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Peptic ulcer

Documents in English

NHI.no

Magesår bilde#1

A peptic ulcer, also known as PUD or peptic ulcer disease is an ulcer located to the mucosa in the stomach or in the duodenum (first part of the small intestine, just after the stomach). These ulcers often recur, there is a 75% chance that an peptic ulcer will return within a year if not treated.

 Peptic ulcer disease is associated with 

. 75% of the ulcers located to the stomach and 99% of the ulcers located in the duodenum are caused by this bacteria. 25% of the ulcers located to the stomach is caused (or worsened) by drugs such as Aspirin and other NSAIDs. These drugs can have a damaging effekt on the mucosa, espescially in the stomach.

What is a peptic ulcer?

About 10% of the public will develop a peptic ulcer during their lifetime. The prevalence in our part of the world is gradually getting smaller, the prevalence is higher in third world countries. This is even more so for ulcers located to the duodenum. The living-standard in the western world prevents transmission of 

Peptic ulcers are about as common in females (9,5%) as in men (10,5%) according to a Norwegian study (Sørreisa-studien, 1992). Ulcers in the duodenum is most frequent in the agegroup 30-55 years, while stomach-ulcers are more common in the agegroup 55-70 years.

About 20-50% of the population is infected with the 

-bacteria. The prevalence of the infection rises with advancing age. A peptic ulcer only develops in 15-20% of those with an 

-infection. This means that an infection with the bacteria is not enough for you to develop neither peptic ulcers or a 

. Only a small fraction of the infected population develop ulcers or tumors. 

Occurence

As mentioned earlier, peptic ulcers are caused by the bacteria 

. This bacteria can only be found in the acidic environment of your stomach or in the first part of your small intestine (doudenum). 

 can cause inflammation and ulcers in this tissue, but most often it does no harm. The risk of ulcers will remain as long as this bacteria is found in your stomach. This risk will be enhanced by smoking.

An acidic environment is nessesary to develop peptic ulcers, but those who develop the condition does not need to have a higher level of acid production than healty people. Despite of this fact, medicin that reduce the level of acid in your stomach can reduce the symptoms from your ulcer, but they can only ease the discomfort - they can not eradicate the infection and avoid future recurrence of the peptic ulcer. These drugs are called antacids, H2 antagonists or proton pump inhibitors (PPI)

Ulcers can also be caused or worsened by drugs such as Aspirin and other NSAIDs. About 25% of the stomach ulcers and a small fraction of the duodenic ulcers are cused by this group of drugs. These drugs have an errosive effect on the mucosa that lines the stomach. Read more about stomach ulcers cased by errosive drugs 

Peptic ulcers are caused by a damage in the stomac mucosa caused by infection with 

 or from errosive drugs. The damage in the protective lining of the stomach work as opening a door for the stomach acid and an enzyme (pepsin) to do harm. This causes the ulcer which develop trough the mucosa and into the muscle tissue of the stomach or the intestine. The diametre of the ulcer is usually more than 5 mm. Vessels that line the wound can be punctuated by the errosive effect mentioned, and a gastrointestinal bleeding can occur as a complication (perforated peptic ulcer). 

Cause

Symptoms of a peptic ulcer vary in intensity and can be difficult to recognize. The symptoms will change during the course of the day, and from day to day. Abdominal pain (classically epigastric) that is eased by eating or antacids is the most common complaint. Almost half of the patients that have this condition deny any correlation between the pain and meals. Another fairly common complaint is to wake up in the middle of the night because of abdominal pain. A history of heartburn, gastroesophageal reflux disease (GERD) and use of certain forms of medication can raise the suspicion for peptic ulcer. Reduced appetite and weight loss, nausea and vomiting as well as bloating and abdominal fullness is more linked to stomach ulcers than to duodenal ulcers. A bleeding ulcer can cause symptoms of anemia (you become faint, pale and dizzy).

About one out of four will experience complications caused by peptic ulcers. Elderly and people that frequently use NSAIDs are at larger risk of this. Gastrointestinal bleeding is the most common complication, perforation (a hole in the wall) can lead to dire consequences. Scarring and swelling due to ulcers causes retention (narrowing in the duodenum and gastric outlet obstruction). These patient often presents with severe vomiting. When NSAIDs is the cause of the condition, about 60% will not display any symptoms until a complication occurs. The reason for this is that the analgetic effect of the NSAIDs hide the symptoms.

 This complication occuirs in 15-20% of those with a peptic ulcer (the most common complication). Sudden large bleeding can be life threatening and is the most common cause of death in peptic ulcers. It occurs when the ulcer erodes one of the blood vessels. Up to about 20% of those who develop a gastrointestinal bleeding has not experienced any symptoms until the bleeding starts. Hematemesis (vomiting of blood) can occur due to bleeding directly from a gastric ulcer, or from damage to the esophagus from severe/continuing vomiting, and melena (tarry, foul-smelling faeces due to oxidized iron from hemoglobin) can cause the development of anemia.

(a hole in the wall). This complication will strike about 1-2% of the people with peptic ulcers. Erosion of the gastro-intestinal wall by the ulcer leads to spillage of stomach or intestinal content into abdominal cavity. Often the first sign of the complication is sudden intense abdominal pain, some people will complain of pain radiating to the back due to this condition. Perforation leads to acute peritonitis, a lift-threatening condition.

 This is a condition tha will occur in less than 5% of those with a peptic ulcer. Scarring and swelling due to ulcers causes narrowing in the duodenum and gastric outlet obstruction. This can cause severe vomiting as the stomach needs adittional time to empty itself. Bloating and abdominal fullness can also be a result of this.

 About 5% of the ulcers in the stomach are cused by malignant tumors. Duodenal ulcers are generally benign. Biopsies are the most common way of determening if the ulcer is benign. The biopsy is controlled by a patologist, and in that way checked for cancer of the stomach. This is why an 

 (UGIE) is very important with this condition. As a rule, all patients above the age of 50-55 should recive an UGIE. 

Symptoms

The medical history is always important, but to confirm the diagnosis of peptic ulcer medical history is not enough. One study that too place in Trondheim, Norway showed that when the diagnosis of peptic ulcer is made from medical history alone, the diagnosis is correct in 25% of the cases. 

Medical history is important in making the doctor suspect the diagnosis. Further testing is nessesary since the symptoms can vary by a lot from one patient to the next. Every now and then a peptic ulcer is discovered despite few and subtle symptoms.

A physical examination will in most cases reveal tenderness in the upper central abdominal (epigastric) area. The physical examination is important to rule out other possible conditions as causes of the symptoms.

Blood- and stool samples can be used to verify if you are contaminated with the bacteria 

. If this infection is confirmed and you have symptoms of peptic ulcer you should be referred to an 

, the chances of a peptic ulcer are very small, unless you are taking drugs that can cause peptic ulcers.

The only examination that can reveal a peptic ulcer for sure, is an 

. This is an examination that uses a flexible tube with a camera at the end of it. The tube is passed trough your mouth and down into your stomach and upper intestine.

Diagnosis

-bacteria, the treatment of peptic ulcers have changed dramatically. Ulcers that used to be treated to relive symptoms with antacids or H2 antagonists, are today healed from their peptic ulcer. Treatment of 

 usually leads to clearing of the infection, relief of symptoms and eventual healing of ulcers. Recurrence of infection is reduced to a few percent. If this occurs and retreatment is required, there might be a need to try different antibiotics. There are no perfect drugs developed for this condition yet, but usually 3 or 4 medicines in combination are used to eradicate the infection. A combination of 2 antibiotics and 1 proton pump inhibitor (PPI) is usually perscribed (

). There are several different combinations of these drugs, but the effectiveness is pretty much the same.

The treatment usually lasts for 7-10 days. It is very important that the treatment is followed as prescribed. If you are not taking your pills correctly, the risk of a returning peptic ulcer is enhanced greatly. If you follow the prescribed treatment as planned, the chance of eradication of the infection and then the peptic ulcer is 85-90%. 

 Patients with a uncomplicated peptic ulcer disease need no controll after completed treatment. If the cure was sucessfull, you will stay free of symptoms from peptic ulcer. If the problems recur a new UGIE might be needed to check witch antibiotics are most effectfull for you.

Patients with peptic ulcer without infection with 

 has no need for antibiotics. They will be treated with a proton pump inhibitor (PPI) alone.

Sugical treatment is rarely used after we learned that a bacteria was the cause of peptic ulcer disease. In some rare cases the doctors are not able to eradicate the infection and ,hence the cause of, the disease. In these cases surgery might be an option. Perforation of the stomach and bleeding ulcers can also be in the need of surgery.

Therapy

The peptic ulcer i chronically recurring if not treated. Most people who recieve tripple treatment turn out healthy from this disease. The risk of reccurance used to be 75%, now it is less than 5%. For most people the treatment will be able to cure the person from the peptic ulcer disease. completly..

Peptic ulcer: Therapy