Peptic Ulcer

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Peptic ulcer is a disorder of the upper gastrointestinal tract that results when gastric acid, bacteria, drugs, or other things cause breaks in the mucosa, the moist tissue that lines the stomach, duodenum (part of the small intestine), and other digestive organs. Ulcers can develop in the esophagus, stomach, duodenum, or other areas of the GI tract. In men, duodenal ulcers are more common than stomach ulcers; in women, the opposite is true. If you suspect you might have an ulcer, it's important to find out so it can be treated. Ulcers can lead to serious complications.

Approximately 500,000 new cases of peptic ulcer are reported each year. At any given time, as many as 5 million people are affected in the United States alone. Patients with peptic ulcer disease may experience a range of symptoms, from mild abdominal pain and burning to bleeding, vomiting, or catastrophic perforation of the organ lining, a life-threatening condition requiring emergency surgery. Thirty-five percent of patients diagnosed with gastric ulcers will suffer serious complications, such as bleeding and perforation. Although mortality rates from peptic ulcer disease are low, the high prevalence of ulcers and the resulting pain, suffering, and expense are very costly.

Ulcer treatment has improved significantly in the past two decades thanks to the discovery that a chief cause of ulcers is the bacterium Helicobacter pylori—one possible reason ulcers seem to run in families. In patients with ulcers due to H. pylori, eradication of the bacterium has been shown to heal ulcers and prevent their reoccurrence. In addition, new acid-reducing drugs are now available and have made a dramatic difference for patients.

This section has more on:

  • Need-to-know anatomy
  • Causes
  • Risk factors
  • Need-to-know anatomy

    The stomach is an arc-shaped organ located in the upper part of the abdomen just beneath the diaphragm. One end of the stomach joins the esophagus where a ring of muscle called a sphincter allows food into the stomach as it's swallowed. The other end narrows to a channel called the pylorus that connects the stomach and the duodenum, or the upper part of the small intestine.

    The duodenum, or the first portion of the small intestine, is about 12 inches long and extends from the narrow opening of the pylorus, a thick ring of muscle that helps regulate the flow of food from the stomach, to about the middle of the small intestine. It is shaped in a sharp curve that almost completes a circle.

    Glands in the stomach produce acid and an enzyme called pepsin that help the body digest food. Normally, the stomach and the duodenum also produce mucus that protect them from the effects of the acid. In people with peptic ulcers, the defenses break down, often because of an infection with the H. pylori bacterium, and sores form in the lining of the stomach (gastric ulcer) and the duodenum (duodenal ulcer).

    Causes

    The integrity of the upper gastrointestinal tract is dependent upon the balance between "hostile" factors that can damage the mucous lining (mucosa) of the stomach and upper part of the small intestine (duodenum), such as stomach acid, and "protective" factors, such as hormonelike prostaglandins and mucus. When the effects of hostile factors overwhelm the natural defenses of the mucosa, ulcers form.

    For many years, doctors believed that an overabundance of stomach acid due to food, alcohol, stress, or other environmental factors was the cause of ulcers. Indeed, the corrosive actions of pepsin (secreted by the mucosa to break down protein) and hydrochloric acid (released in the digestive process) are significant contributors to ulcer formation.

    But the key cause of most ulcers is now believed to be infection with a common bacterium called Helicobacter pylori or H. pylori. Although the mechanism by which H. pylori leads to ulcers is not fully understood, scientists believe the bacterium causes chronic inflammation of the stomach or duodenum, which, in turn, weakens the mucosa, allowing acid to cause a sore, or ulcer, in the lining. Once an individual has been infected with H. pylori, the infection continues indefinitely until it is eradicated with antibiotics. Scientists are not yet sure how H. pylori is spread, but it may be through contaminated food or water or person-to-person contact. In the United States, an estimated 30 percent of the population is colonized with H. pylori; 1 in 6 will develop ulcers.

    This section also discusses other contributors to ulcer formation.

    Other contributors to ulcer formation

    NSAIDs: Chronic use of nonsteroidal anti-inflammatory drugs, or NSAIDs, such as aspirin or ibuprofen, inhibits the body's production of prostaglandins, the powerful hormonelike chemicals that protect the stomach lining and are integral to the body's inflammatory process. NSAIDs reduce inflammation from arthritis, tendonitis, and other conditions—but they also shut off the protective mechanism that keeps the mucosa healthy. NSAIDs are more likely to cause stomach ulcers rather than duodenal ulcers.

    Smoking: Cigarette smoking and H. pylori are cofactors in peptic ulcer disease, although their exact relationship is unclear. Cigarette smoking may increase susceptibility, diminish the gastric mucosal defensive factors, or provide a more favorable milieu for H. pylori infection. Smokers are about two times as likely to develop ulcer disease as nonsmokers.

    Stress: Numerous studies have presented conflicting conclusions about the role of psychological stress in peptic ulcer disease. Stress may worsen ulcers, not cause them. However, in patients with duodenal ulcers, stress has been shown to increase acid secretion. Physical stress, meanwhile, may increase the risk of stomach ulcers. People with severe burns or those undergoing major surgery often require treatment to prevent ulcers.

    Zollinger-Ellison syndrome (ZES): This rare disorder causes tumors in the pancreas and duodenum and ulcers in the stomach and duodenum. The tumors secrete a hormone called gastrin that causes the stomach to produce too much acid. The ulcers caused by ZES are less responsive to treatment than ordinary peptic ulcers. What causes people with ZES to develop tumors is unknown, but approximately 25 percent of ZES cases are associated with a genetic disorder called multiple endocrine neoplasia type 1.

    Risk factors

    Ulcer disease has become a disease predominantly affecting older individuals, with the peak incidence occurring between 55 and 65 years of age. In part, this is explained by the fact that older people are at highest risk of H. pylori infection, one of the main causes of ulcers; H. pylori is found in more than 60 percent of patients with gastric and duodenal ulcers. Fully half of the country's population older than 60 is thought to be infected with H. pylori, which results in ulcer disease in 10 to 15 percent of those affected.

    Other risk factors include:

    Family history: Among first-degree relatives of ulcer patients, the lifetime chance of developing an ulcer is three times as great as that of the general population. Approximately 20 to 50 percent of duodenal ulcer patients report a family history of duodenal ulcers. Gastric ulcer patients also report clusters of family members who suffer from stomach ulcers.

    Poverty or poor sanitation: Lower socioeconomic status, poor sanitation, or living in areas without safe drinking water increases the risk of infection with H. pylori and hence the risk of peptic ulcer disease.

    In people who develop NSAID-associated gastric and duodenal ulcers, risk factors include advanced age, a history of previous ulcer disease, concomitant use of corticosteroids and blood-thinning drugs, or serious systemic disorders such as arthritis.

    Last reviewed on 7/28/09

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