What is a peptic ulcer?

A peptic ulcer is a sensitive, raw patch, very much like a mouth ulcer, which forms a break in the lining of the stomach or the duodenum. Gastric ulcers occur in the stomach and duodenal ulcers occur in the duodenum, the first part of the intestine after the stomach.

How is an ulcer formed?

The stomach produces hydrochloric acid and pepsin, which together start the digestion of food. In theory, these two substances could digest the lining of the stomach or duodenum just as they do the food, but several defence mechanisms protect the lining from such attack. Ulcers occur when the acid and pepsin break the defences and ‘eat’ away at the lining of the stomach and duodenum. The involvement of pepsin has led to the general description of ulcers as ‘peptic’. It is often thought that people with ulcers are making too much acid and pepsin. However, for the majority of sufferers this is not so and the amount of acid produced tends to get less with age.

A very important cause of developing an ulcer is a germ or bacterium called Helicobacter pylori, known as H. pylori. This is found in the lining of the stomach of about half of the adults in Britain and it is now certain that having this germ present makes developing ulcers much more likely. Patients with duodenal ulcer almost always have this germ present and at least 80% of gastric ulcer patients also have it.

Medical research is actively investigating why it is that only some people who are infected with the germ get ulcers.

Who has an ulcer?

Ulcers are common in Britain and men are more prone to suffer than women. About one in ten men and one in fifteen women suffer from an ulcer at some time in their lives, but in most people they heal up with treatment. People who have H. pylori present in the lining of their stomach are far more likely to develop further ulcers and so it is important that they receive treatment to clear this infection. This can usually be done by using a combination of tablets including antibiotics. Ulcers are rare in children and are more likely to occur as people get older. Sometimes peptic ulcers tend to run in families. Another important cause of ulcers is the group of drugs used in the treatment of pain, particularly arthritis and rheumatism, called the Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). Aspirin is one of this group.

People throughout the world suffer from ulcers, but they are most common in Europe, North America, Southern India and Bangladesh.

What are the symptoms?

Severe pain in the abdomen:

	usually felt at the top of the stomach, centrally between the ribs and sometimes going through to the back
	often burning in quality
	often eased by eating, only to recur once the food leaves the stomach
	often worse at night (in duodenal ulcer patients and may wake them up)
	sometimes accompanied by vomiting.

What increases the risks?

Sometimes there is no apparent explanation for the development of an ulcer. However, it is known that smoking, heavy alcohol intake - especially spirits - and certain medicines such as aspirin and anti-inflammatory drugs, can cause ulcers to develop or make existing ones worse.

Smoking makes ulcers more likely to develop and also slows the healing process. It also makes recurrence more likely.

The action of aspirin and other anti-inflammatory drugs:

	prevent the formation of protective substances
	are harmful to the stomach lining
	can cause ulcers to bleed.

Patients who regularly have to take aspirin or anti-inflammatory pain killing drugs should discuss with their doctor how to minimise the effects on their stomach.

Stress probably does not cause ulcers, but does worsen symptoms if an ulcer is present. Stressful situations worsen their symptoms, possibly because the stomach produces more acid in response to stress.

How is an ulcer diagnosed?

The usual tests used are either an endoscopy or a barium meal. These are usually done on an out-patient basis.

What is an endoscopy?

After going without food, the patient is helped to swallow a slim flexible tube which enables the lining of the gullet, the stomach and duodenum to be seen. Before the procedure is carried out, a mild sedative and/or a numbing agent for the back of the mouth may be used. Where necessary cell tests (biopsy) and also tests to detect Helicobacter pylori can be taken for analysis.

What is a barium meal?

A barium meal is an x-ray which involves swallowing a tasteless, white liquid. Ulcers show up as craters or pits in the lining of the stomach and duodenum.

What can be done for an ulcer?

About one-third of duodenal ulcers heal by themselves within a month. Dietary treatment used to be recommended for ulcers, but drug treatment is now so effective that the main dietary advice is simply to avoid foods which cause indigestion. These vary from patient to patient. A bland diet is not necessary but it is sensible to ensure regular meals.

The aim of treatment is to:

	eradicate Helicobacter pylori infection when present. Combinations of drugs including antibiotics are used for one or two weeks to kill the germ.
	reduce stomach acid. The most commonly used drugs do this by inhibiting the cells which produce gastric acid. Antacids, such as Milk of Magnesia, act by neutralising, for a short time, the acid after it has been produced.
	boosting the body’s defences. Other drugs help the stomach lining to resist being ‘eaten’ away by the digestive process.

Do ulcers come back after treatment?

Most ulcers heal in four to eight weeks but they are very likely to come back in the future unless Helicobacter pylori infection is successfully treated. If the germ is killed by treatment, the chances of recurrence are tiny. Where this is not achieved, or the ulcer is not caused by infection then another way of preventing ulcer recurrence is to continue to take acid reducing tablets.

What are the side-effects?

Generally ulcer drugs have few side-effects. Some antacids may cause constipation, others may cause diarrhoea. Antibiotic treatments are less pleasant and may cause mild stomach upset and diarrhoea. They are usually only given for 1-2 weeks.

Are operations necessary to treat ulcers?

Because we now have such effective medical treatment operations are rarely needed today.

Occasionally, surgery may be required as an emergency if a deep ulcer causes a complication, such as bleeding or perforation of the wall of the stomach or duodenum.

There are also a few people who had ulcers years ago and have persisting problems as a result of scarring. This may cause a narrowing of the centre of the stomach which can be relieved by surgery or endoscopy.

How can an ulcer be avoided?

	don’t smoke
	don’t take aspirin unless essential - use paracetamol instead
	avoid taking anti-arthritis pain killers or other anti-inflammatory drugs if at all possible: your doctor will advise.

Is an ulcer there for life?

Like mouth ulcers, peptic ulcers tend to come and go. Without treatment recurrence is quite common. The treatment of Helicobacter pylori infection provides a cure from further trouble for most but not all patients. For the rest, care should be taken to avoid factors likely to provoke recurrence such as irritant drugs, smoking, alcohol to excess, or stress. Self help is important. For such people drugs to reduce acid production by the stomach are helpful.

The need for research

Although many of the factors leading to peptic ulcers are known, they are very complicated and much more needs to be discovered.

Current research is identifying how Helicobacter pylori causes ulcers in some people and not in others. Research is also finding how Helicobacter infection is acquired and how it can most effectively, simply and cheaply be eradicated.

Perhaps unidentified dietary factors are important which might explain the odd world-wide distribution of the problem. Perhaps there are better ways of bolstering the defence mechanisms - particularly against the pain killing drugs that interfere with them. Work is already in progress to find answers to these important questions. It is vital that research continues if digestive disease is to be conquered.