are also more likely to occur in men than in women.³ 

When should I see a doctor?

Always see a doctor for peptic and stomach ulcers, especially if you have a family history of upper GI malignancy. Although over-the-counter medications can manage peptic ulcer disease symptoms, the ulcers will not heal unless we treat the underlying cause.^2,3

Prompt diagnosis is also vital since some gastrointestinal diseases (Ex: Gastritis, gastroesophageal reflux disease (GERD), pancreatitis, and cholecystitis) and life-threatening conditions (Ex: Heart attacks, mesenteric ischemia, and mesenteric vasculitis) have similar symptoms to peptic ulcer disease.³

Always seek emergency care in case of the severe symptoms mentioned above as 

untreated ulcers can result in complications like perforations in the stomach and small intestines, gastrointestinal obstruction, stomach cancer, and upper GI bleeding.^1,2,3

Summary

Peptic ulcer disease is the formation of painful sores in the stomach and duodenum due to exposure to stomach acid and digestive juices. Helicobacter pylori infection and NSAID overuse are the main reasons for damage to the mucus barrier protecting the stomach and intestine lining. 

Peptic ulcers require medical attention since complications like ulcer bleeding, perforations, obstruction, and stomach cancer could occur if left untreated. Peptic ulcer treatment involves a combination of medications that are acid reducers, relieve ulcer symptoms and protect the stomach lining. It may also include surgery in severe cases.

Peptic ulcer prevention includes moderating NSAID use, undergoing H. pylori diagnostic tests, and minimising aggravating factors like stress and diet. People at risk, in particular, should be aware of these strategies and diligently adopt them.