• Peptic Ulcer

    (PUD; Duodenal Ulcer; Ulcer, Peptic; Ulcer, Duodenal)


    Peptic ulcer is a sore in the lining of the stomach or the first part of the small intestine. This area of the small intestine is called the duodenum. Peptic ulcers may be named by their location:
    Gastric Ulcer
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    Upsets in the balance of stomach acid and digestive juices can lead to an ulcer. This can be caused by:
    • Bacterium Helicobacter pylori (H pylori)—common cause
    • Use of nonsteroidal anti-inflammatory drugs (NSAIDs)—blocks the body's ability to protect the stomach lining; common cause
    • Diseases that cause acid production to increase, such as Zollinger-Ellison syndrome
    Not all people that take NSAIDs or with H pylori infection develop ulcers.
    Rare causes include:

    Risk Factors

    Risk factors for ulcer from H pylori infection include:
    • Age: 60 or older
    • Sex: male
    • Race: Black and Hispanic
    • Lower socio-economic group
    • A crowded and unsanitary living environment
    • Cigarette smoking
    • Family history of ulcer disease
    • Type O blood
    Risk factors for ulcer from anti-inflammatory drugs include:
    • Age: 60 or older
    • Sex: male
    • History of stomach upset from NSAIDs
    • Prior peptic ulcer disease
    • Cigarette smoking
    • Alcohol abuse


    Peptic ulcers do not always cause symptoms. Symptoms may come and go. Food may increase gastric ulcer pain. Food will often relieve duodenal ulcer pain.
    Symptoms include:
      Gnawing pain
      • May awaken you from sleep
      • May change when you eat
      • May last for a few minutes or several hours
      • Feels like unusually strong hunger pangs
    • Nausea
    • Vomiting
    • Loss of appetite
    • Bloating
    • Burping
    Ulcers can cause serious problems and severe abdominal pain. Problems include:
      Bleeding—symptoms may include:
      • Black, tarry stools
      • Vomiting what looks like coffee grounds
      • Weakness
      • Dizziness
      • Anemia
      Perforated ulcer—a break through the wall of the stomach or duodenum that will cause:
      • Sudden and severe pain
      Scar tissue that narrows and eventually closes off the outlet of the stomach to the intestines and can cause:
      • Vomiting
      • Weight loss
      • Intense pain
    Duodenal Ulcer
    duodenal ulcer
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    The doctor will ask about your symptoms and medical history. A physical exam will be done. Tell your doctor about all medication you are taking.
    Tests may include:
    • Rectal exam and stool guaiac test—to test for hidden blood
    • Blood test or breath test—to check for H pylori infection
      • A blood test can also check for Zollinger-Ellison syndrome
    • Upper GI series—a series of x-rays of the upper digestive system taken after drinking a barium solution
    • Endoscopy—a thin, lighted tube inserted down the throat to look inside the digestive tract used to:
      • Obtain tissue samples to test for H pylori infection or for cancer
      • Eliminate other serious causes of gastrointestinal symptoms


    The goal is to remove the source of the problem and heal the ulcer. Gastric ulcers may take longer to heal.
    Treatments include:


    Some medications block or reduce acid production. Some coat the ulcer to protect it. If H pylori caused the ulcer, you will need to take a combination of drugs to kill the bacteria. This usually consists of antibiotics and a proton-pump inhibitor. It is very important to take these drugs as directed. The doctor may order tests 6-12 months after treatment. This is done to check that the bacteria are gone.
    Medications may include:
    • Antacids—may provide some relief from heartburn; do not heal ulcers
    • Antibiotics (such as amoxicillin, tetracycline, and clarithromycin)
    • Bismuth-containing drug (Pepto-Bismol)
    • Proton pump inhibitors—to decrease stomach acid production (such as omeprazole, lansoprazole)
    • H 2 blockers—to decrease stomach acid production (such as famotidine, ranitidine, cimetidine, nizatidine)
    • Medications to coat ulcer (such as sucralfate)
    • Medications to protect stomach against NSAID damage (such as misoprostol)

    Lifestyle Changes

    • If you smoke, quit. Smoking interferes with ulcer healing.
    • Do not drink alcoholic beverages.
    • Avoid NSAIDS. This includes over-the-counter drugs like aspirin and ibuprofen.
    • Spicy or fatty foods may worsen symptoms. You can temporarily stop eating them. Keep in mind they did not cause the ulcer. They probably do not affect ulcer healing.
    • If stress increases ulcer pain, learn and practice stress-management techniques.

    Surgery and Endoscopy

    You may need surgery if you have bleeding, a perforation, or an obstruction. Surgical options include:
    • Highly elective vagotomy—This is a technique that cuts only part of the vagus nerve. This surgery does not require extra drainage.
    • Vagotomy with antrectomy—This involves cutting the vagus nerve combined with removing the lower part of the stomach (antrum). The antrum makes a chemical that promotes acid production. Without that chemical, acid production drops.
    This may be done to stop bleeding. A thin, lighted tube is inserted down the throat into the stomach or intestine. Heat, electricity, epinephrine, or a substance called “fibrin glue” can then be applied to the area. This should stop the blood flow.
    Vagotomy and Drainage
    Vagotomy is the cutting of parts of the vagus nerve. This procedure can greatly reduce acid production. Cutting the entire nerve can also create problems with stomach. In this case, drainage must be created. Drainage may be done with one of the following:
    • Pyloroplasty—widening the opening between the stomach and the duodenum, allowing stomach contents to flow more easily into the intestine
    • Gastroduodenostomy—creating a new opening to connect the stomach and the duodenum
    • Gastrojejunostomy—creating a new opening to connect the stomach and the jejunum (the second part of the small intestine)
    Two other forms of vagotomy include:
    • Highly elective vagotomy—cuts only part of the vagus nerve; does not require extra drainage
    • Vagotomy with antrectomy—the vagus nerve is cut and the lower part of the stomach (antrum) is removed; the antrum makes a chemical that promotes acid production


    To decrease the risk of ulcer from H pylori infection:
    • Wash your hands after using the bathroom and before eating or preparing food.
    • Drink water from a safe source.
    • Don't smoke . Cigarette smoking increases the chances of getting an ulcer.
    To decrease the risk of ulcer from NSAIDs:
    • Use other drugs when possible for managing pain.
    • Take the lowest possible dose.
    • Do not take drugs longer than needed.
    • Do not drink alcohol while taking the drugs.
    • Ask your doctor about switching to a newer NSAID. Look for one that is less likely to cause ulcers. Talk to your doctor about taking other drugs to protect your stomach and intestine lining.
    • Don't smoke. Cigarette smoking increases the chances of getting an ulcer.


    The American College of Gastroenterology http://www.acg.gi.org

    American Gastroenterological Association http://www.gastro.org


    BC HealthGuide http://www.bchealthguide.org

    C-Health http://chealth.canoe.ca


    Conn HF, Rakel RE. Conn's Current Therapy 2001. 53rd ed. Philadelphia, PA: WB Saunders Company; 2001.

    Dambro MR, Griffith HW, Griffith JA. Griffith's 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams & Wilkins; 1999.

    Fauci AS ed. Harrison's Principles of Internal Medicine. 15th ed. Columbus, OH: McGraw Hill; 2001.

    H pylori and peptic ulcer. National Institute of Diabetes and Digestive and Kidney Diseases website. Available at: http://digestive.niddk.nih.gov/ddiseases/pubs/hpylori. Published October 2004. Accessed June 13, 2008.

    Ulcers. The American College of Gastroenterology website. Available at: http://www.acg.gi.org/patients/patientinfo/ulcers.asp. Accessed June 13, 2008.

    Ulcers. American Gastroenterological Association website. Available at: http://www.gastro.org. Accessed June 13, 2008.

    Ulcers and H pylori infection. America Academy of Family Physicians website. Available at: http://familydoctor.org/online/famdocen/home/common/digestive/disorders/271.html. Published May 1999. Updated December 2006. Accessed June 13, 2008.

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