Peptic Ulcers: What You Need to Know

Ulcers of the gastrointestinal (GI) tract are called peptic ulcers. “Peptic” means that the problem is a result of digestive acids, and “ulcer” means an open sore. Approximately 4 million Americans have peptic ulcer disease that leads to 1 million hospitalizations and 6500 deaths annually.^1,2 The 2 most common peptic ulcers are gastric ulcers, which occur in the stomach, and duodenal ulcers, which occur in the upper portion of the small intestine.³ Although the GI tract is coated with a remarkably resilient protective mucous membrane, if that membrane is compromised, digestive acids can come in contact with these organs and an ulcer can develop.

Causes

The GI tract is full of healthy bacteria that help protect and maintain good digestive health. What can compromise its mucous membrane, you ask? Not spicy food or stress as was once thought. The 2 most common causes of peptic ulcers are bacterial infections and medications.^3,4 The bacterium known to disrupt the lining of the GI tract by causing inflammation is Helicobacter pylori (H pylori).^2,5 About half the people in the world are infected with H pylori, although many will never develop an ulcer.^3,6

Several medications are known to cause injury to the GI tract. The most common class is nonsteroidal anti-inflammatory drugs (NSAIDs), which may damage the mucous membrane in various ways.⁷ For a complete list of these medications, please see the Table.

Other medications that may be responsible for peptic ulcers include aspirin; clopidogrel; bisphosphonates, such as alendronate and risedronate; solid form potassium supplements; corticosteroids used in combination with NSAIDs; anticoagulants, such as heparin; and some forms of chemotherapy.⁷

A rare disease called Zollinger- Ellison syndrome may also cause peptic ulcers. This occurs from gastrinomas (tumors) that produce and discharge large amounts of gastrin, a hormone that stimulates acid production.⁸

Risk Factors

Factors that may increase the risk of peptic ulcers include being 50 years or older, alcohol abuse, tobacco use, family or personal history of peptic ulcer disease, regular use or overuse of any of the above medications, localized radiation treatments, and respiratory ventilation.^1,9

Symptoms

Symptoms of a peptic ulcer range from nonexistent to life-threatening blood loss. The most common symptom is a burning pain that can occur anywhere from the belly button to the breast bone. This pain can occur at any time, but usually occurs when the stomach is empty, and may be temporarily relieved by eating foods that buffer stomach acid or by taking acid-reducing medications.

Other symptoms may include nausea, vomiting, appetite changes, unexplained weight loss, frequent burping, chest pain, fatigue, weight loss, and feeling bloated. Less common, but more severe symptoms include bright red or black, tarry stool, which is a sign of a lower GI bleed, or vomiting bright red or dark granules (similar to coffee grounds), which is a sign of an upper GI bleed.^1,3,4,6,9,10

Complications

If left untreated, peptic ulcers can lead to blockage of the digestive tract from scar tissue, severe infection (peritonitis), or internal bleeding resulting in anything from anemia to death.³ Patients should seek immediate medical attention if they vomit blood or food eaten hours to days before, feel cold and clammy or weak and dizzy, or have sudden and severe pain, ongoing nausea, repeated vomiting, or bloody stool.¹⁰

Diagnosis

For diagnosis of an ulcer, patients typically undergo an upper endoscopy (with or without biopsy for H pylori) or an upper GI (a series of x-rays after drinking barium).⁹ A test for H pylori is also in order. This can include a blood test, a stool test, or a breath test.¹ The doctor may also order tests for anemia or a stool occult blood test to check for bleeding.⁹

Treatment

Treatment goals are to heal the ulcer and prevent it from recurring. Active NSAID-induced ulcers are treated with proton-pump inhibitors (PPIs) such as dexlansoprazole, esomeprazole, lansoprazole, omeprazole, pantoprazole, or rabeprazole and NSAID cessation.^5,11 For patients with a known history of ulcers in whom NSAID therapy is necessary, the lowest effective dose and duration should be coupled with maintenance treatment with a PPI or misoprostol. ¹¹

Patients testing positive for H pylori will have to undergo treatment with 2 antibiotics to help prevent antibiotic resistance and an acid reducer to help heal the organ lining. In addition to the PPIs listed above, other acid reducers include histamine blockers (cimetidine and ranitidine) and bismuth subsalicylate.⁶ A 2-week regimen has been shown to be more effective than a 1-week regimen.¹¹ Triple therapy includes amoxicillin, clarithromycin, and a PPI. If the patient has an allergy to penicillins, amoxicillin should be replaced with metronidazole.¹¹ If the standard form of treatment fails, patients should undergo a quadruple therapy regimen consisting of a PPI or ranitidine plus bismuth, metronidazole, and tetracycline.¹¹

Peptic ulcers can be complex and dangerous. Take your antibiotics with food and finish the entire course as prescribed. For best results, a PPI dose should be separated by 2 hours from an antibiotic dose. Some antibiotics can make the skin extra sensitive to the sun and may decrease the effectiveness of birth control pills.

Prevention

Infection with H pylori may occur from contact with contaminated food or water or from close personal contact with an infected individual.⁶ To protect against infection, wash hands with soap and water, especially after using the toilet and before eating, and drink only from clean, safe sources. Minimize personal contact with infected individuals.⁵

Acetaminophen may be a viable alternative, but if taking aspirin or NSAIDs is unavoidable, speak to a provider. Co-therapy with a PPI or misoprostol may be necessary, especially if a patient has tested positive for H pylori. Avoiding alcohol and tobacco may also help.

Dr. Kenny earned her doctoral degree from the University of Colorado Health Sciences Center. She has 20-plus years’ experience as a community pharmacist and is a clinical medical writer and the Colorado Education Director for the Rocky Mountain Chapter of the American Medical Writers Association.

References

• Understanding peptic ulcer disease. American Gastroenterological Association website. www.gastro.org/info_for_patients/2013/6/6/understanding-peptic-ulcer-disease. Accessed April 9, 2015.
• Helicobacter pylori and peptic ulcer disease. Centers for Disease Control and Prevention website. www.cdc.gov/ulcer/economic.htm. Published October 1998. Updated September 28, 2006. Accessed April 9, 2015.
• Mayo Clinic Staff. Peptic ulcer. Mayo Clinic website. www.mayoclinic.org/diseases-conditions/peptic-ulcer/basics/definition/con-20028643. Published July 26, 2013. Accessed April 9, 2015.
• Schafer T. Peptic ulcer disease. American College of Gastroenterology website. http://patients.gi.org/topics/peptic-ulcer-disease/. Published November 2007. Updated December 2012. Accessed April 9, 2015.
• Peptic ulcer disease and H. pylori. National Institute of Diabetes and Digestive and Kidney Diseases website. www.niddk.nih.gov/health-information/health-topics/digestive-diseases/peptic-ulcer/Documents/hpylori_508.pdf. Published August 2014. Accessed April 9, 2015.
• H. pylori infection. Mayo Clinic website. www.mayoclinic.org/diseases-conditions/h-pylori/basics/definition/CON-2003903. Accessed April 9, 2015,
• Vella V. Drug-induced peptic ulcer disease. J Malta College Pharm Pract. 2005;10:15-19.
• Mayo Clinic Staff. Zollinger-Ellison syndrome. Mayo Clinic website. www.mayoclinic.org/diseases-conditions/zollinger-ellison-syndrome/basics/definition/con-20024097. Published October 12, 2011. Accessed May 5, 2015.
• Peptic ulcer. MedlinePlus website. www.nlm.nih.gov/medlineplus/ency/article/000206.htm. Updated July 18, 2013. Accessed April 9, 2015.
• FamilyDoctor.org editorial staff. Ulcers. FamilyDoctor.org website. http://familydoctor.org/familydoctor/en/diseases-conditions/ulcers.printerview.all.html. Published July 1996. Updated May 2014. Accessed May 5, 2015.
• Anand BS. Peptic ulcer disease treatment & management. Medscape website. http://emedicine.medscape.com/article/181753-treatment. Updated January 9, 2015. Accessed April 9, 2015.