Ulcers (Digestive)

Definition

In general, an ulcer is any eroded area of skin or a mucous membrane, marked by tissue disintegration. In common usage, however, ulcer usually is used to refer to disorders in the upper digestive tract. The terms ulcer, gastric ulcer, and peptic ulcer often are used loosely and interchangeably. Peptic ulcers can develop in the lower part of the esophagus, the stomach, the first part of the small intestine (the duodenum), and the second part of the small intestine (the jejunum).

Description

It is estimated that 2% of the adult population in the United States has active peptic ulcers, and that about 10% will develop ulcers at some point in their lives. There are about 500,000 new cases of peptic ulcer in the United States every year, with as many as 4 million recurrences. The male/female ratio for ulcers of the digestive tract is 3:1.

The most common forms of peptic ulcer are duodenal and gastric. About 80% of all ulcers in the digestive tract are duodenal ulcers. This type of ulcer may strike people in any age group but is most common in males between the ages of 20 and 45. The incidence of duodenal ulcers has dropped over the past 30 years. Gastric ulcers account for about 16% of peptic ulcers. They are most common in males between the ages of 55 and 70. The single most common cause of gastric ulcers is the use of nonsteroidal anti-inflammatory drugs, or NSAIDs. The widespread use of NSAIDs is thought to explain why the incidence of gastric ulcers in the United States is rising.

Causes and symptoms

Causes of peptic ulcers

There are three major causes of peptic ulcers: infection, certain types of medication, and disorders that cause oversecretion of stomach juices.

HELICOBACTER PYLORI INFECTION. Helicobacter pylori is a rod-shaped gram-negative bacterium that lives in the mucous tissues that line the digestive tract. Infection with H. pylori is the most common cause of duodenal ulcers. About 95% of patients with duodenal ulcers are infected with H. pylori, as opposed to only 70% of patients with gastric ulcers.

USE OF NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS). Nonsteroidal anti-inflammatory drugs, or NSAIDs, are painkillers that many people use for headaches, sore muscles, arthritis, menstrual cramps, and similar complaints. Many NSAIDs are available without prescriptions. Common NSAIDs include aspirin, ibuprofen (Advil, Motrin), flurbiprofen (Ansaid, Ocufen), ketoprofen (Orudis), and indomethacin (Indacin). Chronic NSAID users have 40 times the risk of developing a gastric ulcer as nonusers. Users also are three times more likely than nonusers to develop bleeding or fatal complications of ulcers. Aspirin is the NSAID that is most likely to cause ulcers.

MISCELLANEOUS SYNDROMES AND DISORDERS. Fewer than 5% of peptic ulcers are due to these disorders. They include Zollinger-Ellison syndrome, a disorder in which small tumors, called gastrinomas, secrete a hormone (gastrin) that stimulates the production of digestive juices. Because of this excess secretion, these disorders are sometimes called hypersecretory syndromes.

OTHER RISK FACTORS. Smoking is an important risk factor that increases a patient's chance of developing an ulcer, decreases the body's response to therapy, and increases the chances of dying from ulcer complications. Blood type appears to be a predisposing factor for ulcer location; people with type A blood are more likely to have gastric ulcers, while those with type O are more likely to develop duodenal ulcers. The role of emotional stress in ulcer development is currently debated. Present research indicates that an individual's attitudes toward stress, rather than the amount of stress by itself, is a better predictor of vulnerability to peptic ulcers. Preferences for high-fat or spicy foods do not appear to be significant risk factors.

Symptoms

GASTRIC ULCERS. The symptoms of gastric ulcers include feelings of indigestion and heartburn, weight loss, and repeated episodes of gastrointestinal bleeding. Ulcer pain often is described as gnawing, dull, aching, or resembling hunger pangs. The patient may be nauseated and suffer loss of appetite. About 30% of patients with gastric ulcers are awakened by pain at night. Many patients have periods of chronic ulcer pain alternating with symptom-free periods that last for several weeks or months. This characteristic is called periodicity.

DUODENAL ULCERS. The symptoms of duodenal ulcers include heartburn, stomach pain relieved by eating or antacids, weight gain, and a burning sensation at the back of the throat. The patient is most likely to feel discomfort two to four hours after meals, or after having citrus juice, coffee, or aspirin. About 50% of patients with duodenal ulcers awake during the night with pain, usually between midnight and three a.m. A regular pattern of ulcer pain associated with certain periods of day or night or a time interval after meals is called rhythmicity.

Not all digestive ulcers produce symptoms; as many as 20% of ulcer patients have so-called painless or silent ulcers. Silent ulcers occur most frequently in the elderly and in chronic NSAID users.

Complications

Between 10-20% of peptic ulcer patients develop complications at some time during the course of their illness. All of these are potentially serious conditions. Complications are not always preceded by diagnosis of or treatment for ulcers; as many as 60% of patients with complications have not had prior symptoms.

HEMORRHAGE. Bleeding is the most common complication of ulcers. It may result in anemia, vomiting blood (hematemesis), or the passage of bright red blood through the rectum (melena). About half of all cases of bleeding from the upper digestive tract are caused by ulcers. The mortality rate from ulcer hemorrhage is 6-10%.

PERFORATION. About 5% of ulcer patients develop perforations, which are holes in the duodenal or gastric wall through which the stomach contents can leak out into the abdominal cavity. The incidence of perforation is rising because of the increased use of NSAIDs, particularly among the elderly. The signs of an ulcer perforation are severe pain, fever, and tenderness when the doctor touches the abdomen. Most cases of perforation require emergency surgery. The mortality rate is about 5%.

PENETRATION. Ulcer penetration is a complication in which the ulcer erodes through the intestinal wall without digestive fluid leaking into the abdomen. Instead, the ulcer penetrates into an adjoining organ, such as the pancreas or liver. The signs of penetration are more severe pain without rhythmicity or periodicity, and the spread of the pain to the lower back.

OBSTRUCTION. Obstruction of the stomach outlet occurs in about 2% of ulcer patients. It is caused by swelling or scar tissue formation that narrows the opening between the stomach and the duodenum (the pylorus). Over 90% of patients with obstruction have recurrent vomiting of partly digested or undigested food; 20% are seriously dehydrated. These patients also usually feel full after eating only a little food, and may lose weight.

Diagnosis

Physical examination and patient history

The diagnosis of peptic ulcers should rarely be made on the basis of a physical examination alone. However, a 2003 report showed that many ulcer diagnoses made based solely on physical exams actually are only dyspepsia, or upper adnominal pain and discomfort not caused by ulcers. The only significant finding may be mild soreness in the area over the stomach when the doctor presses (palpates) it. The doctor is more likely to suspect an ulcer if the patient has one or more of the following risk factors:

• male sex
• age over 45
• recent weight loss, bleeding, recurrent vomiting, jaundice, back pain, or anemia
• history of using aspirin or other NSAIDs
• history of heavy smoking
• family history of ulcers or stomach cancer

Endoscopy and imaging studies

An endoscopy is considered the best procedure for diagnosing digestive ulcers and for taking samples of stomach tissue for biopsies. An endoscope is a slender tube-shaped instrument that allows the doctor to view the tissues lining the stomach and duodenum. Duodenal ulcers are rarely malignant. If the ulcer is in the stomach, however, the doctor will take a tissue sample because 3-5% of gastric ulcers are malignant. Radiological studies are sometimes used instead of endoscopy because they are less expensive, more comfortable for the patient, and are 85% accurate in detecting malignancies.

Laboratory tests

BLOOD TESTS. Blood tests usually give normal results in ulcer patients without complications. They are useful, however, in evaluating anemia from a bleeding ulcer or a high white cell count from perforation or penetration. Serum gastrin levels can be used to screen for Zollinger-Ellison syndrome.

TESTS FOR HELICOBACTER PYLORI. It is important to test for H. pylori because almost all ulcer patients who are not taking NSAIDs are infected. Noninvasive tests include blood tests for immune response and a breath test. In the breath test, the patient is given an oral dose of radiolabeled urea. If H. pylori is present, it will react with the urea and the patient will exhale radiolabeled carbon dioxide. Invasive tests for H. pylori include tissue biopsies and cultures performed from fluid obtained by endoscopy.

Treatment

Medications

Most drugs that are currently given to treat ulcers work either by lowering the rate of stomach acid secretion or by protecting the mucous tissues that line the digestive tract.

ANTISECRETORY DRUGS. Medications that lower the rate of stomach acid secretions fall into two major categories: proton pump inhibitors, which bind an enzyme that secretes stomach acid, and H2 receptor antagonists, which work by reducing intracellular acid secretion. The proton pump inhibitors include omeprazole (Prilosec) and lansoprazole (Prevacid). The H2 receptor antagonists include ranitidine (Zantac), cimetidine (Tagamet), famotidine (Pepcid), and nizatidine (Axid). Both types of drugs have few serious side effects and appear to be safe for long-term use.

PROTECTIVE DRUGS. The drugs that are currently used to protect the stomach tissues are sucralfate (Carafate), which forms a pastelike substance that clings to the mucous tissues and prevents further damage from stomach acid; and bismuth preparations. A third type of protective drug includes misoprostol (Cytotec), which is often given to patients with ulcers caused by NSAIDs.

Surgery

Surgical treatment of ulcers is generally used only for complications and suspected malignancies. The most common surgical procedures that are used are vagotomies, in which the connections of the vagus nerve to the stomach are cut in order to reduce acid secretion; and antrectomies, which involve the removal of a part of the stomach (the antrum).

Eradication of Helicobacter pylori

Most doctors presently recommend treatment to eliminate H. pylori in order to prevent ulcer recurrences. Without such treatment, ulcers recur at the rate of 80% per year. A 2003 report showed that eradication H. pylori alone usually prevents recurring bleeding ulcers. The usual regimen used to eliminate the bacterium is a combination of tetracycline, bismuth subsalicylate (Pepto-Bismol), and metronidazole (Metizol).

Alternative treatment

Alternative treatments can relieve symptoms and promote healing of ulcers. A primary goal of these treatments is to rebalance the stomach's hydrochloric acid output and to enhance the mucosal lining of the stomach.

KEY TERMS

Duodenum— The first of the three segments of the small intestine. The duodenum connects the stomach and the jejunum. Most peptic ulcers are in the duodenum.

Helicobacter pylori — A gram-negative rodshaped bacterium that lives in the tissues of the stomach and causes inflammation of the stomach lining.

Zollinger-Ellison syndrome— A disorder characterized by the presence of tumors (gastrinomas) that secrete a hormone (gastrin), which stimulates the production of digestive juices.

Food allergies have been pointed to as a major cause of peptic (stomach) ulcers. An elimination/challenge diet can help identify the allergenic food(s) and continued elimination of these foods can assist in healing the ulcer. People with ulcers should not take aspirin. They also should stop smoking, since smoking irritates the mucosal lining of the stomach. Antacids should be avoided by anyone with an ulcer, because they can cause a rebound effect of increasing gastric acid secretion, as well as deplete vital nutrients necessary for healing. Stress reduction is also important for ulcer sufferers.

Botanical medicine offers a variety of remedies that may be helpful in ulcer treatment. Deglycyrrhizinated licorice or DGL, in a chewable or powder form, can help heal the mucous membranes and increase mucous so that it mixes with saliva to protect the membranes. Raw cabbage juice, high in glutanic acid, is very effective in healing an ulcer (one quart per day in divided doses). Soothing herbs, such as plantain (Plantago major ), marsh mallow (Althaea officinalis ), and slippery elm (Ulmus fulva ); astringent herbs, such as geranium (Pelargonium odoratissimum ); and the anitmicrobial herb goldenseal (Hydrastis canadensis ) can all be effective. Nutritionists advise taking antioxidant nutrients, including vitamins A, C, and E, zinc, and selenium.

Prognosis

The prognosis for recovery from ulcers is good for most patients. Very few ulcers fail to respond to the medications that are currently used to treat them. Recurrences can be eliminated completely or cut to 5% by eradication of H. pylori. Most patients who develop complications recover without problems even when emergency surgery is necessary.

Prevention

Strategies for the prevention of ulcers or their recurrence include the following:

• eradication of H. pylori in patients already diagnosed with ulcers
• giving misoprostol to patients who must take NSAIDs
• avoiding unnecessary use of aspirin and NSAIDs
• giving up smoking
• cutting down on alcohol, tea, coffee, and sodas containing caffeine.

Resources

PERIODICALS

"Many Peptic Ulcer Diagnoses Based on Symptoms Alone." AORN Journal August 2003: 210.

Worcester, Sharon. "Eradicating H. Pylori May Prevent Bleeding Ulcers: No [Histamine. Sub2] Blockers Needed." Internal Medicine News September 15, 2003: 33.

ORGANIZATIONS

American College of Gastroenterology. 4900-B South Thirty-First St., Arlington, VA 22206-1656. (703) 820-7400. 〈http://www.acg.cgi.gi.org/acghome/html〉.

Digestive Health Initiative. 7910 Woodmont Ave., #914, Bethesda, MD 20814. (800) 668-5237. 〈http://www.gastro.org./dhi.html〉.

Ulcers

Definition

In general, an ulcer is any eroded area of skin or a mucous membrane, marked by tissue disintegration. In common usage, however, ulcer usually is used to refer to disorders in the upper digestive tract. Peptic ulcers develop on the inside lining of the stomach, upper small intestine (duodenum) or on the esophagus. A peptic ulcer of the stomach is commonly referred to as a gastric ulcer. A duodenal ulcer is a sore that develops on the upper small intestine, and an esophageal ulcer develops on the esophagus.

Description

An ulcer occurs when the lining of the stomach, upper small intestine(duodenum) or the esophagus is eroded by acidic digestive fluids that are secreted by the stomach. It is estimated that 2% of the adult population in the United States has active peptic ulcers, and that about 10% will develop ulcers at some point in their lives. There are about 500,000 new cases of peptic ulcer in the United States every year, with as many as 4 million recurrences. The male/female ratio for ulcers of the digestive tract is 3:1.

The most common forms of peptic ulcer are duodenal and gastric. About 80% of all ulcers in the digestive tract are duodenal ulcers. This type of ulcer may strike people in any age group but is most common in males between the ages of 20 and 45. The incidence of duodenal ulcers has dropped over the past 30 years. Gastric ulcers account for about 16% of peptic ulcers. They are most common in males between the ages of 55 and 70. The single most common cause of gastric ulcers is the use of nonsteroidal anti-inflammatory drugs, or NSAIDs. The widespread use of NSAIDs is thought to explain why the incidence of gastric ulcers in the United States is rising.

Causes and symptoms

Causes of peptic ulcers

There are three major causes of peptic ulcers: infection, certain types of medication, and disorders that cause oversecretion or reflux of stomach juices.

helicobacter pylori infectionHelicobacter pylori is a rod-shaped gram-negative bacterium that lives in the mucous tissues that line the digestive tract. Infection with H. pylori is the most common cause of

duodenal ulcers. About 95% of patients with duodenal ulcers are infected with H. pylori, as opposed to only 70% of patients with gastric ulcers.

use of nonsteroidal anti-inflammatory drugs (nsaids) Nonsteroidal anti-inflammatory drugs, or NSAIDs, are painkillers that many people use for headaches, sore muscles, arthritis, menstrual cramps, and similar complaints. Many NSAIDs are available without prescriptions. Common NSAIDs include aspirin, ibuprofen (Advil, Motrin), flurbiprofen (Ansaid, Ocufen), ketoprofen (Orudis), and indomethacin (Indacin). Chronic NSAID users have 40 times the risk of developing a gastric ulcer as nonusers. Users also are three times more likely than nonusers to develop bleeding or fatal complications of ulcers. Aspirin is the NSAID that is most likely to cause ulcers.

miscellaneous syndromes and disorders Fewer than 5% of peptic ulcers are due to these disorders. They include Zollinger-Ellison syndrome, a disorder in which small tumors, called gastrinomas, secrete a hormone (gastrin) that stimulates the production of digestive juices. Because of this excess secretion, these disorders are sometimes called hypersecretory syndromes.

other risk factorsSmoking is an important risk factor that increases a patient's chance of developing an ulcer, decreases the body's response to therapy, and increases the chances of dying from ulcer complications. Blood type appears to be a predisposing factor for ulcer location; people with type A blood are more likely to have gastric ulcers, while those with type O are more likely to develop duodenal ulcers. The role of emotional stress in ulcer development is currently debated. Present research indicates that an individual's attitudes toward stress, rather than the amount of stress by itself, is a better predictor of vulnerability to peptic ulcers. Preferences for high-fat or spicy foods do not appear to be significant risk factors.

Symptoms

gastric ulcers The symptoms of gastric ulcers include feelings of indigestion and heartburn, weight loss, and repeated episodes of gastrointestinal bleeding. Ulcer pain often is described as gnawing, dull, aching, or resembling hunger pangs. The patient may be nauseated and suffer loss of appetite. About 30% of patients with gastric ulcers are awakened by pain at night. Many patients have periods of chronic ulcer pain alternating with symptom-free periods that last for several weeks or months. This characteristic is called periodicity.

duodenal ulcers The symptoms of duodenal ulcers include heartburn, stomach pain relieved by eating or antacids, weight gain, and a burning sensation at the back of the throat. The patient is most likely to feel discomfort two to four hours after meals, or after having citrus juice, coffee, or aspirin. About 50% of patients with duodenal ulcers awake during the night with pain, usually between midnight and three a.m. A regular pattern of ulcer pain associated with certain periods of day or night or a time interval after meals is called rhythmicity.

Not all digestive ulcers produce symptoms; as many as 20% of ulcer patients have so-called painless or silent ulcers. Silent ulcers occur most frequently in the elderly and in chronic NSAID users.

Complications

Between 10–20% of peptic ulcer patients develop complications at some time during the course of their illness. All of these are potentially serious conditions. Complications are not always preceded by diagnosis of or treatment for ulcers; as many as 60% of patients with complications have not had prior symptoms.

hemorrhage Bleeding is the most common complication of ulcers. It may result in anemia, vomiting blood (hematemesis), or the passage of bright red blood through the rectum (melena). About half of all cases of bleeding from the upper digestive tract are caused by ulcers. The mortality rate from ulcer hemorrhage is 6–10%.

perforation About 5% of ulcer patients develop perforations, which are holes in the duodenal or gastric wall through which the stomach contents can leak out into the abdominal cavity. The incidence of perforation is rising because of the increased use of NSAIDs, particularly among the elderly. The signs of an ulcer perforation are severe pain, fever, and tenderness when the doctor touches the abdomen. Most cases of perforation require emergency surgery. The mortality rate is about 5%.

penetration Ulcer penetration is a complication in which the ulcer erodes through the intestinal wall without digestive fluid leaking into the abdomen. Instead, the ulcer penetrates into an adjoining organ, such as the pancreas or liver. The signs of penetration are more severe pain without rhythmicity or periodicity, and the spread of the pain to the lower back.

obstruction Obstruction of the stomach outlet occurs in about 2% of ulcer patients. It is caused by swelling or scar tissue formation that narrows the opening between the stomach and the duodenum (the pylorus). Over 90% of patients with obstruction have recurrent vomiting of partly digested or undigested food; 20% are seriously dehydrated. These patients also usually feel full after eating only a little food, and may lose weight.

Diagnosis

Physical examination and patient history

The diagnosis of peptic ulcers should rarely be made on the basis of a physical examination alone. The only significant finding may be mild soreness in the area over the stomach when the doctor presses (palpates) it. The doctor is more likely to suspect an ulcer if the patient has one or more of the following risk factors:

• male sex
• age over 45
• recent weight loss, bleeding, recurrent vomiting, jaundice, back pain, or anemia
• history of using aspirin or other NSAIDs
• history of heavy smoking
• family history of ulcers or stomach cancer

Imaging studies

• Upper endoscopy (EGD-esophagogastroduodenoscopy. An endoscopy is considered the best procedure for diagnosing digestive ulcers and for taking samples of stomach tissue for biopsies. An endoscope is a slender tube-shaped instrument that allows the doctor to view the tissues lining the stomach and duodenum. Duodenal ulcers are rarely malignant. If the ulcer is in the stomach, however, the doctor will take a tissue sample because 3–5% of gastric ulcers are malignant.
• Upper gastrointestinal (upper GI) x ray. For this test, the patient swallows a white liquid that coats and then exposes the digestive tract so that an ulcer is detectable. While the UP X-ray involves minimal discomfort for the patient it is less accurate than the endoscopy

Laboratory tests

blood tests Blood tests usually give normal results in ulcer patients without complications. They are useful, however, in evaluating anemia from a bleeding ulcer or a high white cell count from perforation or penetration. Serum gastrin levels can be used to screen for Zollinger-Ellison syndrome.

tests for helicobacter pylori It is important to test for H. pylori because almost all ulcer patients who are not taking NSAIDs are infected. Noninvasive tests include blood tests for immune response and a breath test. In the breath test, the patient is given an oral dose of radiolabeled urea. If H. pylori is present, it will react with the urea and the patient will exhale radiolabeled carbon dioxide. Invasive tests for H. pylori include tissue biopsies and cultures performed from fluid obtained by endoscopy. Stool sample tests are particularly useful because samples can be used to detect the presence of H. pylori and also to monitor a patient's response to treatment after a diagnosis has been made.

Treatment

Medications

Most drugs that are currently given to treat ulcers work either by lowering the rate of stomach acid secretion or by protecting the mucous tissues that line the digestive tract.

antisecretory drugs Medications that lower the rate of stomach acid secretions fall into two major categories: proton pump inhibitors, which bind an enzyme that secretes stomach acid, and H2 receptor antagonists, which work by reducing intracellular acid secretion. The proton pump inhibitors include omeprazole (Prilosec) and lansoprazole (Prevacid). The H2 receptor antagonists include ranitidine (Zantac), cimetidine (Tagamet), famotidine (Pepcid), and nizatidine (Axid). Both types of drugs have few serious side effects and appear to be safe for long-term use.

protective drugs The drugs that are currently used to protect the stomach tissues are sucralfate (Carafate), which forms a pastelike substance that clings to the mucous tissues and prevents further damage from stomach acid; and bismuth preparations. A third type of protective drug includes misoprostol (Cytotec), which is often given to patients with ulcers caused by NSAIDs.

Surgery

Surgical treatment of ulcers is generally used only for complications and suspected malignancies. The most common surgical procedures that are used are vagotomies, in which the connections of the vagus nerve to the stomach are cut in order to reduce acid secretion; and antrectomies, which involve the removal of a part of the stomach (the antrum).

Eradication of Helicobacter pylori

Most doctors presently recommend treatment to eliminate H. pylori in order to prevent ulcer recurrences. Without such treatment, ulcers recur at the rate of 80% per year. The usual regimen used to eliminate the bacterium is a combination of tetracycline, bismuth subsalicylate (Pepto-Bismol), and metronidazole (Metizol).

Alternative treatment

Alternative treatments can relieve symptoms and promote healing of ulcers. A primary goal of these treatments is to rebalance the stomach's hydrochloric acid output and to enhance the mucosal lining of the stomach.

Food allergies have been pointed to as a major cause of peptic (stomach) ulcers. An elimination/challenge diet can help identify the allergenic food(s) and continued elimination of these foods can assist in healing the ulcer. People with ulcers should not take aspirin. They also should stop smoking, since smoking irritates the mucosal lining of the stomach. Antacids should be avoided by anyone with an ulcer, because they can cause a rebound effect of increasing gastric acid secretion, as well as deplete vital nutrients necessary for healing. Stress reduction is also important for ulcer sufferers.

Botanical medicine offers a variety of remedies that may be helpful in ulcer treatment. Deglycyrrhizinated licorice or DGL, in a chewable or powder form, can help heal the mucous membranes and increase mucous so that it mixes with saliva to protect the membranes. Raw cabbage juice, high in glutanic acid, is very effective in healing an ulcer (one quart per day in divided doses). Soothing herbs, such as plantain (Plantago major), marsh mallow (Althaea officinalis), and slippery elm (Ulmus fulva); astringent herbs, such as geranium (Pelargonium odor-atissimum); and the anitmicrobial herb goldenseal (Hydrastis canadensis) can all be effective. Nutritionists advise taking antioxidant nutrients, including vitamins A, C, and E, zinc, and selenium.

Prognosis

The prognosis for recovery from ulcers is good for most patients. Very few ulcers fail to respond to the medications that are currently used to treat them. Recurrences can be eliminated completely or cut to 5% by eradication of H. pylori. Most patients who develop complications recover without problems even when emergency surgery is necessary.

Prevention

Strategies for the prevention of ulcers or their recurrence include the following:

• eradication of H. pylori in patients already diagnosed with ulcers
• giving misoprostol to patients who must take NSAIDs
• avoiding unnecessary use of aspirin and NSAIDs
• giving up smoking
• cutting down on alcohol, tea, coffee, and sodas containing caffeine.

KEY TERMS

Duodenum —The first of the three segments of the small intestine. The duodenum connects the stomach and the jejunum. Most peptic ulcers are in the duodenum. Helicobacter pylori—A gram-negative rod-shaped bacterium that lives in the tissues of the stomach and causes inflammation of the stomach lining.

Zollinger-Ellison syndrome —A disorder characterized by the presence of tumors (gastrinomas) that secrete a hormone (gastrin), which stimulates the production of digestive juices.

Resources

PERIODICALS

“Peptic Ulcers and Bacterial Infections.” Harvard Men's Health Watch (June 2007): NA.

Harvard Health Publications Group “Digestion Digest.” Harvard Health Commentaries (2006): NA.

Harvard Health Publications Group “Medical Myths: Does Food Cause Ulcers?.” Harvard Health Commentaries (2006): NA.

ORGANIZATIONS

American College of Gastroenterology. 4900-B South Thirty-First St., Arlington, VA 22206-1656. (703) 8207400. http://www.acg.cgi.gi.org/acghome/html.

American Gastroenterological Association. 4930 Del Ray Avenue, Bethesda, MD 20814. (301)654-2055. http://www.gastro.org

International Foundation for Functional Gastrointestinal Disorders. P.O. Box 170864, Milwaukee, WI 53217-8076.(888)964-2001. http://www.iffgd.org

National Digestive Diseases Clearinghouse (NDDIC). 2 Information Way.

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Building 31, Room 9A04, 31 Center Drive, MSC 2560, Bethesda, MD 208792-2560. (301) 496-3583. http://www.niddk.nih.gov.

Rebecca J. Frey Ph.D.

Lisa M. Piazza M.A.

ULCERS

DEFINITION

An ulcer is any break in the skin or in a mucous membrane. Mucous membrane is a thin tissue that lines the interior surface of body openings. The term ulcer is used most commonly to refer to ulcers that occur in the upper part of the digestive system, such as peptic ulcers. At one time, doctors believed that ulcers were caused by too much stress. However, it is now known that bacterial infection accounts for more than three-quarters of all peptic ulcers.

DESCRIPTION

Experts estimate that about 2 percent of the adult population in the United States have active ulcers and that about 10 percent of all adults will have an ulcer at some point in their lives. Males have about three times as many ulcers as females.

Ulcers are sometimes classified according to the part of the digestive system in which they occur. Gastric ulcers occur in the stomach. Duodenal ulcers occur in the duodenum. The duodenum (pronounced doo-uh-DEE-nuhm) is the upper part of the small intestine, adjacent to the stomach.

A peptic ulcer is one that occurs in the upper digestive tract, in which the break in the mucous membrane is exposed to gastric acidic secretion. About 80 percent of all peptic ulcers occur in the duodenum. They are most common among males between the ages of twenty and forty-five. Gastric ulcers account for about 16 percent of all peptic ulcers and are most common in males between the ages of fifty-five and seventy.

CAUSES

There are three major causes of peptic ulcers: infection, certain types of medications, and other medical problems that cause the release of too much stomach juices.

Ulcers: Words to Know

Duodenum:

The upper part of the small intestine, joined to the lower part of the stomach.

Endoscope:

An instrument consisting of a long, narrow tube that can be inserted down the patient's throat to study the health of the patient's digestive system.

Helicobacter pylori :

A bacterium that lives in mucous membrane and is responsible for the development of ulcers.

Nonsteroidal anti-inflammatory drugs (NSAIDs):

A group of drugs used to treat pain and fever, including aspirin, ibuprofen, and acetaminophen.

Peptic ulcer:

A general name referring to ulcers in any part of the digestive system.

Helicobacter pylori is a bacterium that lives in mucous membranes in the digestive system. It causes about 95 percent of all duodenal ulcers and 70 percent of all gastric ulcers.

The use of nonsteroidal anti-inflammatory drugs (NSAIDS) also tends to cause ulcers. Nonsteroidal anti-inflammatory drugs are painkillers. People use these drugs for headaches, sore muscles, menstrual cramps, and similar complaints. Some common NSAIDS are aspirin, ibuprofen (pronounced i-byoo-PRO-fuhn, trade names Advil, Motrin), and acetaminophen (pronounced uhsee-tuh-MIN-uh-fuhn, trade name Tylenol). People who use NSAIDS on a regular basis are forty times more likely to get ulcers than those who do not. Aspirin is the NSAID most likely to cause ulcers. Aspirin should not be given to children because of the risk of Reye's syndrome (see Reye's syndrome entry).

Some medical problems can increase the risk of ulcers. For example, Zollinger-Ellison syndrome causes an unusually large release of digestive juices in the stomach and this excess secretion can create ulcers.

Other factors may also increase a person's risk for ulcers. For example, smokers are more likely to develop an ulcer and are also more likely to die from the complications of an ulcer. People with blood type A are more likely to have gastric ulcers, while those with type O are more likely to develop duodenal ulcers.

Scientists are still debating the role of stress in the formation of ulcers. Stress is no longer regarded as a primary cause of the disorder. But some specialists think that it may be a contributing factor.

SYMPTOMS

The symptoms of gastric ulcers include feelings of indigestion and heartburn, weight loss, and repeated cases of bleeding in the stomach. Ulcer pain is sometimes described as gnawing, dull, aching, or similar to hunger pangs. Patients may experience nausea or appetite loss. In many cases, ulcer pain comes and goes over long periods of time.

The primary symptoms of duodenal ulcers include heartburn, stomach pain, weight gain, and a burning feeling at the back of the throat. A patient is most likely to feel discomfort two to four hours after meals.

About 20 percent of all people with peptic ulcers experience no symptoms. This form of the condition is called painless or silent ulcers. Between 10 to 20 percent of all peptic ulcer patients develop complications at some time in their illness. All of these complications can be very serious. In many cases, complications appear without any other signs of an ulcer. Some common complications include:

• Hemorrhage. Bleeding is the most common complication of ulcers. If bleeding continues, a patient may become anemic. Anemia (see anemias entry) is a condition that develops when a person does not have enough red blood cells. It can lead to extreme tiredness, weight loss, and, in the worst cases, death. About 6 to 10 percent of all patients with a bleeding ulcer die of the problem.
• Perforation. A perforation is a hole in the wall of the stomach or intestine. The hole allows stomach fluids to leak out into the abdominal cavity. These fluids are very acidic and can cause serious damage to body tissues. The signs of perforation include severe pain, fever, and tenderness of the abdomen. About 5 percent of patients with a perforated ulcer die of the condition.
• Penetration. Penetration occurs when an ulcer spreads to some organ adjacent to the digestive system. It may affect the liver or pancreas, for example. Signs of penetration include severe pain that spreads to the lower back.
• Obstruction. Over time, ulcers can form scar tissue. In some cases, this scar tissue can block the opening between the stomach and the duodenum. Food is not able to move all the way through the digestive system. The most common symptom of an obstruction is vomiting. The vomiting is caused by undigested food expelled from the stomach. Obstruction occurs in about 2 percent of all ulcer patients.

DIAGNOSIS

The first indication of an ulcer is likely to be a patient's complaint about one or more of the described symptoms. When a patient visits a physician for diagnosis, a physical examination alone is not enough. A doctor will look for certain factors in the patient's history that may suggest the presence of an ulcer. These factors include:

• If the patient is male
• Age over forty-five
• Recent weight loss, bleeding, repeated episodes of vomiting, back pain, or anemia
• History of using aspirin or other NSAIDs
• History of heavy smoking
• Family history of ulcers or stomach cancer

Endoscopy (pronounced en-DOS-kuh-pee) is one of the best ways to diagnose an ulcer. An endoscope consists of a long, narrow tube that can be inserted down the patient's throat. The tube contains a light and a tiny camera at one end. The doctor can actually look at the interior walls of the stomach and duodenum. If necessary, tiny scissors may also be attached to the endoscope. The scissors can be used to cut off a small sample of mucous membrane, which can be examined for the presence of stomach cancer. About 5 percent of ulcers develop into stomach cancer.

Imaging techniques can also be used to diagnose ulcers. These techniques are not as reliable as endoscopy but they are more comfortable for the patient. Imaging requires the patient to drink a fluid containing a substance that is opaque, or nontransparent, to X rays. An X-ray photograph is then taken of the patient's digestive system. The opaque substance appears as a white patch on the photograph and shows any abnormal structures, such as an ulcer, that may be present.

Blood tests are usually not very helpful in diagnosing ulcers. However, they may indicate when a patient has become anemic because of a bleeding ulcer.

The most important laboratory tests to perform are those that detect the Helicobacter pylori bacterium. One such test is a breath test. A patient is given a drink containing a radioactive substance that the bacterium will react with if it is present. The patient is then asked to breathe into a mechanism that determines whether the patient's breath is radioactive. If it is, that means the bacterium is present. This kind of test is important since the vast majority of people with ulcers are infected with Helicobacter pylori.

TREATMENT

Many symptoms of ulcers can be treated with over-the-counter medications. These medications may relieve the pain, nausea, and general discomfort caused by ulcers. However, they do not cure the disorder.

Two other types of medications are designed to reduce the symptoms of ulcers. Antisecretory drugs are drugs that reduce the amount of acid produced in the stomach. Acid attacks mucous membranes and can produce ulcers, so by lowering the amount of stomach acid released, the risk of ulcer formation can be reduced.

Protective drugs are also used to treat ulcers. A protective drug is a substance that forms a thin lining over mucous membranes, which protects the mucous membranes from attack by stomach acid.

Surgery is generally not used to treat ulcers. However, some of the complications caused by ulcers may require surgery. For example, doctors may cut the vagus nerve to the stomach. The vagus nerve (pronounced VAY-guhss) controls the release of stomach acid. After the cut, less stomach acid will be released, thus reducing the risk of ulcer formation.

One direct method for treating ulcers is to kill the bacteria that is responsible for most the vast majority of deaths caused by ulcers. Unless these bacteria are eliminated from the digestive system, ulcers will come back again and again. The drug used to kill Helicobacter pylori is the antibiotic tetracycline (pronounced tet-ruh-SI-kleen).

Alternative Treatment

Herbalists believe that a variety of natural products can help heal ulcers. For example, they recommend raw cabbage juice to help heal an ulcer. Some herbs that may soothe the symptoms of ulcers include plantain, marsh mallow, slippery elm, geranium, and goldenseal. Nutrition experts recommend taking certain vitamins and minerals, including vitamins A, C, and E, and the minerals zinc and selenium.

PROGNOSIS

The prognosis for recovery from ulcers is good for most patients. Nearly all ulcers respond to the medications now used to treat them. The rate of recurrence of ulcers can be cut to 5 percent through the elimination of the Helicobacter pylori bacterium.

PREVENTION

Methods for preventing ulcers include the following:

• Elimination of the Helicobacter pylori bacterium
• Avoiding unnecessary use of aspirin and other NSAIDs
• Giving up smoking
• Cutting down on alcohol, tea, coffee, sodas, and other products that contain caffeine

FOR MORE INFORMATION

Books

Ostrov, Rikki. Ulcers: A Guide to Diagnosis, Treatment and Prevention. Thorsons Publications, 1996.

Thompson, W. Grant. The Ulcer Story: The Authoritative Guide to Ulcers, Dyspepsia, and Heartburn. New York: Plenum Press. 1996.

Organizations

American College of Gastroenterology. 4900-B South 31st Street, Arlington, VA 22206-1656. (703) 820-7400.

American Gastroenterological Association. 7910 Woodmont Avenue, #914, Bethesda, MD 20814. (800) 668-5237. http://www.gastro.org.

International Foundation for Functional Gastrointestinal Disorders. PO Box 17864, Milwaukee, WI 53217. (888) 964-2001.

Ulcers

Definition

Description

Demographics

Causes and symptoms

Diagnosis

Treatment

Nutrition/Dietetic concerns

Prognosis

Prevention

Resources

Definition

An ulcer is any area of skin or mucous membrane that erodes, causing the tissue to degenerate. In common use, ulcers refer to disorders such as these that occur in the upper digestive tract. They may be called gastric ulcers, peptic ulcers, or simply ulcers.

Description

Gastric ulcers refer to those that occur in the lining of the stomach. Peptic ulcers also can develop in the lower part of the esophagus, the stomach, the first part of the small intestine (duodenum), and the second part of the small intestine (jejunum).

Duodenal and gastric ulcers are the most common types. About 80% of all ulcers occur in the digestive tract and are called duodenal ulcers. Gastric ulcers account for about 16% of peptic ulcers. While it was once believed that stress and eating spicy foods caused ulcers, it was later discovered that most ulcers are caused by a bacterial infection. Some foods can aggravate ulcer symptoms.

The body makes strong acids to digest food. A thin lining protects the stomach and intestines from these acids. But if something damages the lining, the acids can reach the stomach and duodenal walls. Ulcers can get larger and cause bleeding.

Demographics

One in 10 Americans will develop an ulcer at some time in their lives. The American Gastroenterological Association estimates that four million Americans have peptic ulcer disease. Ulcers can occur at any age, but are more common as people get older, particularly in people over age 60. In fact, as many as one-half of people over age 60 may have an ulcer. At least two-thirds of ulcers are believed to be caused by bacteria and most of the remaining ulcers are caused by use of non-steroidal anti-inflammatory drugs (NSAIDS). Many people are infected with the bacterium that causes ulcers although ulcers may not actually develop from the bacterium.

Causes and symptoms

The bacterium that causes peptic ulcers is called Helicobacter pylori, or H. pylori. Although the discovery that H. pylori was the major cause of ulcers only occurred in the 1990s, it is believed that the bacterium has been around in humans’ digestive tracts for at least 60,000 years. The exact source of H. pylori and the way in which it is transmitted from one person to another is not known. Theories include transmission through water, saliva, and person-to-person contact. Researchers also do not yet know why some people with the infection develop ulcers while others do not. They believe it may be due to characteristics of the infected person, the type of H. pylori, and other possible factors.

Use of NSAIDs is the second most common cause of ulcers. These drugs include aspirin, ibuprofen, and naproxen. Frequent and long-term use of these drugs to reduce pain and inflammation may lead to ulcers, as these drugs also weaken the lining of digestive walls. Many older people use these drugs frequently to help relieve pain and inflammation from arthritis, which may help explain the higher number of older adults with peptic ulcers.

The most common symptom of a peptic ulcer is a burning sensation that occurs in the stomach between the breastbone and belly button. Although the pain can occur at any time, it often is worse between meals when the stomach is more likely to be empty. The pain often is described as a dull ache and it may be severe enough to cause waking during the night. The pain may last minutes or several hours and may come and go. Sometimes, the pain goes away after eating.

Other symptoms of ulcers include a feeling of fullness more quickly than normal during a meal, general loss of

appetite, a bloating or heavy feeling in the stomach, upset stomach or nausea and vomiting, weight loss, and blood in the stool. In some cases, blood is the first and only symptom of an ulcer.

Once an ulcer bleeds and continues bleeding without proper treatment, a person may become anemic and weak.

Diagnosis

The physician will note symptoms and history and will perform one or more of several tests available to detect peptic ulcer disease.

H. pylori breath test

This is a safe and simple laboratory test that is used to detect active H. pylori infection. It involves breathing into a balloon-like bag, then drinking a small amount of a clear solution and breathing into the bag again 20 to 30 minutes later. The air that is breathed into the bag the second time is tested for an increase in carbon dioxide. The test involves some preparation, such as avoiding antibiotics and acid-relieving medications for weeks before the test. No eating or drinking is allowed one hour before the test, but the procedure lasts only about 30 minutes and normal diet can be resumed immediately following the test. This test also is effective at monitoring treatment, since a patient can be retested to determine if H. pylori antibodies are still present a month or more later.

Fecal occult blood test

The fecal occult blood test is used to detect tiny or invisible blood in the stool, or feces. It may be used to

KEY TERMS

Anemia, anemic— Anemia is the condition in which the blood’s hemoglobin, which is the part of the blood rich in iron, decreases.

Antibodies— Proteins in the immune system that help fight disease.

Peptic— A description that relates to digestion.

detect ulcers, screen for colorectal cancer , or a number of other diseases. The test requires collection of three stool samples that should be taken one day apart. The samples are returned to the physician’s office or a laboratory and are examined under a microscope for signs of blood. Certain foods and medicines affect test results and should not be eaten or used about two to three days before beginning the test.

Upper GI series

An upper gastrointestinal (GI) series is an x-ray examination that helps diagnose problems in the esophagus, stomach, and duodenum. It may be the first test a physician orders to detect an ulcer. Clearly showing the inside lining of these organs requires drinking a thick, white liquid called barium. The barium coats the linking and as it moves through the digestive system, the radiologist can follow the milkshake-like liquid on images, using a machine called a fluoroscope. The resulting images detect some ulcers, but not all of them. The procedure takes one to two hours or longer if imaging the small intestine as well. No food or drink is allowed after midnight the night before the examination so the stomach will be empty for the procedure. The barium can cause constipation and a white-colored stool for a few days following the procedure.

Upper GI endoscopy

Upper GI endoscopy uses a thin, flexible, lighted tube to help see inside the esophagus, stomach, and duodenum. In some cases, the endoscopy may follow the upper GI series. In other cases, the physician may perform the endoscopy first. The physician sprays the throat with a numbing agent before inserting the tube to help prevent gagging. Pain medication and sedatives also help patients relax during the procedures. The camera at the end of the tube transmits pictures that allow the physician to carefully examine the lining of the organs. The scope also has a device that blows a small amount of air, which can open folds of tissue so the physician can more easily examine the stomach lining and look for ulcers. No eating or drinking will be allowed for eight to 10 hours before the procedure.

Treatment

The treatment of H. pylori infection is called ‘‘triple therapy’’, since a combination approach is used. Two antibiotics, often clarithromycin and amoxicillin, are prescribed for about two weeks. In addition, use of bismuth subsalicylate (a common brand name is Pepto Bismol) will be used along with the antibiotics. Follow-up tests should be ordered to be certain that the H. pylori has cleared up.

Other medicines help treat ulcers and their symptoms. Acid blockers and proton pump inhibitors reduce the amount of acid made in the stomach. This helps relieve pain and promotes healing of ulcers. These drugs are available by prescription or over=the-counter and are sold as ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet), and nizatidine (Axid).

If an ulcer has erupted to the point that it has bled, treatment of anemia may require iron supplements. An ulcer that has caused a perforation or obstruction in the stomach to develop may require surgery. The surgery will remove the ulcer or the ulcer can be covered with tissue from another part of the intestine. Other options may be to tie off the bleeding vessel or to cut off the nerve supply to the base of the stomach.

Nutrition/Dietetic concerns

The old school of though about spicy foods causing ulcers has been shown tobe untrue. But those who have ulcers may still need to watch what they eat to relieve symptoms of peptic ulcer disease. The effect of diet on ulcers varies for everyone, but certain foods and drinks can worsen pain. Drinking coffee can increase pain, whether it contains caffeine or is decaffeinated. Tea, chocolate, chili powder, mustard seed, meat extracts, black pepper, and nutmeg are other foods and spices that may cause discomfort for those with ulcers. With proper use of medications, dietary restrictions should not be necessary, except to ease symptoms.

People with ulcers should avoid alcoholic beverages. Eating a balanced diet is advised. Avoiding large meals in one setting may help relieve feelings of bloating and fullness. It is best to eat small, frequent meals when having ulcer pain. The American Gastroentero-logical Association recommends eating food that has been properly prepared and only drinking water from clean, safe sources to help prevent ulcers.

Prognosis

The prognosis for recovery from ulcers is good for most patients. Very few ulcers fail to respond to current treatments, particularly since discovery of H. pylori. If the bacterium is eliminated, an individual most likely will not have ulcer recurrence. Most patients who develop complications such as perforation will recover without problems, even if emergency surgery is necessary.

Prevention

Until more is learned about the transmission of H. pylori, it is unlikely that individuals can totally prevent infection with the bacterium. Careful hand washing after using the restroom and before eating may help prevent infection. Other prevention techniques are to eat only properly prepared food and to drink water from clean, safe sources. Restricting use of NSAIDs or discussing appropriate use of these medicines with a physician may help lessen risk of ulcers. Smoking and drinking alcohol damage the lining of the digestive tract, so eliminating these behaviors also will help prevent peptic ulcers. Cigarette smoking also increases risk of ulcer bleeding and stomach perforation and can cause some medications to fail. Avoiding certain foods such as coffee and various spices may help ease ulcer symptoms. But will not prevent ulcers.

Resources

ORGANIZATIONS

American College of Gastroenterology. P.O. Box 342260, Bethesda, MD 20827. (301) 263-9000. <http://www.acg.gi.org>

American Gastroenterological Association. 4930 Del Ray Ave., Bethesda, MD 20814. (301) 654-2055. <http://www.gastro.org>

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892. (800) 891-5389. <http://digestive.niddk.nih.gov>

Teresa G. Odle

Ulcers

Gastric and duodenal ulcers

Cause of gastric and duodenal ulcers

Symptoms of gastric and duodenal ulcers

Treatment of gastric and duodenal ulcers

Prevention of gastric and duodenal ulcers

Decubitus ulcers

An ulcer is a sore that develops in the lining of the stomach or the duodenum, the short section of small intestine that leads away from the stomach, or on the surface of the skin as a result of infection with bacteria. An ulcer in the stomach is called a gastric ulcer; an ulcer in the duodenum is called a duodenal ulcer; and an ulcer on the skin is called a decubitus ulcer.

Gastric and duodenal ulcers

Until recently, the sole cause of gastric and duodenal ulcers was thought to be overproduction of stomach acid due to prolonged stress, smoking, or poor eating habits. However, in 1992, researchers confirmed that many ulcers are caused by infection with bacteria capable of living in the highly acidic environment of the stomach. This revolution in ulcer research has radically changed the way ulcers are diagnosed and treated. For instance, instead of treating ulcer patients with acid-reducing drugs for months or even years, patients with the bacterially-caused ulcers take a week-long course of antibiotics. And in contrast to the 50%–95% relapse rate with conventional treatment, the new antibiotic treatment has reduced the recurrence rate to 20%.

Cause of gastric and duodenal ulcers

Until recently, excess stomach acid was believed to be the cause of ulcers. Hydrochloric acid (HCL) is normally produced in the stomach to help break down food. HCL is secreted from special cells in the stomach lining, is mixed with the stomach contents, and initiates the preliminary digestion of proteins in the stomach. From the stomach, the partially digested food moves into the duodenum, where more digestion takes place. But before the partially broken down food moves from the stomach to duodenum, the acid must be neutralized. If it is not, the acidic food will irritate the sensitive duodenum. Sodium bicarbonate—the active ingredient in baking soda—is released from other cells in the stomach lining and neutralizes the acid in the partially digested food before it moves into the duodenum.

Sometimes, however, the acid is not neutralized effectively, and the duodenum is irritated by the acidic food. In this case, a duodenal ulcer may develop. Sometimes the lining of the stomach itself cannot tolerate the high levels of acid that are released within the stomach. In this case, a gastric ulcer lining may result. In either of these cases, the ulcers can be traced to a sensitivity to acid or to its overproduction.

But acid overproduction or sensitivity are not the only causes of ulcers. A bacterium called Heliobacter pylori, discovered and named in 1982, has been shown to cause ulcers by colonizing the lining of the stomach. These bacteria can survive in the stomach’s highly acidic environment because they have an enzyme that neutralizes acid. Scientists now believe that most—60%—of all ulcers diagnosed throughout the world can be traced to the H. pylori bacterium.

Symptoms of gastric and duodenal ulcers

The classic symptom of an ulcer is stomach pain. Usually the pain is sharp or burning. Patients commonly note that the pain is more intense when the stomach is empty. Eating can sometimes relieve the pain of an ulcer because excess acid is neutralized by food being introduced into the stomach and duodenum.

If the ulcer is severe enough, it may perforate, or “punch through,” the lining of the stomach. If this perforation occurs, stomach contents may leak into the body cavity, causing infection. The patient may also bleed internally, which may lead to shock. A perforated ulcer is extremely serious. Blood in the stool or vomiting blood are signs that require immediate medical attention.

Treatment of gastric and duodenal ulcers

Before 1992, most ulcers were treated with a regimen of diet and medication. Patients were advised to take over-the-counter antacids and to control their intake of irritating foods and substances, such as alcohol, caffeine, and fried foods. In the 1980s, drug researchers developed sophisticated medications that target the stomach’s acid production mechanism. The patient must take these medications for at least a month, and sometimes years, to suppress the stomach’s acid secretion. These drugs only treat the symptoms of ulcers; they do not cure them. Unfortunately, most ulcers recurred despite these state-of-the-art drugs.

Since the discovery of Heliobacter pylori, new treatments for ulcers that target the bacteria have been implemented in ulcer patients, with good results. Tests can confirm whether or not a patient has Heliobacter pylori. In one of these tests, a tube with a tiny camera on the end is snaked through the patient’s esophagus into the stomach and duodenum. An instrument can be passed through the tube to pinch a bit of the intestinal lining. If Heliobacter pylori bacteria are found in the sample, the patient is put on a course of antibiotic drugs that kill the bacteria, effectively curing the ulcer. In addition, researchers have found that bismuth subsalicylate—the active ingredient in the over the counter medication Pepto Bismol—is also effective against these bacteria. Some evidence suggests that a medication regiment combining antibiotics and bismuth subsalicylate may be the best treatment for bacterial ulcers.

Prevention of gastric and duodenal ulcers

Since the discovery of H. pylori, some researchers have suggested that bacterial ulcers may be prevented with a vaccine given early in childhood. Research has already begun into this kind of vaccine; however, it is unlikely that an H. pylori vaccine will be available within the next few years.

Evidence also suggests that H. pylori infection is highest in areas with poor sanitation facilities, suggesting that the bacteria may be transmitted—like many other human pathogens—by drinking fecally contaminated water. Researchers are currently working on this question, as well as studying transmission routes in the United States. Interestingly, H. pylori has been found in dental plaque, which may explain why the United States, despite its excellent sanitation facilities, has large numbers of people with H. pylori infection: it may be transmitted by kissing or other oral contact.

Despite the revolution brought about by H. pylori, ulcers caused by acid overproduction still represent about 40% of all diagnosed ulcers. But instead of tracing the acid overproduction to nerves, physicians are now digging deeper for the actual cause of the excess acid. Cigarette smoking has long been linked to ulcers. Smoking causes acid to be secreted into the stomach, and if the stomach does not have adequate defenses, the acid secretion, over time, can lead to an ulcer. Aspirin intake is also another culprit. Aspirin irritates the lining of the stomach and may set the stage for an ulcer.

Prevention of both kinds of ulcers is a matter of maintaining a healthy lifestyle. Good hygiene habits and the avoidance of cigarettes and excess aspirin may keep the stomach lining free of ulcers. In the future, a vaccine may entirely eliminate the cause of most ulcers, but until that time, lifestyle still plays the major role in avoiding the pain of ulcers.

Decubitus ulcers

Ulcers on the skin are caused by an infection with certain kinds of bacteria called the Enterocci and the Streptococci. These bacteria invade the skin tissues and multiply, causing the ulcer, or sore, to erupt on the skin surface. Experts believe that many people with bacteria-related ulcers acquired these infections during a stay in a hospital. When bacteria are transmitted within hospital settings, the infection is described as nosocomial. Skin ulcers caused by bacteria are treated with antibiotics.

Others skin ulcers are caused by constant pressure against the skin that does not allow air circulation. For instance, people who are bedridden for long periods of time frequently develop ulcers on the back, buttocks, and backs of the legs. If these ulcers are not treated promptly, they can quickly become infected with bacteria, and

KEY TERMS

Acute gastritis —Irritation of the stomach that lasts for a short period of time

Antibiotic —A drug that targets and kills bacteria

Chronic gastritis —Irritation of the stomach that is long-lasting

Duodenum —The short segment of the small intestine that leads away from the stomach.

Esophagus —The tube down which swallowed substances must pass in order to reach the stomach.

deep wounds can result. Pressure ulcers can be avoided in the bedridden if patients are turned periodically throughout the day so that all the surfaces of the body are exposed to air.

Still another type of skin ulcer primarily affects people with diabetes. One of the complications of diabetes is neuropathy, a condition in which nerve endings become irritated. The nerves may eventually die and the area in which the nerves are located becomes anesthetized. Diabetic patients typically experience neuropathy in the feet. If they injure their feet, the neuropathy may prevent them from feeling any pain from the injury. The injury worsens until a full-blown ulcer develops. People with diabetes are encouraged to examine their feet daily for signs of injury and to seek prompt care for any foot injury, even minor injuries.

Kathleen Scogna