Peptic ulcer

A peptic ulcer is a break larger than 5 mm in diameter on the inside lining of the stomach and/or duodenum, a mucous lawyer that protects the interior of these organs from the action of the acids and digestive juices.

It is a very common disease that produces a burning stomach pain and usually decrease the quality of life of these patients.

The main causes of the gastric ulcer and the duodenal ulcer are related to the Helicobacter pylori bacterium and the administration of NSAIDs (Nonsteroidal Anti-Inflammatory Drugs), aspirin derivates such as ibuprofen, diclofenac, etc.

Helicobacter pylori

It is a bacterium that colonizes the mucosa of the stomach. It is present around the world but to a lesser extent in developed countries with access to safe drinking water and with a better healthcare system.

The risk factors involve in the infection by H. pylori are poor health conditions, overcrowding and living with people already infected.

People with the bacteria present in the stomach will have chronic gastritis but only 10% to 15% will suffer from peptic ulcer.

It is very important to diagnose and treat the peptic ulcer because there is a possibility that it may develop into gastric cancer if it is not properly treated.

It is not clear the underlying mechanism, but it seems that the H. pylori bacterium (a bacterium with a high resistance to antibiotics) produces an internal damage to the mucosa that decrease the action of the innate immune system.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Patients which take NSAIDs frequently, such as acetylsalicylic acid or aspirin, often have nausea, burning stomach and epigastric pain (pain below the ribs in the upper abdomen). In up to 30% an ulcer is observed when doing a gastroscopy. Sometimes, it can lead to bleeding or perforated ulcers.

NSAIDs work on a chemical level that may reduce the protection of the stomach against acids. That may lead to inflammation (gastritis) and ruptures or disruptions (ulcers).

Other risk factors are:

• Smoking
• Alcohol
• History of smoking or alcohol intake (even if they have already been suspended)
• Chronic disease related to the lungs or the kidneys.

The main symptom of peptic ulcer is the presence of pain or discomfort in the abdominal area with one of the following features:

• Epigastric pain (upper abdominal pain) described as burning or gnawing discomfort that occurs 30 min to 60 minutes after a meal.
• Stomach pain at night (when the stomach is empty).
• Dull pain not irradiated.
• Pain for weeks followed by periods free of symptoms.
• Pain when pressing the epigastrium (below the ribs in the upper abdomen).
• Other symptoms resulting from the above such as weight loss, loss of appetite, bloating, belching, nausea or vomiting (less frequent).

This pain is usually related to heartburn or painful burning in the esophagus (behind the sternum) due to the reflux (flow back) of gastric acids into the esophagus.

The symptoms are very specific for the diagnosis.

Gastroscopy is the recommended procedure to confirm the diagnosis. A biopsy is taken for analysis, especially if there are injuries compatibles with cancer and a culture for Helicobacter Pylori is performed.

The diagnosis of Helicobacter Pylori infection can be also confirmed by a simple test that measures the CO2 in the breath (urea breath test). It is a very effective procedure. It is also used after the treatment to confirm that the infection is solved or if it is necessary to prescribe more antibiotics. The presence of the bacteria in feces can also be determined.

The treatment depends on the presence or absence of Helicobacter Pylori and the history of the use of NSAIDs.

There are some general facts about the treatment of peptic ulcer that should be considered:

• Treatment with antibiotic is recommended in patients infected with Helicobacter Pylori
• Complete the treatment is the key to the healing. It is necessary to take three different antibiotics for at least 14 days and antacids for 4 to 6 weeks. 4 weeks after the treatment a new test will be performed (a urea breath test or a stool test).
• There is not just a recommended antibiotic therapy. There are several options.
• Antiulcer agents (AntiH2-Omeprazole) are recommended to relieve the symptoms and help the healing.
• There is no evidence about when the antacids should be continued or not. It depends on what the doctor and the patient consider appropriate depending on the symptoms and the quality of life.
• If the symptoms persist, a new endoscopic study (gastroscopy) will be needed.
• Gastric ulcers that do not heal after 12 weeks of treatment and duodenal ulcers that do not heal after 8 weeks of treatment are considered refractory ulcers.
• In all patients with peptic ulcer the use of NSAIDs should be investigated. Whenever possible, it is advisable to stop using them.
• Refractory ulcers must be followed by a gastroenterologist. If the cause of the ulcer is unknown, surgery may be necessary to avoid the risk of hemorrhage and perforated peptic ulcers.
• The role of diet in peptic ulcers is not clear.