Peptic Ulcer Disease – Symptoms, Causes and Treatment

Summary

Peptic Ulcer Disease is a condition in which the stomach acid acts on the stomach lining resulting in open sores or ulcers in different parts of the digestive tract. It can lead to a lot of pain and discomfort to the person after consuming meals. If diagnosed late, or left untreated for long, it results in complications that may even require surgery. However, the condition is curable in most patients. In this article, we will learn more about this disease.

Introduction to the Digestive tract

Food that we consume goes through the esophagus or food-pipe and into the stomach. Here, pepsin, an enzyme which is responsible for digesting food, as well as the acid present in the stomach, act on the food breaking it down as much as possible. Thereafter, the food enters the duodenum (the early part of the small intestine), and thereafter the intestines, for further digestion and final elimination of undigested food.

Stomach-acid plays an important part in the whole process. Our stomachs naturally produce this acid. This acid is not as corrosive as industrial or commercial-grade acids, but nevertheless it can be corrosive. To prevent the stomach-acid from attacking the stomach and corroding it, there is a thin lining of mucous that lines it and most organs of the digestive system.

This mucous lining (also called mucosa) has three layers, and is quite durable. It lasts a person’s lifetime in most people, without any special care required for the same. Even if there are minor damages to the lining, once in a while, it is capable of self-repair, to ensure smooth functioning. This is due to a hormone-like substance called prostaglandin present in the body that positively impacts various body functions and plays a role in self-repair of the stomach lining.

However, sometimes, or in some people, the lining is no longer working effectively. This is due to a chronic or long-term condition and doesn’t happen overnight. As a result, the stomach-acid starts corroding the linings of the digestive organs. Over time, acid can bore through all three layers of the mucosa. This leads to open sores at the spot that can be painful to the patient. It makes consuming food, water or beverages difficult. It can delay digestion and also cause constipation.

Peptic Ulcer Disease (PUD) is an umbrella term, and depending on which part of the GI tract is affected, there are different types of this condition:

• Duodenal ulcers: The sores develop at the duodenum and this is the most common type. Accounts for almost 80% of all cases of PUD
• Stomach ulcers: The sores develop inside the stomach and this is the next most common type. Accounts for almost 20% of all cases of PUD
• Esophageal ulcers: In this, due to chronic reflux of food, stomach acid refluxes upwards, thereby corroding the esophagus or food-pipe, and causing sores there. The esophagus doesn’t have a mucous lining so it is even more vulnerable than other parts of the GI tract. Thankfully, this condition is quite rare.
• Jejunal ulcers: The jejunum is the central part of the small intestine. Sometimes, the jejunum may have a medical condition like a cancer. Or, an overweight patient opts for a weight-loss surgery. In such a case, the duodenum is bypassed, and the stomach is stapled or connected directly to the jejunum. In some patients, this causes ulcers to develop here. The condition is also called anastomotic ulcer, marginal ulcer or stomal ulcer, and is quite rare.

Causes

There are 3 major causes and a whole lot of secondary causes:

H pylori infection: Heliobacter pylori is a bacterium that is commonly found in nature. It enters our body through the food, water and beverages we consume and stays in the GI tract. It is one of the members of the gut microbiome. Most of the time, it is harmless and the population of this bacteria stays under control, or is regulated by the body. However, sometimes, these bacteria grow out of proportion, which upsets the natural balance of the gut microbiome. As a consequence, there is severe inflammation in the stomach lining. Chronic inflammation of the stomach lining destroys its ability to self-repair. It then becomes easy for this bacteria and stomach acid to corrode the lining, which leads to ulcers or open sores developing at the spot.

Overuse of NSAIDs: Non-Steroidal Anti-Inflammatory Drugs are over-the-counter medicines such as aspirin and ibuprofen. They act as pain-killers and are commonly prescribed for any condition that causes chronic pain (such as arthritis and innumerable conditions). They must be used as per doctor’s prescription. However, patients with a low tolerance of pain start reaching out to these OTC drugs at the slight hint of pain. Such overuse of NSAIDs is unhealthy and causes various complications in the long run. One such outcome is PUD. NSAIDs block the effect of prostaglandin which helps the stomach-lining repair itself. So, small events that lead to corrosion of the stomach lining do not heal now, leading to open sores or PUD.

Other medications: Some other medicines that are taken along with NSAIDs can increase the risk for PUD when taken for long. This includes: steroids, risedronate (Actonel), anticoagulants, alendronate (Fosamax), selective serotonin reuptake inhibitors (SSRIs) and low-dose aspirin.

Other reasons:

• Kissing and intimacy which increases the chance of H pylori infection
• Infections from viruses and bacteria other than H pylori
• Ischemia or loss of blood supply in the stomach due to cardiovascular disease
• Severe physiological stress or trauma, from serious injuries (like a vehicle accident, serious falls and collisions, suicide-attempts, assault, etc) and life-threatening diseases
• Stomach cancer
• Chemotherapy or radiation therapy for stomach cancer
• Crohn’s disease
• Zollinger-Ellison syndrome

Risk Factors

• An episode of PUD in the past
• Age: Being 65 years or more
• Long-term heavy smoking
• Frequent and heavy consumption of alcohol
• Untreated stress (physical, mental, emotional)
• Frequent consumption of spicy foods (not the cause of peptic ulcers as commonly believed, but a risk factor, as such foods increase inflammation in the stomach)

Symptoms

PUD can cause gastrointestinal bleeding, or perforations (holes) in the gastric lining, or both. The symptoms may be due to either or both outcomes.

• Blood in the stools
• Black or tarry stools
• Vomiting and nausea
• Vomits that are dark in colour like coffee grounds
• Dizziness or fainting (syncope)
• Pallor or pale skin
• Rapid heart-rate and/or chest pain
• Sudden and shooting pain in the abdomen
• Swelling in the abdomen
• Abdomen feels tender to touch and hurts easily
• Fever and chills
• Gas, bloated feeling and frequent burping
• Lack of appetite and resulting weight loss
• Unexplained weight-loss

Complications from severe PUD

• Internal bleeding: As the ulcers spread, they can rupture blood-vessels in the stomach, leading to internal bleeding. The bleeding may be slow and chronic leading to slow blood loss and hence anaemia. Or it can be rapid leading to severe blood-loss that will require hospitalization and/or a blood-transfusion. Such blood-loss can cause black or bloody vomit, and black or bloody stools.
• Perforation (a hole in the stomach wall): The ulcer can bore a hole in the wall of the stomach or small intestine. This puts the person at the risk of serious infections of the abdominal cavity which is called peritoneum, and the condition as peritonitis.
• Obstruction: The inflammation can cause swelling of the stomach wall. At the same time, the internal bleeding leads to scar-tissue developing. These 2 conditions cause obstruction to the free flow of food from stomach to duodenum. This results in vomiting and loss of appetite as the person feels full early on. Both these result in weight-loss.
• Gastric cancer: A severe bout of H pylori infection puts the person at high risk of gastric cancer.

Treatment

Medications resolve PUD in most of the cases. However, some of the complications from PUD may require medical procedures to correct the situation.

• Antibiotics: These medicines help fight infection due to H pylori or any other bacteria. Includes drugs such as Doxycycline, Amoxicillin, Clarithromycin and Metronidazole
• Cytoprotective agents: These create a coating around the GI lining and protect it from the peptic corrosion. Includes drugs such as Sucralfate, Bismuth subsalicylate and Misoprostol.
• Histamine receptor blockers (H2 blockers): These reduce the production of stomach acid by blocking the chemical that triggers the production. Drugs include Famotidine, Nizatidine and Cimetidine
• Proton pump inhibitors (PPIs): These reduce stomach-acid production and also coat the GI lining. Drugs include Esomeprazole, Rabeprazole, Dexlansoprazole, Pantoprazole, Omeprazole and Lansoprazole.
• Procedure for bleeding: An endoscopy will reveal the location of bleeding. Then using a minimally invasive procedure, the doctors will stop the bleeding either by cauterizing the wound or injecting medicines into it.
• Procedure for obstruction: If there is an obstruction at the start of the duodenum, it has to be cleared by suctioning the stomach which helps decompress it. In rare cases, open surgery may be required.

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