Peptic Ulcer (PUD; Gastric Ulcer; Duodenal Ulcer; Ulcer, Peptic; Ulcer, Gastric; Ulcer, Duodenal)

Risk factors for ulcer from H pylori infection include: Age: 60 or olderSex: maleRace: Black and HispanicLower socio-economic groupA crowded and unsanitary living environmentCigarette smokingFamily history of ulcer diseaseType O blood Risk factors for ulcer from anti-inflammatory drugs include: Age: 60 or olderSex: maleHistory of stomach upset from NSAIDsPrior peptic ulcer diseaseCigarette smoking Alcohol abuse SymptomsPeptic ulcers do not always cause symptoms. Symptoms may come and go. Food may increase gastric ulcer pain, but food usually relieves duodenal ulcer pain. Symptoms include: Gnawing pain May awaken you from sleepMay change when you eatMay last for a few minutes or several hoursFeels like unusually strong hunger pangsNauseaVomitingLoss of appetiteBloatingBurping Ulcers can cause serious problems and severe abdominal pain. Problems include: Bleeding, which may occur with no other symptomsSymptoms of bleeding include: Black, tarry stoolsVomiting what looks like coffee groundsWeaknessDizzinessAnemiaBreaking through the wall of the stomach or duodenum (called a perforated ulcer)Sudden and severe pain is a common symptom of a perforated ulcer. Scar tissue that narrows and eventually closes off the outlet of the stomach to the intestinesThis blocks food from passing through the digestive system. Symptoms of scar tissue blockage include: VomitingWeight lossIntense pain Duodenal Ulcer 2008 Nucleus Medical Art, Inc.

DiagnosisThe doctor will ask about your symptoms and medical history, and perform a physical exam. Tell your doctor about all medications you are taking. Tests may include: Rectal exam and stool guaiac testto test for hidden blood Blood test or breath testto check for H pylori infection A blood test can also check for gastrin levels if Zollinger-Ellison syndrome is suspected.Upper GI seriesa series of x-rays of the upper digestive system taken after drinking a barium solution Endoscopya thin, lighted tube inserted down the throat to look inside the digestive tract During this procedure, the doctor can take tissue samples to test for H pylori infection or for cancer. Endoscopy is also helpful to eliminate other serious causes of gastrointestinal symptoms. TreatmentThe goals of treatment are to remove the source of the problem and heal the ulcer. Gastric ulcers may take longer to heal than duodenal ulcers.Treatments include: Medication Some medications block or reduce acid production. Some coat the ulcer to protect it. If H pylori caused the ulcer, you will need to take a combination of drugs to kill the bacteria. This usually consists of antibiotics and a proton-pump inhibitor. It is very important to take these drugs as directed. The doctor may order tests 6-12 months after treatment to check that the bacteria are gone.

Medications may include: Antacidsthey do not heal ulcers, but may provide some relief from heartburnAntibiotics (amoxicillin, tetracycline, and clarithromycin)Bismuth-containing drug (Pepto-Bismol)Proton pump inhibitorsto decrease stomach acid production (omeprazole, lansoprazole) H 2 blockersto decrease stomach acid production (famotidine, ranitidine, cimetidine, nizatidine)Medications to coat ulcer (sucralfate)Medications to protect stomach against NSAID damage (misoprostol) Lifestyle ChangesIf you smoke, quit. Smoking interferes with ulcer healing. Do not drink alcoholic beverages.Avoid NSAIDS, including over-the-counter drugs like aspirin and ibuprofen.If spicy or fatty foods worsen symptoms, you can temporarily stop eating them. Keep in mind they did not cause the ulcer and probably do not affect ulcer healing. If stress increases ulcer pain, learn and practice stress-management techniques. Surgery and Endoscopy You may need surgery if you have bleeding, a perforation, or an obstruction. Surgical options include: EndoscopyThis may be done to stop bleeding. In this procedure, a thin, lighted tube is inserted down the throat into the stomach or intestine. Then, heat, electricity, epinephrine, or a substance called fibrin glue can be applied to the bleeding area to stop blood flow. Vagotomy and drainageVagotomy is the cutting of branches of the vagus nerve. Cutting the vagus nerve can greatly reduce acid production. Cutting through the entire nerve, though, can also interfere with the stomachs ability to empty itself. Therefore, drainage must be created. Drainage may be done with one of the following: PyloroplastyWidening the opening between the stomach and the duodenum, allowing stomach contents to flow more easily into the intestineGastroduodenostomyCreating a newopening to connect the stomach and the duodenumGastrojejunostomyCreating a newopening to connect the stomach and the jejunum (the second part of the small intestine)Highly elective vagotomyThis is a technique that cuts only part of the vagus nerve. This surgery does not require extra drainage.Vagotomy with antrectomyThis involves cutting the vagus nerve combined with removing the lower part of the stomach (antrum). The antrum makes a chemical that promotes acid production. Without that chemical, acid production drops. Prevention To decrease the risk of ulcer from H pylori infection:

Wash your hands after using the bathroom and before eating or preparing food.Drink water from a safe source.Don't smoke. Cigarette smoking increases the chances of getting an ulcer. To decrease the risk of ulcer from NSAIDs: Use other drugs when possible for managing pain.Take the lowest possible dose.Do not take drugs longer than needed.Do not drink alcohol while taking the drugs.Ask your doctor about switching to a newer NSAID that is less likely to cause ulcers, or about taking other drugs to protect your stomach and intestine lining. Don't smoke. Cigarette smoking increases the chances of getting an ulcer. RESOURCES: The American College of Gastroenterologyhttp://www.acg.gi.org/ American Gastroenterological Associationhttp://www.gastro.org/ CANADIAN RESOURCES: BC HealthGuidehttp://www.bchealthguide.org/ C-Healthhttp://chealth.canoe.ca/ References: Conn HF, Rakel RE. Conn's Current Therapy 2001. 53rd ed. Philadelphia, PA: WB Saunders Company; 2001. Dambro MR, Griffith HW, Griffith JA. Griffith's 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams & Wilkins; 1999. Fauci AS ed. Harrison's Principles of Internal Medicine. 15th ed. Columbus, OH: McGraw Hill; 2001.

H pylori and peptic ulcer. National Institute of Diabetes and Digestive and Kidney Diseases website. Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/hpylori/. Published October 2004. Accessed June 13, 2008. Ulcers. The American College of Gastroenterology website. Available at: http://www.acg.gi.org/patients/patientinfo/ulcers.asp. Accessed June 13, 2008. Ulcers. American Gastroenterological Association website. Available at: http://www.gastro.org. Accessed June 13, 2008. Ulcers and H pylori infection. America Academy of Family Physicians website. Available at: http://familydoctor.org/online/famdocen/home/common/digestive/disorders/271.html. Published May 1999. Updated December 2006. Accessed June 13, 2008. Last reviewed October 2007 by Daus Mahnke, MDPlease be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.