Peptic Ulcer Disease: Prevention, Diagnosis and treatment

An ulcer is a term used to describe the break in the lining of any part of the body. The term peptic ulcer refers collectively to ulcers in the lining of the stomach (gastric ulcers) and the lining of the duodenum (duodenal ulcers).

The cause of peptic ulcers

As part of its regular function, the stomach produces both acid and a chemical called pepsin that helps to catalyse the digestion process of food before it is absorbed within the body. Acid and pepsin are not able to digest food on their own but they are capable of attacking the duodenum and the lining of the stomach. Ulcers develop when both these chemicals break through the stomach’s natural defences – a protective layer of sticky mucous and fluid that protects the lining – and come into contact with the lining.

The two predominant factors that affect the lining of the stomach and make individuals more susceptible to peptic ulcers are: 

• a bacterial infection called Helicobacter pylori (more commonly referred to as H pylori) and
• the regular use of non-steroidal anti-inflammatory drugs (NSAIDs) and/or aspirin

H pylorus is the main global cause of peptic ulcers, accounting for approximately 95% of duodenal ulcers and 80% of all gastric ulcers (1). The infection makes individuals more susceptible through inflaming the stomach and duodenal lining which weakens their defences and disrupting the normal mechanism that stops the production of acid and pepsin after meals have been fully digested.

Risk factors for the development of peptic ulcers

There are a number of other identified risk factors for the development of peptic ulcers. They include:

• smoking (which also makes any subsequent treatment less effective)
• the inherent of ulcer tendencies from close family members
• steroid drugs (such as prednisolone) 
• bile acids
• changes in gastric mucin consistency

It had previously been considered that peptic ulcers were a consequence of high levels of stress, but there is currently no evidence to support this claim.

Symptoms of a peptic ulcer?

Many people have undiagnosed peptic ulcers that never cause a problem.

However, when they do become symptomatic, the most common complaint is generalised pain in the abdomen that can last from anywhere between a few minutes to a few hours around 1-2 hours after mealtime. Patients may also experience a ‘knife like’ pain the small of the back or in the stomach, increased levels of nausea and/or heartburn and a pain sensation just below the breastbone.

Some patients have stated that the acute pain can be relieved through the use of antacids – this is also usually a strong indicator of a peptic ulcer. Ulcers that bleed usually causes patients to vomit blood which may have the appearance of ground coffee, or to pass stools that are entirely black in colour.

Diagnosing peptic ulcer disease

The most accurate diagnostic test is an endoscopy that involves passing a thin tube through the mouth, down the gullet, and into the stomach and duodenum in order to allow the appropriate healthcare professional to make a quick diagnosis. This method is considered uncomfortable by many patients but the procedure is relatively quick and allows excellent views that can allow for an immediate diagnosis, as well as the quick collection of a sample of the stomach lining to confirm or deny H pylori infection.

Alternatives to endoscopy?

There is good emerging evidence that a simple test for H pylori infection is usually a strong indicator of peptic ulcer disease and that it is a cheaper, less invasive test than endoscopy (2).

Breath test. The best available indicator of H pylori infection is a breath test in which the patient swallows a small amount of fluid containing trace radioactive urea. As H pylorus splits any urea in the stomach into both water and carbon dioxide (3), the subsequent measure of the amount of carbon dioxide in the patient’s breath is an indicator of their infection status.

A blood test may occasionally be undertaken but it is not as diagnostically sound or efficacious as endoscopy or breath test (4).

Stool antigen tests, in which a small section of faeces is studied for H pylorus infection, are being developed as a future test but are not currently in use (5).

Barium meals – an X-ray procedure that involves swallowing a white, tasteless fluid that outlines the walls of the stomach and duodenum – are now very rare due to the quality of other diagnostic tests that have been developed since their previous widespread use (6).

How is it treated?

For H pylori related ulcers, the recommended first line treatment is a standard acid-reducing drug that is taken in conjunction with two antibiotics over the course of seven days. For NSAID induced or related ulcers, the standard prescription is an acid suppressing drug over 4-8 weeks and the cessation of any NSAID medication. Acid reducing drugs have minimal side effects, although they may cause diarrhoea in some patients. In the large majority of patients, this treatment is often adequate enough to heal existing ulcers and prevent their reoccurrence (providing other lifestyle factors that may result in the development of further ulcers are addressed).

Preventing peptic ulcer disease

Addressing lifestyle factors that contribute towards an increased risk, such as smoking, the excessive consumption of alcohol and the regular use of NSAIDs do help reduce the likelihood of developing peptic ulcers.

References

1. Vakil N (2010) Dyspepsia, peptic ulcer, and H. pylori: a remembrance of things past. Am J Gastroenterol 105(3):572-4
2. Cai S, Garcia Rodriguez LA, Masso-Gonzalez EL, et al (2009) Uncomplicated peptic ulcer in the UK: trends from 1997 to 2005 Aliment Pharmacol Ther 30(10):1039-48
3. Mynatt RP, Davis GA, Romanelli F (2009) Peptic ulcer disease: clinically relevant causes and treatments Orthopedics 32(2):104
4. Prabhu V, Shivani A (2014) An overview of history, pathogenesis and treatment of perforated peptic ulcer disease with evaluation of prognostic scoring in adults Ann Med Health Sci Res 4(1):22-9
5. Niv Y (2010) H. pylori/NSAID--negative peptic ulcer--the mucin theory (2010) Med Hypotheses 75(5):433-5
6. Najm WI (2011) Peptic ulcer disease Prim Care 38(3):383-94