Stomach and duodenal ulcer

What a peptic ulcer is

The lining of the stomach and duodenum exists in a delicate balance: on one side acid and pepsin, which digest food, and on the other mucus and protective mechanisms. When this balance is upset, acid eats through the lining and a sore deeper than gastritis forms, which can reach the lower layers of the wall. By location we speak of a gastric ulcer (in the stomach) or a duodenal ulcer.

Ulcers are common and, when properly treated, heal in a few weeks. Without treatment of the cause they can return or become complicated. Contrary to what is often believed, an ulcer is not caused by ordinary stress or spicy food; these factors may worsen complaints but are not the underlying cause.

Symptoms

The typical symptom is pain or burning in the upper abdomen (epigastrium), which may be related to food: in a duodenal ulcer it is often relieved after eating but returns after a few hours or at night; in a gastric ulcer it often worsens during or after eating. There may also be:

• nausea, a feeling of fullness or discomfort after eating;
• bloating, frequent belching or loss of appetite;
• in some cases, weight loss.

Some ulcers cause no pain and are found only when they cause a complication such as bleeding. Symptoms alone cannot reliably distinguish an ulcer from gastritis or dyspepsia, so an examination is needed.

Causes and risk factors

• Helicobacter pylori infection is the most common cause: the bacterium weakens the protection of the lining and lets acid act.
• Nonsteroidal anti-inflammatory drugs (ibuprofen, naproxen, diclofenac and others) and aspirin, even in low doses, especially in older people and when combined with anticoagulants, corticosteroids or alcohol.
• Smoking delays healing and increases the risk of recurrence.
• More rarely: critical illness, some medicines (for example bisphosphonates), other infections and conditions with very high acid production, such as Zollinger–Ellison syndrome.

Aspirin prescribed for the heart or to prevent stroke is not stopped on your own. The risk of a heart attack or stroke without it is often greater than the risk of an ulcer. The doctor decides whether stomach protection with a PPI or a change in treatment is needed.

How the diagnosis is made

• Gastroscopy shows the ulcer directly, assesses its size and depth, and allows biopsies. For gastric ulcers biopsies are usually taken to exclude a malignant process (cancer), because a gastric ulcer can mask one.
• Testing for H. pylori is always done (breath test, stool antigen or biopsy). Blood antibodies are not suitable for confirmation.
• Review of medicines you take, especially anti-inflammatory drugs and aspirin.
• Blood tests for anemia, if slow bleeding is suspected.

When an ulcer appears without a clear cause (no H. pylori and no anti-inflammatory drugs) or keeps returning, the doctor looks for other, rarer causes.

How it is treated

• Acid suppression, usually with a proton pump inhibitor (PPI), for a few weeks. The duration depends on the type and size of the ulcer.
• Eradication of H. pylori when present, with a regimen of medicines for about two weeks, followed by a test of cure to confirm eradication. This is often the key to lasting healing: after eradication an ulcer rarely returns.
• Review of anti-inflammatory drugs: stopping them when possible and, when they are essential, adding stomach protection.
• Stopping smoking.

For gastric ulcers, a follow-up gastroscopy after a few weeks is often planned to confirm healing and exclude cancer; for duodenal ulcers this is usually not needed. An ulcer can return if the cause persists.

Complications

• Bleeding: vomiting of blood or of material that looks like coffee grounds, melena (black tarry stools), anemia, weakness or fainting. It may be hidden and slow (anemia without any visible sign) or sudden and severe.
• Perforation: the ulcer breaks through the full thickness of the stomach or duodenal wall. Very severe, sudden pain with a rigid, board-like abdomen.
• Obstruction: narrowing of the stomach outlet from scarring or inflammation, with repeated vomiting and weight loss.

These conditions are treated in hospital, often with urgent endoscopy to stop bleeding or, when needed, with surgery. It is precisely to prevent them that treating the cause in time matters.

Daily care

Do not smoke and do not take anti-inflammatory drugs without medical advice. Alcohol delays healing and should be limited. Diet is adjusted to tolerance: no diet cures an ulcer and many foods do not need to be cut out. Take medicines on the prescribed schedule and complete the full course of treatment, even after complaints have gone.

Contact your doctor if pain returns after settling, if you have weight loss or repeated vomiting, and call 127 for any sign of bleeding.