ULCERS

DEFINITION

An ulcer is any break in the skin or in a mucous membrane. Mucous membrane is a thin tissue that lines the interior surface of body openings. The term ulcer is used most commonly to refer to ulcers that occur in the upper part of the digestive system, such as peptic ulcers. At one time, doctors believed that ulcers were caused by too much stress. However, it is now known that bacterial infection accounts for more than three-quarters of all peptic ulcers.

DESCRIPTION

Experts estimate that about 2 percent of the adult population in the United States have active ulcers and that about 10 percent of all adults will have an ulcer at some point in their lives. Males have about three times as many ulcers as females.

Ulcers are sometimes classified according to the part of the digestive system in which they occur. Gastric ulcers occur in the stomach. Duodenal ulcers occur in the duodenum. The duodenum (pronounced doo-uh-DEE-nuhm) is the upper part of the small intestine, adjacent to the stomach.

A peptic ulcer is one that occurs in the upper digestive tract, in which the break in the mucous membrane is exposed to gastric acidic secretion. About 80 percent of all peptic ulcers occur in the duodenum. They are most common among males between the ages of twenty and forty-five. Gastric ulcers account for about 16 percent of all peptic ulcers and are most common in males between the ages of fifty-five and seventy.

CAUSES

There are three major causes of peptic ulcers: infection, certain types of medications, and other medical problems that cause the release of too much stomach juices.

Helicobacter pylori is a bacterium that lives in mucous membranes in the digestive system. It causes about 95 percent of all duodenal ulcers and 70 percent of all gastric ulcers.

The use of nonsteroidal anti-inflammatory drugs (NSAIDS) also tends to cause ulcers. Nonsteroidal anti-inflammatory drugs are painkillers. People use these drugs for headaches, sore muscles, menstrual cramps, and similar complaints. Some common NSAIDS are aspirin, ibuprofen (pronounced i-byoo-PRO-fuhn, trade names Advil, Motrin), and acetaminophen (pronounced uhsee-tuh-MIN-uh-fuhn, trade name Tylenol). People who use NSAIDS on a regular basis are forty times more likely to get ulcers than those who do not. Aspirin is the NSAID most likely to cause ulcers. Aspirin should not be given to children because of the risk of Reye's syndrome (see Reye's syndrome entry).

Some medical problems can increase the risk of ulcers. For example, Zollinger-Ellison syndrome causes an unusually large release of digestive juices in the stomach and this excess secretion can create ulcers.

Other factors may also increase a person's risk for ulcers. For example, smokers are more likely to develop an ulcer and are also more likely to die from the complications of an ulcer. People with blood type A are more likely to have gastric ulcers, while those with type O are more likely to develop duodenal ulcers.

Scientists are still debating the role of stress in the formation of ulcers. Stress is no longer regarded as a primary cause of the disorder. But some specialists think that it may be a contributing factor.

SYMPTOMS

The symptoms of gastric ulcers include feelings of indigestion and heartburn, weight loss, and repeated cases of bleeding in the stomach. Ulcer pain is sometimes described as gnawing, dull, aching, or similar to hunger pangs. Patients may experience nausea or appetite loss. In many cases, ulcer pain comes and goes over long periods of time.

The primary symptoms of duodenal ulcers include heartburn, stomach pain, weight gain, and a burning feeling at the back of the throat. A patient is most likely to feel discomfort two to four hours after meals.

About 20 percent of all people with peptic ulcers experience no symptoms. This form of the condition is called painless or silent ulcers. Between 10 to 20 percent of all peptic ulcer patients develop complications at some time in their illness. All of these complications can be very serious. In many cases, complications appear without any other signs of an ulcer. Some common complications include:

• Hemorrhage. Bleeding is the most common complication of ulcers. If bleeding continues, a patient may become anemic. Anemia (see anemias entry) is a condition that develops when a person does not have enough red blood cells. It can lead to extreme tiredness, weight loss, and, in the worst cases, death. About 6 to 10 percent of all patients with a bleeding ulcer die of the problem.
• Perforation. A perforation is a hole in the wall of the stomach or intestine. The hole allows stomach fluids to leak out into the abdominal cavity. These fluids are very acidic and can cause serious damage to body tissues. The signs of perforation include severe pain, fever, and tenderness of the abdomen. About 5 percent of patients with a perforated ulcer die of the condition.
• Penetration. Penetration occurs when an ulcer spreads to some organ adjacent to the digestive system. It may affect the liver or pancreas, for example. Signs of penetration include severe pain that spreads to the lower back.
• Obstruction. Over time, ulcers can form scar tissue. In some cases, this scar tissue can block the opening between the stomach and the duodenum. Food is not able to move all the way through the digestive system. The most common symptom of an obstruction is vomiting. The vomiting is caused by undigested food expelled from the stomach. Obstruction occurs in about 2 percent of all ulcer patients.

DIAGNOSIS

The first indication of an ulcer is likely to be a patient's complaint about one or more of the described symptoms. When a patient visits a physician for diagnosis, a physical examination alone is not enough. A doctor will look for certain factors in the patient's history that may suggest the presence of an ulcer. These factors include:

• If the patient is male
• Age over forty-five
• Recent weight loss, bleeding, repeated episodes of vomiting, back pain, or anemia
• History of using aspirin or other NSAIDs
• History of heavy smoking
• Family history of ulcers or stomach cancer

Endoscopy (pronounced en-DOS-kuh-pee) is one of the best ways to diagnose an ulcer. An endoscope consists of a long, narrow tube that can be inserted down the patient's throat. The tube contains a light and a tiny camera at one end. The doctor can actually look at the interior walls of the stomach and duodenum. If necessary, tiny scissors may also be attached to the endoscope. The scissors can be used to cut off a small sample of mucous membrane, which can be examined for the presence of stomach cancer. About 5 percent of ulcers develop into stomach cancer.

Imaging techniques can also be used to diagnose ulcers. These techniques are not as reliable as endoscopy but they are more comfortable for the patient. Imaging requires the patient to drink a fluid containing a substance that is opaque, or nontransparent, to X rays. An X-ray photograph is then taken of the patient's digestive system. The opaque substance appears as a white patch on the photograph and shows any abnormal structures, such as an ulcer, that may be present.

Blood tests are usually not very helpful in diagnosing ulcers. However, they may indicate when a patient has become anemic because of a bleeding ulcer.

The most important laboratory tests to perform are those that detect the Helicobacter pylori bacterium. One such test is a breath test. A patient is given a drink containing a radioactive substance that the bacterium will react with if it is present. The patient is then asked to breathe into a mechanism that determines whether the patient's breath is radioactive. If it is, that means the bacterium is present. This kind of test is important since the vast majority of people with ulcers are infected with Helicobacter pylori.

TREATMENT

Many symptoms of ulcers can be treated with over-the-counter medications. These medications may relieve the pain, nausea, and general discomfort caused by ulcers. However, they do not cure the disorder.

Illustration of the stomach with peptic ulcers. A peptic ulcer is one that occurs in the upper digestive tract. (Reproduced by permission of

Electronic Illustrators, Inc.

)

Two other types of medications are designed to reduce the symptoms of ulcers. Antisecretory drugs are drugs that reduce the amount of acid produced in the stomach. Acid attacks mucous membranes and can produce ulcers, so by lowering the amount of stomach acid released, the risk of ulcer formation can be reduced.

Protective drugs are also used to treat ulcers. A protective drug is a substance that forms a thin lining over mucous membranes, which protects the mucous membranes from attack by stomach acid.

Surgery is generally not used to treat ulcers. However, some of the complications caused by ulcers may require surgery. For example, doctors may cut the vagus nerve to the stomach. The vagus nerve (pronounced VAY-guhss) controls the release of stomach acid. After the cut, less stomach acid will be released, thus reducing the risk of ulcer formation.

One direct method for treating ulcers is to kill the bacteria that is responsible for most the vast majority of deaths caused by ulcers. Unless these bacteria are eliminated from the digestive system, ulcers will come back again and again. The drug used to kill Helicobacter pylori is the antibiotic tetracycline (pronounced tet-ruh-SI-kleen).

Alternative Treatment

Herbalists believe that a variety of natural products can help heal ulcers. For example, they recommend raw cabbage juice to help heal an ulcer. Some herbs that may soothe the symptoms of ulcers include plantain, marsh mallow, slippery elm, geranium, and goldenseal. Nutrition experts recommend taking certain vitamins and minerals, including vitamins A, C, and E, and the minerals zinc and selenium.

PROGNOSIS

The prognosis for recovery from ulcers is good for most patients. Nearly all ulcers respond to the medications now used to treat them. The rate of recurrence of ulcers can be cut to 5 percent through the elimination of the Helicobacter pylori bacterium.

PREVENTION

Methods for preventing ulcers include the following:

• Elimination of the Helicobacter pylori bacterium
• Avoiding unnecessary use of aspirin and other NSAIDs
• Giving up smoking
• Cutting down on alcohol, tea, coffee, sodas, and other products that contain caffeine

FOR MORE INFORMATION

Books

Ostrov, Rikki. Ulcers: A Guide to Diagnosis, Treatment and Prevention. Thorsons Publications, 1996.

Thompson, W. Grant. The Ulcer Story: The Authoritative Guide to Ulcers, Dyspepsia, and Heartburn. New York: Plenum Press. 1996.

Organizations

American College of Gastroenterology. 4900-B South 31st Street, Arlington, VA 22206-1656. (703) 820-7400.

American Gastroenterological Association. 7910 Woodmont Avenue, #914, Bethesda, MD 20814. (800) 668-5237. http://www.gastro.org.

International Foundation for Functional Gastrointestinal Disorders. PO Box 17864, Milwaukee, WI 53217. (888) 964-2001.