Multiple: Ulcers

Definition
Description
Demographics
Causes and Symptoms
Diagnosis
Treatment
Prognosis
Prevention
The Future
For more information

Definition

An ulcer is an open sore that forms in the skin or the lining of the mouth or digestive tract (esophagus, stomach, and intestines). It may be caused by pressure that cuts off circulation in the skin over bony parts of the body in bedridden patients; by complications of diabetes; or by infections that inflame the skin or mucous membranes (soft tissues that line the digestive and respiratory tracts) and lead to erosion of tissue. Ulcers can occur in different parts of the body. Ulcers in the digestive tract are called peptic ulcers.

Description

Peptic ulcers are sores in the soft tissues that line the esophagus, the stomach, and the duodenum (the first part of the small intestine). They develop when tissues have been eaten away by stomach acid and digestive juices. As the tissues break down, the person experiences a burning or gnawing pain in the upper part of the abdomen. Although most peptic ulcers are small in size, the high acidity of the digestive juices in the stomach can cause intense pain when the acid in the juices touches the open sores.

Demographics

Peptic ulcer disease, or PUD, is a very common disorder of the digestive system in developed countries. In the United States, treatments for PUD

account for 10 percent of the health care costs for digestive diseases. About 4.5 million Americans have PUD at any given time, and one person in ten will develop a peptic ulcer at some point in his or her life. There are approximately 350,000–500,000 new cases of PUD and more than 1 million ulcer-related hospitalizations each year in the United States. About 6,000 people die each year of complications from peptic ulcers.

Peptic ulcers are largely a disease of adults; they are relatively rare in children and adolescents. The location of peptic ulcers varies somewhat according to age and sex, however; duodenal ulcers are more common in adults between the ages of thirty and sixty and are twice as common in men as in women. Gastric (stomach) ulcers are more common in adults over sixty and are more common in women than in men.

Peptic ulcers are somewhat more common among African Americans and Hispanics than among Caucasians and Asian Americans in the United States.

Causes and Symptoms

Most peptic ulcers are caused either by infection by a bacterium called Helicobacter pylori or by heavy use of over-the-counter nonsteroidal anti-inflammatory drugs, or NSAIDs. About 61 percent of all duodenal ulcers and 63 percent of gastric ulcers are caused by H. pylori. This spiral-shaped bacterium is found in the digestive tracts of about 50 percent of the

world's population; however, most people who have H. pylori in their digestive systems do not have any ulcer symptoms.

In about 20 percent of people infected with H. pylori, the bacterium is able to weaken the mucous tissues that protect the deeper layers of stomach and intestinal muscle. Once H. pylori burrows through the mucous tissues, the acid in the digestive juices irritates the tissues further and eventually produces an ulcer.

The next most common cause of peptic ulcers is NSAIDs. These are pain relievers that include such drugs as aspirin, ibuprofen, naproxen, and newer anti-arthritis drugs like celecoxib. NSAIDs can weaken the protective lining of the stomach, causing peptic ulcers directly or making it easier for H. pylori to penetrate the lining. Elderly people are at increased risk of PUD caused by NSAIDs because many of them take these drugs routinely for arthritis or headaches.

Before H. pylori was identified as a major cause of PUD in 1982, doctors thought that ulcers were caused by eating spicy foods or having a stressful job, but these theories are no longer accepted.

A small proportion of peptic ulcers are caused by:

• Stress related to recovery from severe burns
• Zollinger-Ellison syndrome, a rare disease that produces tumors that cause the stomach to secrete abnormally high levels of acid
• Excessive alcohol drinking
• Smoking
• Being treated with radiation therapy for cancer

The most noticeable symptom of PUD is a burning or gnawing pain behind the breastbone or in the upper middle portion of the abdomen several hours after a meal. The pain is often worse in the early morning or at night, and can last anywhere from a few minutes to several hours. It may also come and go over a period of a few days or weeks. The pain of a peptic ulcer is usually relieved by eating a small amount of bland food, by taking antacids, or by vomiting. Other symptoms of PUD include:

• Nausea and vomiting
• Black or tarry-looking stools
• Vomiting up blood
• Chest pain
• Unintended weight loss
• Loss of energy

Diagnosis

Peptic ulcers are usually diagnosed by a series of tests:

• Upper GI (gastrointestinal) series: This is the medical term for an imaging study in which the patient drinks a chalky liquid containing barium, a substance that coats the lining of the esophagus, stomach, and small intestine and shows up on an x ray. Most ulcers, though not all, will be visible on the x-ray photograph.
• Endoscopy. An endoscope is a thin, flexible tube with a light and a miniature camera at one end. The doctor threads the endoscope down through the esophagus into the stomach. The instrument can be used to remove a small sample of the stomach lining for biopsy as well as to take photographs of the inside of the digestive tract.
• Tests for H. pylori. If the doctor detects a peptic ulcer through an upper GI series or an endoscopy, further testing must be done to see whether the ulcer is caused by H. pylori, because the treatment is different from that for ulcers caused by NSAIDs or other factors. H. pylori can be detected by a blood test that measures antibodies to the bacterium, by a biopsy of stomach tissue removed during an endoscopy, or by a breath test. The breath test is done by having the patient drink a solution of urea (a watery compound containing nitrogen) combined with radioactive carbon. If H. pylori is present in the patient's stomach, the bacterium will break down the urea and release the carbon, which the patient will exhale in the form of carbon dioxide. The patient breathes into a plastic bag about thirty minutes after drinking the urea and carbon solution,and theamount ofcarbondioxide in the breath is measured.

Treatment

Treatment of PUD depends on whether the ulcer is caused by H. pylori, by NSAIDs, or by lifestyle factors. Ulcers caused by NSAIDs, by smoking, or by heavy drinking can be treated by quitting smoking, cutting back on alcohol, and by substituting other painkilling medications for NSAIDs. These ulcers can also be treated by prescription medications that coat the lining of the stomach until the ulcer heals, or other medications that block the production of stomach acid.

Peptic ulcers caused by H. pylori are treated by a combination of two or more medications. The goal of this type of therapy is to eliminate the bacterium.

• Antibiotics. Two or three different antibiotics are given together to eliminate H. pylori because one antibiotic alone will not kill the bacterium. There are now two combination drugs available for
• H. pylori infection, each drug combining two antibiotics plus a drug to block acid production. These combination medications are called Prevpac and Helidac.
• Pepto-Bismol plus antibiotics. The combination of Pepto-Bismol with two antibiotics works for 80–95 percent of people infected with H. pylori.
• Medications that block the production of stomach acid.
• Antacids. Antacids work by neutralizing stomach acid rather than preventing its production; they also provide rapid relief from the pain of a peptic ulcer.

Most peptic ulcers respond to treatment with medications. In rare cases, the doctor may recommend surgery to treat the ulcer. The most common surgical procedures done to treat PUD are cutting part of the nerve from the brain to the stomach that controls the production of stomach acid and removing the portion of the stomach that produces a hormone that stimulates acid production.

Prognosis

The prognosis for peptic ulcers is excellent; almost all patients can be treated successfully by avoiding NSAIDs, taking appropriate medications, and getting treatment for H. pylori infection.

Prevention

People can do several things to lower their risk of peptic ulcers:

• To avoid infection with H. pylori, people should stay away from contaminated food and water and observe strict standards of personal hygiene. They should wash hands carefully with warm water and soap every time they use bathroom, change a diaper, and before and after they prepare food.
• They should use lower doses of NSAIDs, use acetaminophen (Tylenol) in place of NSAIDs, or consult their doctor about pain relievers that are easier on the stomach.

• They should quit smoking.
• They should lower the amount of alcohol, tea, and coffee that they drink.

The Future

Peptic ulcers caused by H. pylori appear to be decreasing in frequency in the United States, while those caused by NSAIDs are increasing, particularly among the elderly. This increase is not surprising given the aging of the general population and the number of age-related health problems that are treated with NSAIDs. Considerable research is presently directed toward finding pain-relieving drugs that would be easier on the digestive system. One experimental drug in clinical trials is a combination of ibuprofen, an NSAID, with a drug that blocks acid production. The researchers are investigating whether the combination medication will reduce the rate of ulcer development in patients who need a daily dose of ibuprofen over long periods of time.

SEE ALSO Alcoholism; Burns and scalds; Canker sores; Diabetes; Gangrene; Irritable bowel syndrome; Smoking; Stress

WORDS TO KNOW

Duodenum: The first part of the small intestine.

Gastric: Related to the stomach.

Peptic ulcer: The medical term for an ulcer in the digestive tract.

For more information

BOOKS

Jacoby, David B., and Robert M. Youngson. Encyclopedia of Family Health, 3rd ed. Tarrytown, NY: Marshall Cavendish, 2004.

Miskovitz, Paul, and Marian Betancourt. The Doctor's Guide to Gastrointestinal Health. Hoboken, NJ: Wiley, 2005.

PERIODICALS

Brody, Jane E. “Personal Health: Canker Sores.” New York Times, June 10, 1987. Available online at http://query.nytimes.com/gst/fullpage.html?res=9B0DE5DA1138F933A25755C0A961948260&sec=&spon=&pagewanted=all (accessed October 1, 2008).

WEB SITES

American Academy of Family Physicians (AAFP). Ulcers and H. pylori Infection. Available online at http://www.familydoctor.org/online/famdocen/home/common/digestive/disorders/271.html (updated December 2006; accessed October 1, 2008).

American College of Gastroenterology (ACG). Peptic Ulcer Disease. Available online at http://www.acg.gi.org/patients/gihealth/peptic.asp (accessed October 1, 2008).

American Dental Association (ADA). Common Mouth Sores. Available online at http://www.ada.org/public/topics/mouth_sores.asp#faq (accessed May 13, 2008).

Mayo Clinic. Peptic Ulcer. Available online at http://www.mayoclinic.com/health/peptic-ulcer/DS00242 (updated May 15, 2007; accessed September 30, 2008).

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). H. pylori and Peptic Ulcer. Available online at http://www.digestive.niddk.nih.gov/ddiseases/pubs/hpylori/index.htm (updated October 2004; accessed October 1, 2008).

TeensHealth. Ulcers. Available online at http://www.kidshealth.org/teen/diseases_conditions/digestive/ulcers.html (updated May 2006; accessed September 30, 2006).