Peptic ulcers occur when stomach acid and other digestive juices erode the inner lining of the stomach or the first part of the small intestine. This inner lining is a complex mucous barrier that protects the gastrointestinal (GI) lining from the corrosive acids and other chemicals that the stomach produces to digest food. When the barrier breaks down, the lining is exposed to the destructive potential of the digestive juices.

For many years, scientists believed that acidic foods and stress caused peptic ulcers and treated the ulcers with surgery and medications to lessen the symptoms. However, research conducted in the 1980s revealed that the most common cause of peptic ulcers is infection by bacteria called Helicobacter pylori, which can survive in the acidic environment of the stomach. The bacteria can produce a change in the mucous barrier, which causes ulcers.

In addition to bacteria, some medications that irritate the GI lining can also cause peptic ulcers. For example, chronic use of pain relievers such as nonsteroidal anti-inflammatory drugs (NSAIDs) may alter the balance of the mucous barrier in the stomach and make it more susceptible to ulcers.

For both of these major causes of peptic ulcers (bacteria and medications), the mechanisms are not well understood. Each has been identified as a cause, but many people carry the bacteria or take NSAIDs and do not develop ulcers.

The most common symptom of peptic ulcer is mild to moderately severe pain just below the breastbone.  The pain often occurs once or a few times daily, typically two to three hours after eating. It generally lasts from one to several weeks, then disappears for a while. Other symptoms may include heartburn and nausea and vomiting. Some people may experience no symptoms and become aware of their ulcers when complications develop. Potential complications of peptic ulcers include bleeding, penetration to other organs, perforation and obstruction.

Peptic ulcers are usually diagnosed following an evaluation of medical history, a physical examination and diagnostic tests. Some physicians may simply treat for peptic ulcers if a patient’s medical history and physical examination strongly suggest their presence. However, tests are usually needed to confirm the diagnosis and determine the cause of the ulcers. A common testing procedure is endoscopy, in which a flexible tube with a camera is inserted through the mouth and down to the stomach to view the lining.

A peptic ulcer is a sore that forms in the gastrointestinal tract. Peptic ulcers occur when stomach acid and digestive juices break down and corrode the lining of the esophagus, stomach or duodenum, the upper portion of the small intestine. Peptic ulcers get their name from pepsin, one of the stomach enzymes that helps digest food. Although many people think that peptic ulcers occur only in the stomach, the majority of them occur in the duodenum.

The stomach and the surrounding portions of the GI tract provide a delicately balanced environment to process food. Strong acids and other chemicals in the stomach break down food into more basic components that can move through the digestive system. These chemicals, or gastric juices, are also strong enough to damage the lining that protects the stomach and other GI organs. A complex, multilayered coating forms a barrier to protect the lining.

This barrier is composed of many elements, including mucus, bicarbonate and chemicals called prostaglandins. Any change among the balance of these elements can weaken the barrier, allowing gastric juices to damage the underlying tissue. At first this damage may only irritate or inflame the lining, a condition called gastritis. Eventually enough corrosion forms a sore called a peptic ulcer.

Most peptic ulcers are the size of a pencil eraser or smaller. Peptic ulcers may heal on their own, only to recur after some time. Peptic ulcer disease refers to a tendency to develop these recurrent ulcers.

Peptic ulcers are quite common. According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), one in every 10 Americans will develop a peptic ulcer at some time in their lives. Duodenal ulcers occur most frequently in patients between the ages of 30 and 50 years and are twice as common in men as in women, according to the American College of Gastroenterology (ACG). Gastric ulcers tend to occur after the age of 60 years and are more common in women.

Peptic ulcers are generally referred to by their locations and sometimes by how they were formed. Different types of peptic ulcers include:

• Duodenal ulcers. This most common type of peptic ulcer forms in the duodenum.
  
  
• Gastric ulcers. Occur in the stomach, usually along the upper curve of the stomach.
  
  
• Esophageal ulcers. Occur in the lower section of the esophagus, where they form when stomach acid backs up or refluxes into the esophagus.
  
  
• Stress ulcers. May develop in the stomach or duodenum following severe illness, injury or trauma, such as severe burns or peritonitis.
  
  
• Marginal ulcers. Also known as anastamotic ulcers, these may occur following the removal of part of the stomach (partial gastrectomy), where the remaining stomach connects to the small intestine.

Peptic ulcers sometimes produce no symptoms, and as a consequence, may go undetected while they worsen. Left untreated, ulcers continue to corrode the GI lining and may eventually lead to serious complications. Potential complications of peptic ulcers include:

• Hemorrhage (bleeding). Bleeding ulcers may not produce pain, but may include hematemesis (vomiting blood), melena (black, tarry stool), dizziness and fainting.
  
  
• Penetration. An ulcer cuts through the wall of the stomach or duodenum and continues into a nearby organ (e.g., liver, pancreas).
  
  
• Perforation. An ulcer cuts through the stomach or duodenum wall and creates a direct opening to the abdominal cavity (peritoneum), allowing the contents of the organ to spill out. This invasion of the peritoneum may lead to an infection or inflammation called peritonitis, which can be fatal if left untreated.
  
  
• Obstruction. Swelling or scarring around an ulcer narrows the opening from the stomach to the duodenum, preventing food from properly passing through. Patients often vomit large volumes of food eaten hours before.

For many years, physicians thought that stressful lifestyles and diets containing spicy foods contributed to the corrosion that causes peptic ulcers. In the 1980s, physicians identified the Helicobacter pylori (H. pylori) bacterium, which has since been associated with most peptic ulcers. H. pylori infection causes almost two-thirds of all peptic ulcers, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Unlike most bacteria, H. pylori are able to survive and even thrive in the highly acidic gastric (stomach) environment. They grow in the mucous barrier that protects the gastrointestinal (GI) lining from the digestive juices. H. pylori bacteria also produce large amounts of urease, an enzyme that breaks down to form ammonia. Ammonia neutralizes the acidity around the bacteria, further protecting them.

H. pylori interferes with the mucosal defenses against the digestive juices, as well as producing its own toxins. Further, chronic infections cause the overproduction of stomach acid, which may irritate and break down the weakened stomach lining. H. pylori infection also causes gastritis, an irritation of the GI lining, which sometimes develops before a peptic ulcer.

Any contact that transports H. pylori bacteria to the stomach may produce H. pylori infection. However, the mechanisms of H. pylori action on the GI lining are not well understood. Many people harbor the H. pylori bacteria, but not all of them develop peptic ulcers or gastritis. H. pylori can be passed through food, water or close contact with a person who has the bacteria. In addition to the stomach, H. pylori bacteria have been found in saliva and feces.

Nearly two-thirds of the world’s population carries the H. pylori bacteria, according to the U.S. Centers for Disease Control and Prevention. In the United States, the bacteria occur more commonly in older adults, African Americans and Hispanics.

Nearly all peptic ulcers that are not caused by H. pylori bacteria result from the use of certain medications. Many medications may irritate the GI lining and cause peptic ulcers. Certain pain relievers called nonsteroidal anti-inflammatory drugs (NSAIDs) are most likely to do so, especially with chronic use. These commonly used pain relievers (including aspirin and ibuprofen) reduce the action of prostaglandins, one of the components of the mucous barrier in the stomach. Other medications, including corticosteroids, may also lead to the formation of peptic ulcers. However, not all people taking these medications develop ulcers.

Almost all cases of peptic ulcers are caused by either H. pylori bacteria or the use of anti-inflammatory medications. A few cases may be attributed to other causes such as severe stress resulting from significant illness or injury (e.g., kidney failure, severe burns, peritonitis). Such stress may cause decreased blood flow to the organ lining and impair the healing ability of the mucous barrier. Although rare, cancerous tumors in the stomach or pancreas may also cause peptic ulcers.

In addition to the known causes of peptic ulcers, certain risk factors have been identified for their development. These include:

• Family history of peptic ulcers. Heredity may predispose a patient to peptic ulcer formation.
  
  
• Age. The risk of peptic ulcers increases with age. The ability of the stomach lining to resist damage decreases with age. In addition, older people are more likely to harbor the H. pylori bacteria and take more NSAIDs for medical conditions.
  
  
• Personal differences in stomach acid production. Some people normally produce a lot of stomach acid and some produce much less. Those who produce more have a greater risk of peptic ulcers.
  
  
• Substance abuse. Excessive alcohol consumption, cigarette smoking or illicit drug use can weaken the stomach lining’s defenses against digestive acids. Smoking also makes ulcers heal much more slowly.
  
  
• Diet. Although diet does not directly cause peptic ulcers, it may increase the risk of developing them and make them worse. Many foods (especially those that are spicy, acidic, fried or fatty) may irritate the stomach lining.
  
  
• Stress. Even minor stresses can increase the production of stomach acids and slow digestion, increasing the risk of peptic ulcers and making existing ulcers worse.

Symptoms of peptic ulcers may vary greatly from person to person. Children and the elderly tend to have symptoms that do not follow the usual patterns or no symptoms at all. Patients who are very ill or taking corticosteroids may have less intense symptoms. When symptoms are absent, peptic ulcers may only be discovered when complications, which can be potentially life-threatening, arise. However, most peptic ulcers are cured without the development of complications.

The most common symptom of peptic ulcers is pain just below the breastbone. It is usually a steady, burning or gnawing sore pain or dull pain. It generally only lasts for minutes but may wake the patient up at night. The pain often occurs once or a few times daily, typically two to three hours after eating and usually lasts for one to several weeks. In some cases, pain may disappear and recur. Drinking or eating generally relieves the pain briefly because it helps buffer the stomach acid. However, it may actually make the pain worse over time.

Some other symptoms associated with peptic ulcers include:

• Nausea and vomiting
• Hunger or loss of appetite
• Weight loss or gain
• Fatigue

These symptoms, especially nausea and vomiting, may occur after eating.

Peptic ulcers with complications such as bleeding or perforation may produce other symptoms. Some of these include:

• Bleeding ulcers may cause hematemesis (vomiting blood), melena (black, tarry stools), dizziness and fainting. When vomiting blood, the blood may be bright red or there may be reddish brown clumps of partially digested blood resembling coffee grounds.
  
  
• An ulcer that penetrates to another organ may cause pain that radiates to other areas and worsens with motion.
  
  
• A perforated ulcer that spills stomach contents into the abdomen can produce radiating pain, difficulty breathing and fever.
  
  
• An ulcer that obstructs the opening to the small intestine may cause vomiting. Patients often vomit large volumes of food eaten hours before. Prolonged obstruction with frequent vomiting may lead to weight loss, dehydration and an imbalance of electrolytes. Obstruction may also result in pain and cramping, feeling unusually full after eating small amounts, bloating, loss of appetite, constipation or diarrhea.

It is important for patients experiencing symptoms of a peptic to consult a physician (often a gastroenterologist) because ulcers may not heal properly without medical attention. Peptic ulcers are usually diagnosed following an evaluation of medical history, a physical examination and diagnostic tests. Some physicians and gastroenterologists may simply treat a patient for peptic ulcers if the medical history and physical exam strongly suggest their presence. This is particularly likely if the patient is experiencing the characteristic abdominal pain. However, tests are usually needed to confirm the diagnosis and determine the cause of the ulcers.

Endoscopy is usually the first test used to diagnose peptic ulcers. While the patient is mildly sedated, a tiny camera attached to a thin tube is inserted through the mouth and esophagus into the stomach and duodenum. Endoscopy can be used to view the lining and sometimes obtain a tissue sample. The biopsy, or laboratory examination, of this tissue sample can be used to determine if an ulcer is cancerous or to identify an infection with the Helicobacter pylori (H. pylori) bacteria.

Barium x-rays may also be used to determine the severity and size of an ulcer. In an upper GI barium test, the patient consumes barium before an x-ray is performed. Barium acts as a contrast medium to make the intestinal organs stand out better on an x-ray. Barium x-rays were formerly the most commonly used diagnosis method for peptic ulcers. However, endoscopy has proven more reliable, especially in detecting smaller ulcers. In addition, endoscopy provides the option of removing tissue for biopsy.

Other tests may also be used to help determine the particular cause of peptic ulcers. Blood tests may be used to detect anemia and antibodies to H. pylori infections. The presence of these antibodies demonstrates that the patient has been infected at some point in the past. It does not necessarily indicate a current infection. Breath tests may be used to measure the activity of urease, an enzyme produced by H. pylori. Fecal tests may be used to detect active infections of H. pylori and signs of gastrointestinal bleeding that may not otherwise be noticeable.

In addition, researchers are currently investigating easier and more cost effective methods of identifying the presence of H. pylori bacteria. One such method that shows a great deal of promise is a simple string test in which patients swallow a capsule that contains a string. A portion of the string is held outside the patient’s mouth, allowing for easy retrieval. The string is then removed from the mouth and analyzed for the presence of the bacteria.

Treatment regimens for peptic ulcers have changed since the identification of Helicobacter pylori (H. pylori) bacteria as the cause of most ulcers. As a result, most peptic ulcers today are relatively easy to cure with medications.

Medications are used to treat the bacterial infection and neutralize or reduce the amount of stomach acids to help healing. Neutralizing or reducing stomach acid helps peptic ulcers heal regardless of their cause. Ulcers caused by medication use generally heal when the medications are discontinued. However, in some cases, symptoms may continue for a while after ulcers are healed.

When peptic ulcers are caused by H. pylori bacteria, antibiotics are used. Two different antibiotics are generally required for one to two weeks. They are usually combined with other medications such as proton pump inhibitors (PPIs), which decrease acid production and aid in healing of the ulcer. According to the American College of Gastroenterology, antibiotics can cure 80 to 90 percent of peptic ulcers. Antibiotics must be taken for the full prescribed period to ensure that the infection is completely gone. Otherwise, recurrence is likely.

Other medications treat symptoms and the lining damage caused by the ulcer. Most medications are used for four to eight weeks. When symptoms are mild, antacids may suffice. These medications neutralize the hydrochloric acid in the stomach. Most are available without a prescription. They need to be taken several times a day and may cause diarrhea or constipation in some people. Although antacids may help reduce symptoms, they do not help to actually heal the ulcer.

Medications that reduce the production of stomach acid are typically taken once or twice a day and can rapidly heal ulcers. These include H2 blockers, which work by blocking histamine, a chemical that stimulates acid secretion. PPIs block the action of the “pumps” in the cells that secrete acid. They are stronger than H2 blockers and may also inhibit the activity of the H. pylori bacteria. Research suggests that PPIs may also reduce bleeding related to peptic ulcers as well as a patient’s need for surgery. However, studies show that use of PPIs may result in increased risk of infection with another bacterium (Clostridium difficile) and increased risk of hip fracture.

Cytoprotective agents are medications that protect the stomach lining. They generally work by forming a protective coat over the base of an ulcer to help ease symptoms and promote healing. These medications are generally taken two to four times per day.

Patients who have peptic ulcers caused by medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) should stop taking those medications. In addition, H2 blockers, PPIs and cytoprotective agents may also be used. If the NSAIDs cannot be discontinued, a physician can treat the ulcer with medications and monitor any further damage caused by the NSAIDs.

Physicians (often gastroenterologists) may recommend a bland diet for patients with peptic ulcers. Foods that irritate the stomach lining may need to be identified and eliminated from the diet, especially those that are spicy, acidic, fried or fatty. However, these measures may not actually help speed healing of ulcers.

It is important for patients with peptic ulcers to avoid other irritants, as well. Medication therapies for other conditions that irritate the gastrointestinal lining may need to be altered. Patients are advised to avoid alcohol and those who smoke are encouraged to quit. Cigarette smoking slows the healing of ulcers and is linked to recurrence.

The bleeding that may accompany ulcers usually stops on its own. However, if it persists, it can often be treated during endoscopy, either by cauterizing (heat-sealing) the bleeding site or injecting a clotting agent into it.

Surgery is rarely used for peptic ulcers today. It may be used in cases of severe, repeated episodes, to treat complications or as therapy for cancerous ulcers. When peptic ulcers perforate the organ wall and cause peritonitis, immediate surgery is required. In some cases, ulcers may recur even after they have been surgically treated. Possible surgeries for peptic ulcers include:

• Ulcer surgery. Ulcers can be closed and patched in either a standard, open surgical procedure or by using a laparoscope. This involves several small incisions to insert delicate tools instead of a single large incision.
  
  
• Vagotomy. In rare cases, this surgery is used to cut a specific nerve that stimulates the production of stomach acid, resulting in a decrease of such acid. This reduces the chance of developing peptic ulcers.
  
  
• Partial gastrectomy. Part of the stomach is surgically removed. This removes the sites of frequent ulcer formation. It may be used when an ulcer does not respond to medical treatment or for complications such as an obstruction or perforation.

Some people may be able to prevent peptic ulcers. Prevention tips include:

• Diet and eating habits. Small, frequent meals are gentler on the stomach than occasional, large meals. Bland diets may not actually prevent ulcers, but can help reduce stomach acid and may minimize ulcer damage. Foods that irritate the lining of the stomach, especially those that are spicy, acidic, fried or fatty, can usually be avoided. Recent research also suggests that consuming vitamin C may also inhibit the growth of Helicobacter pylori (H. pylori) bacteria.
  
  
• Substance avoidance. Alcohol and cigarette smoking can irritate the stomach and reduce digestion and healing times. Avoiding these substances helps to prevent peptic ulcers.
  
  
• Medication awareness. Medications that irritate the stomach lining, such as nonsteroidal anti-inflammatory drugs (NSAIDs) can usually be avoided. COX-2 inhibitors are a type of NSAID that is less likely to irritate the stomach. However, these drugs may increase the risk of heart attack and stroke with long-term use. When these medications cannot be avoided, their potential to cause peptic ulcers may be negated by using medications that reduce the production of stomach acid and protect the lining of the stomach and duodenum (e.g., proton pump inhibitors). Patients should consult their physician about medications that may have fewer damaging effects on the gastrointestinal tract.
  
  
• Stress management. Stress causes irritation to the lining of the stomach and duodenum. There are a number of stress management and relaxation techniques available to reduce this risk factor and help to prevent peptic ulcers.

Scientists recently discovered that a protein called decay-accelerating factor (DAF), which is found in epithelial cells, acts as a receptor for H. pylori bacteria. This discovery may lead to the development of new medications to prevent peptic ulcers from forming.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following peptic ulcer-related questions:

1. Are you certain that I have a peptic ulcer?
   
   
2. What kind of peptic ulcer do I have?
   
   
3. What may have caused my peptic ulcer?
   
   
4. Do I need to change my diet? Should I see a dietician?
   
   
5. I take aspirin on my doctor's advice. What can I do to reduce the risk of ulcers?
   
   
6. Does it seem like I have any complications?
   
   
7. Which medication do you recommend for me?
   
   
8. For how long will I have to take this medication?
   
   
9. How many times a day will I have to take this medication?
   
   
10. How can I prevent peptic ulcers?