Peptic Ulcer

This article was last reviewed on

19 September 2023.

This article waslast modified on 19 September 2023.

What is it?

A peptic ulcer is a break in the mucosal lining of the stomach or duodenum (the upper part of the small intestine), usually caused by an imbalance between factors promoting mucosal damage such as bacterial infection with Helicobacter pylori, gastric acid, pepsin and non-steroidal anti-inflammatory drugs and those promoting defence of the gastrointestinal tract.

The stomach produces hydrochloric acid and enzymes, including pepsin, that break down and digest food. A mucus layer coats the stomach and protects it from the acid. Prostaglandins, hormone-like substances involved in muscle contraction and the inflammatory response, also aid in protecting the lining. When these defences are not performing their job properly, acid and pepsin eat away at the lining, forming an open sore called an ulcer.

H. pylori decreases the stomach’s ability to produce mucus, making it more likely that acid will cause peptic ulcers. Although H. pylori infection is found in many people, it does not cause ulcers in all of them. However, of those who have peptic ulcers more than half have this infection.

Long-term use of non-steroidal anti-inflammatory agents (NSAIDs), such as aspirin, naproxen and ibuprofen can also cause peptic ulcers. Rarely, peptic ulcer is caused by the Zollinger-Ellison syndrome in which a tumour in the small intestine or pancreas produces large amounts of the hormone gastrin. Other rare causes include, certain medications such as potassium chloride and bisphosphonates and Crohn’s disease.

Smoking and heavy alcohol drinking can exacerbate peptic ulcers and slow healing. The risk of peptic ulcers and associated complications increase with age.

About Peptic Ulcer

Symptoms
The most common symptom is abdominal pain that is dull, comes and goes over a period of time, occurs regularly a few hours after eating or during the night, and is relieved by food and/or antacids; this symptom is known as dyspepsia. Another common sign is chronic or recurrent central, upper abdominal pain or discomfort. Weight loss, bloating, nausea and vomiting may also occur.

Peptic ulcers are rarely fatal, but they can be very serious if they go through the stomach or duodenal wall (perforation), break into a blood vessel (haemorrhage) or block food leaving the stomach (obstruction).

Symptoms that require immediate medical attention are:

sharp, sudden, persistent stomach pain

bloody or black stools

vomit that is bloody or looks like coffee grounds

Be aware that:

Weight loss, a low haemogloblin level, or a raised platelet count associated with dyspepsia, reflux or upper abdominal pain may suggest malignancy and requires urgent referral to a specialist.

Diarrhoea associated with dyspepsia may indicate Zollinger-Ellison syndrome and requires urgent specialist referral

Risk factors

H. pylori infection

NSAIDs use

Smoking

Increasing age

Family history of peptic ulcer disease

An intensive care stay in hospital
Tests

The laboratory diagnosis of H. pylori as the likely cause of a peptic ulcer can be made using a number of methods and specimen types. The UK National Institute for Clinical Excellence and Health (NICE) recommends the use of a carbon-13 urea breath test to detect the enzyme activity of H. pylori, a positive result indicating current infection. If the breath test is not available, a stool test to look for the H. pylori antigen should be used. Of least value is a blood test for antibodies to H. pylori because a positive result simply means that you have been infected with H. pylori at some time.

If x-rays of the upper gastrointestinal tract have shown the presence of an ulcer and a stool or breath test is negative, an invasive procedure called endoscopy may be used to detect H. pylori. A tiny camera on the end of a thin tube is fed through the mouth, down the oesophagus to the duodenum and tissue removed (a biopsy) to be examined in the lab for H. pylori antigen and under the microscope for the bacteria. Endoscopy and biopsy allow the diagnosis of other conditions that may be the cause of indigestion, including gastric cancer; endoscopy is the gold standard diagnostic test for peptic ulcer disease. If Zollinger-Ellison syndrome is suspected, then a fasting gastrin blood test may be requested.
Treatment

Before we knew about H. pylori, a peptic ulcer was often cured by treatment with an antacid or a proton pump inhibitor (PPI) drug to reduce the amount of stomach acid produced, but it usually recurred when treatment was stopped. Present day treatment with antibiotics to kill the bacteria, if they are present, greatly reduces the likelihood of an ulcer recurring. In patients who are H. pylori negative the first line treatment is a PPI and second line treatment a H2 antagonist. Patients who are H. pylori positive usually have first line antibiotic treatment. You may be treated with a combination of PPI and antibiotics.
Monitoring

Those with a peptic ulcer and H. pylori should be followed up with a repeat endoscopy 6-8 weeks after beginning treatment. Patients with peptic ulcer and proven H. pylori should be retested for H. pylori 6-8 weeks after beginning treatment.