DEFINITION AND DESCRIPTION
♥ Peptic ulcers are produced by an imbalance between the gastroduodenal mucosal defense mechanisms and damaging forces of
gastric acid and pepsin, combined with superimposed injury from
environmental or immunologic agents.
♥The mucous membrane lining the digestive tract erodes and
causes a gradual breakdown of tissue. This breakdown causes a
gnawing or burning pain in the upper middle part of the belly
₪ As many as 80% of ulcers are associated with Helicobacter
pylori, a spiral-shaped bacterium that lives in the acidic
environment of the stomach.
₪ Ulcers can also be caused or worsened by drugs such as
aspirin and other NSAIDs.
₪ Although H. pylori infection is usually contracted in
childhood, perhaps through food, water, or close contact with
an infected individual. usually doesn't cause problems in
childhood, if left untreated it can cause gastritis (the irritation
and inflammation of the lining of the stomach), peptic ulcer
disease, and even stomach cancer later in life.
₪ Contrary to general belief, more peptic ulcers arise in the
duodenum (first part of the small intestine, just after the
stomach) than in the stomach.
₪ Duodenal ulcers usually first occur between the ages of 30-50
years and are twice as common in men as in women.
₪ Stomach (or gastric) ulcers usually occur in people older than
60 years and are more common in women.
Gastric versus duodenal ulcer — Although there is much overlap, symptoms of a
gastric ulcer may be different than those of a duodenal ulcer.
Duodenal ulcer — "Classic" symptoms of a duodenal ulcer include burning,
gnawing, aching, or hunger-like pain, primarily in the upper middle region of the
abdomen below the breastbone (the epigastric region). Pain may occur or worsen
when the stomach is empty, usually two to five hours after a meal. Symptoms may
occur at night between 11 PM and 2 AM, when acid secretion tends to be greatest.
Feel better when you eat or drink and then worse 1 or 2 hours later (duodenal ulcer)
Gastric ulcer — Symptoms of a gastric ulcer typically include pain soon after eating.
Symptoms are sometimes not relieved by eating or taking antacids.
Feel worse when you eat or drink (gastric ulcer)
Unexplained weight loss
hematemesis (vomiting of blood)
Blood in the stools
low blood cell count (anemia)
Stomach pain wakes you up at night
frequent burping or hiccupping
An early sense of fullness with eating
Helicobacter pylori infection
¤H. pylori is a helix-shaped
¤ Gram-negative, slow-growing organism
¤ about 3 micrometres long with a diameter of about
¤has 4–6 flagella
¤ Helicobacter pylori is composed of a single circular chromosome
with 1,667,867 base pairs, containing about 1590 coding regions
¤It is microaerophilic; that is, it requires oxygen, but at lower
concentration than is found in the atmosphere
¤It contains a hydrogenase which can be used to obtain energy by
oxidizing molecular hydrogen (H2) that is produced by intestinal
☻The bacterium persists in the stomach for decades in
most people. Most individuals infected by H. pylori
will never experience clinical symptoms despite
having chronic gastritis. Approximately 10-20% of
those colonized by H. pylori will ultimately develop
gastric and duodenal ulcers. H. pylori infection is also
associated with a 1-2% lifetime risk of stomach
cancer and a less than 1% risk of gastric MALT
• Regular use of pain relievers. Nonsteroidal antiinflammatory drugs (NSAIDs) can irritate the lining of
stomach and small intestine. These medications, which are
available both by prescription and over-the-counter, include
aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve),
ketoprofen and others. Other prescription medications that can
also lead to ulcers include medications used to treat
osteoporosis called bisphosphonates (Actonel, Fosamax and
• NSAIDs inhibit production of an enzyme (cyclooxygenase)
that produces prostaglandins. These hormone-like substances
help protect stomach lining from chemical and physical injury.
Without this protection, stomach acid can erode the lining,
causing bleeding and ulcers.
• Gastrinomas (Zollinger Ellison syndrome), rare
gastrin-secreting tumors, also cause multiple and
difficult to heal ulcers.
• Excessive alcohol consumption Alcohol can irritate
and erode the mucous lining of stomach and increases
the amount of stomach acid that's produced. It's
uncertain, however, whether this alone can progress
into an ulcer or if it just aggravates the symptoms of
an existing ulcer.
the enterochromaffin-like cells
and G cells
of histamine and
Beverages and foods that contain caffeine
can stimulate acid secretion in the
stomach. This can aggravate an existing
ulcer, but the stimulation of stomach acid
can't be attributed solely to caffeine.
Role of Stress
♫ A study of peptic ulcer patients in a Thai hospital showed that chronic stress
was strongly associated with an increased risk of peptic ulcer, and a combination
of chronic stress and irregular mealtimes was a significant risk factoR.
♫ An expert panel convened by the Academy of Behavioral Medicine Research
concluded that ulcers are not purely an infectious disease and that psychological
factors do play a significant role. Researchers are examining how stress might
promote H. pylori infection.
♫ For example, Helicobacter pylori thrives in an acidic environment, and stress
has been demonstrated to cause the production of excess stomach acid. This was
supported by a study on mice showing that both long-term water-immersionrestraint stress and H. pylori infection were independently associated with the
development of peptic ulcers.
♫ Physical stress, is different. It can increase the risk of developing ulcers,
especially in the stomach. Examples of physical stress that can lead to ulcers are
that suffered by people with injuries such as severe burns, and people undergoing
You’re at risk for peptic ulcer disease if you:
Are 50 years old or older.
Diabetes may increase your risk of having H. pylori
Drink alcohol excessively
Smoke cigarettes or use tobacco.
Have a family history of ulcer disease.
You’re at risk for NSAID-induced ulcers if you:
Are age 60 or older (your stomach lining becomes more fragile with age).
Have had past experiences with ulcers and internal bleeding
Take steroid medications, such as prednisone.
Take blood thinners, such as warfarin.
Consume alcohol or use tobacco on a regular basis.
Experience certain side effects after taking NSAIDs, such as upset stomach
• Take NSAIDs in amounts higher than recommended
• Take NSAIDs for long periods of time
• Stress does not cause an ulcer, but may be a contributing factor
• Chronic disorders such as liver disease, emphysema, rheumatoid arthritis
may increase vulnerability to ulcers
• Improper diet, irregular or skipped meals
• Type O blood (for duodenal ulcers)
ж Gastrointestinal bleeding is the most common
complication. Sudden large bleeding can be lifethreatening. It occurs when the ulcer erodes one of
the blood vessels. Bleeding can occur as slow blood
loss that leads to anemia or as severe blood loss that
may require hospitalization or a blood transfusion.
ж Perforation (a hole in the wall) often leads to
catastrophic consequences. Erosion of the gastrointestinal wall by the ulcer leads to spillage of
stomach or intestinal content into the abdominal
cavity. Perforation at the anterior surface of the
stomach leads to acute peritonitis, initially chemical
and later bacterial peritonitis. The first sign is often
sudden intense abdominal pain. Posterior wall
perforation leads to pancreatitis; pain in this situation
often radiates to the back.
ж Penetration is when the ulcer continues into
adjacent organs such as the liver and pancreas
ж Scar tissue Scarring and swelling due to
ulcers causes narrowing in the duodenum and
gastric outlet obstruction. Patient often
presents with severe vomiting. Peptic ulcers
can also produce scar tissue that can obstruct
passage of food through the digestive tract,
causing you to become full easily, to vomit
and to lose weight.
sudden, severe pain
vomit food eaten hours or
ongoing nausea or
feel cold or clammy
blood in your stools
feel unusually weak or
pain doesn't go away
☻ lowering the amount of acid that stomach
☻neutralizing the acid
☻ protecting the injured area so it can heal
☻ It's also very important to stop smoking and
☻Prevent complications (bleeding, perforation,
☻Reduce financial costs
Antibiotic medications. Doctors use combinations of antibiotics to treat H. pylori
because one antibiotic alone isn't always sufficient to kill the organism. Antibiotics
prescribed for treatment of H. pylori include amoxicillin (Amoxil), clarithromycin
(Biaxin) and metronidazole (Flagyl). Combination drugs that include two antibiotics
together with an acid suppressor or cytoprotective agent (Helidac, Prevpac) have
been designed specifically for the treatment of H. pylori infection.
Acid blockers. Acid blockers — also called histamine (H-2) blockers — reduce the
amount of hydrochloric acid released into digestive tract, which relieves ulcer pain
and encourages healing. Acid blockers work by keeping histamine from reaching
histamine receptors. Histamine is a substance normally present in body. When it
reacts with histamine receptors, the receptors signal acid-secreting cells in stomach
to release hydrochloric acid. Available by prescription or over-the-counter (OTC),
acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid),
cimetidine (Tagamet) and nizatidine (Axid).
Antacids. An antacid may be taken in addition to an acid blocker or in place of one.
Instead of reducing acid secretion, antacids neutralize existing stomach acid and can
provide rapid pain relief.
♪ Proton pump inhibitors. Another way to reduce stomach acid is to shut down the
"pumps" within acid-secreting cells. Proton pump inhibitors reduce acid by blocking the
action of these tiny pumps. These drugs include the prescription and over-the-counter
medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex) and
esomeprazole (Nexium). Doctors frequently prescribe proton pump inhibitors to promote
the healing of peptic ulcers. Proton pump inhibitors also appear to inhibit H. pylori.
♪ Cytoprotective agents. In some cases, your doctor may prescribe these medications that help
protect the tissues that line your stomach and small intestine. They include the prescription
medications sucralfate (Carafate) and misoprostol (Cytotec). Another nonprescription
cytoprotective agent is bismuth subsalicylate (Pepto-Bismol).
♪ Bowel rest: Bed rest and clear fluids with no food at all for a few days. This
gives the ulcer a chance to start healing without being irritated.
♪ Nasogastric tube: Placement of a thin, flexible tube through your nose and
down into your stomach. This also relieves pressure on the stomach and helps it
♪ Urgent endoscopy or surgery if indicated: Damaged, bleeding blood vessels
can usually be repaired with an endoscope. The endoscope has a small heating
device on the end that is used to cauterize a small wound.
Tying off an