Peptic Ulcer (Stomach Ulcer): Symptoms, Causes, Treatment, and Diet

Peptic ulcers may not be painful for some people, but for others the pain is constant.

• Peptic ulcer溃疡的衬里吗esophagus, stomach or duodenum.
• The main symptom of a stomach or duodenal ulcer is upperabdominal pain, which can be dull, sharp, or burning (a hunger-like feeling). (Bloatingand burping are notsymptoms of peptic ulcer, andvomiting, poor appetite, andnauseaare uncommon symptoms of peptic ulcer.)
• Other associated symptoms may include:
  • acid refluxorheartburnand
  • feeling satiated (full) when eating.
• Peptic ulcer formation is related toH. pyloribacteria in the stomach and nonsteroidal anti-inflammatory medications (NSAIDs) in 50% of patients. For the remaining 50% there are miscellaneous causes such asdrugs, lifestyle factors (smoking), severe physiologicalstress, and genetic factors, but less frequently the cause is unknown.
• Ulcerpainmay not correlate with the presence or severity of ulceration.
• Diagnosis of an ulcer can be made with anupper GI seriesorendoscopy.
• Treatment of the esophagus, stomach or duodenal ulcersaims to relievepain, heal the ulcer, and prevent complications. Medical treatment involves antibiotic combinations along with stomach acid suppression medication, for example, antacids,proton pump inhibitors(PPIS) to eradicateH. pylorieliminating precipitating factors such as NSAIDs or suppressing stomach acid alone.
• Complications of esophageal, duodenal or stomach ulcers include:
  • bleeding,
  • perforation, and
  • blockage to the passage of food due to gastric obstruction from the swelling or scaring that surrounds the ulcer.
• If a person with peptic ulcers smokes or takes NSAIDs, the ulcers may recur after treatment.

A peptic ulcer (stomach or duodenal) is a break in the inner lining of the esophagus, stomach, or duodenum. A peptic ulcer of the stomach is called a gastric ulcer; of the duodenum, a duodenal ulcer; and of the esophagus, an esophageal ulcer.

Peptic ulcers occur when the lining these organs is eroded by the acidic digestive (peptic) juices that the cells of the lining secrete of the stomach secrete. A peptic ulcer differs from an erosion because it extends deeper into the lining and incites more of an inflammatory reaction from the tissues that are involved, occasionally with scaring. Peptic ulcer also is referred to as peptic ulcer disease.

Peptic ulcer disease is common, affecting millions of Americans yearly. Moreover, peptic ulcers are a recurrent problem; even healed ulcers can recur unless treatment is directed at preventing their recurrence. The medical cost of treating peptic ulcer and its complications runs into billions of dollars annually. Recent medical advances have increased our understanding of ulcer formation. Improved and expanded treatment options now are available.

The pain of ulcer disease correlates poorly with the presence or severity of active ulceration. Some individuals have persistent pain even after an ulcer is almost completely healed by medication. Others experience no pain at all. Ulcers often come and go spontaneously without the individual ever knowing that they are present unless a serious complication (like bleeding or perforation) occurs.

Symptoms and signs of peptic (esophageal, duodenal, or stomach) ulcers disease vary. Some people with stomach ulcers do not have any symptoms or signs while others may have a few or several.

The most common symptom of a peptic ulcer is a dull or burning pain in the stomach. The pain may be felt anywhere between yourbelly buttonand breastbone. Pain from a peptic or stomach ulcer:

• usually happens when your stomach is empty, for example, such as between meals or during the night;
• may stop briefly if you eat or take antacids;
• may last for minutes to hours; or
• may come and go for several days, weeks, or months.

Peptic ulcer other symptoms and signs that are less common include:

• bloating,
• burping,
• feeling sick to your stomach,
• poor appetite,
• vomiting, and
• weight loss.

Even if your symptoms are mild, you may have a peptic ulcer. You should see your doctor to talk about your symptoms. Without treatment, your peptic ulcer can get worse.

For many years, excess acid was believed to be the major cause of ulcer disease. Accordingly, the emphasis of treatment was on neutralizing and inhibiting the secretion of stomach acid. While acid is still considered necessary for the formation of ulcers and its suppression is still the primary treatment, the two most important initiating causes of ulcers are infection of the stomach by a bacterium named "Helicobacter pylori" (H. pylori) and chronic use of nonsteroidal anti-inflammatory medications or NSAIDs, includingaspirin.Cigarette smokingalso is an important cause of ulcers as well as failure of ulcer healing.

Infection withH. pyloriis very common, affecting more than a billion people worldwide. It is estimated that half of the United States population older than age 60 has been infected withH. pylori. Infection usually persists for many years, leading to ulcer disease in 10% to 15% of those infected. In the past,H. pyloriwas found in more than 80% of patients with gastric and duodenal ulcers. With increasing appreciation, diagnosis and treatment of this infection, the prevalence of infection withH. pylorias well as the proportion of ulcers caused by the bacterium has decreased. It is estimated that currently only 20% of ulcers are associated with the bacterium. While the mechanism by whichH. pylori导致溃疡是复杂的,消除的bacterium by antibiotics has clearly been shown to heal ulcers and prevent their recurrence.

NSAIDs are medications used for the treatment ofarthritisand other painful inflammatory conditions in the body. Aspirin,ibuprofen(Advil,Motrin),naproxen(Aleve,Naprosyn), andetodolac(Lodine) are a few examples of this class of medications. Prostaglandins are substances produced by the body, which are important in helping the linings of the esophagus, stomach, and duodenum to resist damage by the acidic digestive juices of the stomach. NSAIDs cause ulcers by interfering with the production of prostaglandins in the stomach.

Cigarette smokingnot only causes ulcers, but it also increases the risk of complications from ulcers such as bleeding, obstruction, and perforation.Cigarette smokingalso is a leading cause of failure of treatment for ulcers.

Contrary to popular belief,alcohol, coffee, colas, spicy foods, andcaffeinehave no proven role in ulcer formation. Similarly, there is no conclusive evidence to suggest that life stresses or personality types contribute to ulcer disease.

The diagnosis of an ulcer is made by either a barium upper gastrointestinal X-ray (upper GI series) or an upper gastrointestinal endoscopy (EGDoresophagogastroduodenoscopy). The barium upper gastrointestinal (GI) X-ray is easy to perform and involves no risk (other than exposure toradiation) or discomfort. Barium is a chalky substance that is swallowed. It is visible on X- rays and allows the outline of the stomach to be seen onX-rays; however, barium X-rays are less accurate and may miss ulcers up to 20% of the time.

An upper gastrointestinal endoscopy is more accurate than X-rays, but usually involves sedation of the patient and the insertion of a flexible tube through the mouth to inspect the esophagus, stomach, and duodenum.Upper endoscopyhas the added advantage of having the capability of removing small tissue samples (biopsies) to test forH. pyloriinfection. Biopsies are also examined under a microscope to exclude a cancerous ulcer. While virtually all duodenal ulcers are benign, gastric ulcers can occasionally be cancerous. Therefore, biopsies often are performed on gastric ulcers to excludecancer.

There is no conclusive evidence that dietary restrictions and bland diets play a role in ulcer healing. No proven relationship exists between peptic ulcer disease and the intake of coffee and alcohol. However, since coffee stimulates gastric acid secretion, and alcohol can causegastritis, moderation in alcohol and coffee consumption is recommended.

The goal of ulcer treatment is to relieve pain, heal the ulcer, and prevent complications. The first step in treatment involves the reduction of risk factors (NSAIDs and cigarettes). The next step is medications.

Many people harborH. pyloriin their stomachs without ever having pain or ulcers. It is not completely clear whether these patients should be treated with antibiotics. More studies are needed to answer this question.

• Patients with documented ulcer disease andH. pyloriinfection should be treated for both the ulcer and theH. pylori.H. pylorican be very difficult to completely eradicate.
• Treatment for peptic ulcers requires a combination of several antibiotics, sometimes in combination with a proton-pump inhibitor, H2 blockers, orPepto-Bismol.
• Commonly used antibiotics are:
  • tetracycline,
  • amoxicillin,
  • metronidazole(甲硝哒唑),
  • clarithromycin(Biaxin), and
  • levofloxacin(Levaquin).

Eradication ofH. pyloriprevents the return of ulcers (a major problem with all other ulcer treatment options). Elimination of this bacteria also may decrease the risk of developing胃癌in the future.

Treatment with antibiotics carries the risk ofallergicreactions,diarrhea, and sometimes severe antibiotic-inducedcolitis(inflammation of the colon).

Antacids

Antacids neutralize existing acid in the stomach. Antacids such asMaalox,Mylanta, andAmphojelare safe and effective treatments. However, the neutralizing action of these agents is short-lived, and frequent dosing is required. Magnesium containing antacids, such as Maalox and Mylanta, can causediarrhea, while aluminum containing agents like Amphojel can causeconstipation. Ulcers frequently return when antacids are discontinued.

H2 blockers

研究表明,蛋白质的释放stomach called histamine stimulates gastric acid secretion. Histamine antagonists (H2 blockers) are drugs designed to block the action of histamine on gastric cells and reduce the production of acid. Examples of H2 blockers arecimetidine(Tagamet),nizatidine(Axid), andfamotidine(Pepcid). While H2 blockers are effective in ulcer healing, they have a limited role in eradicating H. pylori without antibiotics. Therefore, ulcers frequently return when H2 blockers are stopped.

Generally, H2 blockers are well tolerated and have few side effects even with long-term use. In rare instances, patients reportheadache,confusion, lethargy, orhallucinations. Chronic use of cimetidine may rarely causeimpotenceorbreast swelling. Cimetidine can interfere with the body's ability to handle alcohol. Patients on these drugs who drink alcohol may have elevated blood alcohol levels. These drugs also may interfere with theliver's handling of other medications like苯妥英(Dilantin),warfarin(Jantoven,Coumadin), andtheophylline. Frequent monitoring and adjustments of the dosages of these medications may be needed.

Proton-pump inhibitors (PPIs)

Proton-pump inhibitors such asomeprazole(Prilosec),lansoprazole(Prevacid),pantoprazole(Protonix),esomeprazole(Nexium), andrabeprazole(Aciphex) are more potent than H2 blockers in suppressing acid secretion. The different proton-pump inhibitors are very similar in action and there is no evidence that one is more effective than the other in healing ulcers. While proton-pump inhibitors are comparable to H2 blockers in effectiveness in treating gastric and duodenal ulcers, they are superior to H2 blockers in treating esophageal ulcers. Esophageal ulcers are more sensitive than gastric and duodenal ulcers to minute amounts of acid. Therefore, more complete acid suppression accomplished by proton-pump inhibitors is important for esophageal ulcer healing.

Proton-pump inhibitors are well tolerated. Side effects are uncommon; they includeheadache,diarrhea,constipation,nauseaandrash. Interestingly, proton-pump inhibitors do not have any effect on a person's ability to digest and absorb nutrients. Proton-pump inhibitors have also been found to be safe when used long term, without serious adverse health effects. Although they may promote loss of bone (osteoporosis) and low magnesium levels, both side effects are easily identified and treated.

Sucralfate (Carafate) and misoprostol (Cytotec)

Sucralfate(Carafate) andmisoprostol(Cytotec) are agents that strengthen the gut lining against attacks by acidic digestive juices. Sucralfate coats the ulcer surface and promotes healing. Sucralfate has very few side effects. The most common side effect isconstipationand the interference with the absorption of other medications. Misoprostol is a prostaglandin-like substance commonly used to counteract the ulcerogenic effects of NSAIDs. Studies suggest that misoprostol may protect the stomach from ulceration among people who take NSAIDs chronically. Diarrhea is a common side effect. Misoprostol can cause miscarriages when given topregnantwomen and should be avoided by women of childbearing age.

With modern treatment, people with ulcer disease can lead normal lives without lifestyle changes or dietary restrictions.Cigarettesmokershave been found to have more complications from ulcers and treatment failure.

Eradication of the bacteriaH. pylorinot only heals ulcers but also prevents the recurrence of ulcer disease.

Patients with ulcers generally function quite comfortably. Some ulcers probably heal even without medications (though they probably recur as well). Therefore, the major problems resulting from ulcers are related to ulcer complications. Complications include:

• bleeding,
• perforation, and
• obstruction of emptying of the passage of food.

Patients with bleeding ulcers may report:

• passage of blacktarry stools(melena),
• weakness,
• a sense of light-headedness or ay even pass out upon standing (orthostatic hypotensionorsyncope),
• andvomiting blood(hematemesis). Initial treatment involves rapid replacement of fluids intravenously.

Patients with persistent or severe bleeding may require blood transfusions. An endoscopy is performed to establish the site of bleeding and to stop active ulcer bleeding with the aid of specialized endoscopic instruments.

Perforationthrough the stomach leads to the leakage of stomach contents into the abdominal (peritoneal)cavity, resulting in acuteperitonitis(infection of the abdominalcavity). These patients report a sudden onset of extremeabdominal pain, which is worsened by any type of motion. Abdominal muscles become rigid and board-like.Urgent surgery usually is required.A duodenal ulcer that has perforated can burrow into adjacent organs such as the pancreas or behind the abdomen and into the back. An esophageal ulcer that perforates can cause severe inflammation of the tissues that surround it (mediastinitis).

Duodenumulcers form in the narrow outlet from the stomach, it can obstruct the flow of stomach contents into the duodenum. Duodenal ulcers sometimes also may obstruct the flow of intestinal contents.

Patients with obstruction often report:

• increasingabdominal pain,
• vomiting of undigested or partially digested food,
• diminished appetite, and
• weight loss.

The obstruction usually occurs at or near the pylorus of the stomach. Endoscopy is useful in establishing the diagnosis of obstruction from an ulcer and excluding gastriccanceras the cause of the obstruction. In some patients, gastric obstruction can be relieved by suction of the stomach contents with a tube for 72 hours, along with intravenous anti-ulcer medications, such as cimetidine (Tagamet).

Patients with persistent obstruction require surgery.

With modern treatment, people with ulcer disease can lead normal lives without lifestyle changes or dietary restrictions. Cigarette smokers have been found to have more complications from ulcers and treatment failure. Eradication of the bacteriaH. pylorinot only heals ulcers but also prevents the recurrence of ulcer disease.

Doctors who commonly treat peptic ulcer disease include primary care providers, such as general medicine physicians, family medicine doctors, and internists. Specialists in the diagnosis and treatment of peptic ulcer disease are gastroenterologists.