In general, an ulcer is any eroded area of skin or a mucous membrane, markedby tissue disintegration. In common usage, however, ulcer is usually used torefer to disorders in the upper digestive tract. The terms ulcer, gastric ulcer, and peptic ulcer are often used loosely and interchangeably. Peptic ulcers can develop in the lower part of the esophagus, the stomach, the first partof the small intestine (the duodenum), and the second part of the small intestine (the jejunum).
It is estimated that 2% of the adult population in the United States has active peptic ulcers, and that about 10% will develop ulcers at some point in their lives. There are about 500,000 new cases of peptic ulcer in the United States every year, with as many as 4 million recurrences. The male/female ratiofor ulcers of the digestive tract is 3:1.
The most common forms of peptic ulcer are duodenal and gastric. About 80% ofall ulcers in the digestive tract are duodenal ulcers. This type of ulcer maystrike people in any age group but is most common in males between the agesof 20 and 45. Gastric ulcers account for about 16% of peptic ulcers. They aremost common in males between the ages of 55 and 70. The single most common cause of gastric ulcers is the use of nonsteroidal anti-inflammatory drugs, orNSAIDs. The widespread use of NSAIDs is thought to explain why the incidenceof gastric ulcers in the United States is rising.
There are two major causes of peptic ulcers: Helicobacter pyloriinfection and certain types of medication.
Helicobacter pylori is a rod-shaped bacterium that lives in the mucoustissues that line the digestive tract. Infection with H. pylori is the most common cause of duodenal ulcers. About 95% of patients with duodenal ulcers are infected with H. pylori.
Nonsteroidal anti-inflammatory drugs, or NSAIDs, are painkillers that many people use for headaches, sore muscles, arthritis, menstrual cramps, and similar complaints. Many NSAIDs are available without prescriptions. Common NSAIDsinclude aspirin, ibuprofen (Advil, Motrin), flurbiprofen (Ansaid, Ocufen), ketoprofen (Orudis), and indomethacin (Indacin). Chronic NSAID users have 40 times the risk of developing a gastric ulcer as nonusers. Aspirin is most likely to cause ulcers.
Smoking increases a patient's chance of developing an ulcer, decreases the body's response to therapy, and increases the chances of dying from ulcer complications.
The symptoms of gastric ulcers include feelings of indigestion and heartburn,weight loss, and repeated episodes of gastrointestinal bleeding. Ulcer painis often described as gnawing, dull, aching, or resembling hunger pangs. Thepatient may be nauseated and suffer loss of appetite.
The symptoms of duodenal ulcers include heartburn, stomach pain relieved by eating or antacids, weight gain, and a burning sensation at the back of the throat. The patient is most likely to feel discomfort two to four hours after meals, or after having citrus juice, coffee, or aspirin.
Not all digestive ulcers produce symptoms; as many as 20% of ulcer patients have so-called painless or silent ulcers. Silent ulcers occur most frequentlyin the elderly and in chronic NSAID users.
Between 10-20% of peptic ulcer patients develop complications at some time during the course of their illness. All of these are potentially serious conditions. Complications are not always preceded by diagnosis of or treatment forulcers; as many as 60% of patients with complications have not had prior symptoms.
Bleeding is the most common complication of ulcers. It may result in anemia,vomiting blood, or the passage of bright red blood through the rectum. Abouthalf of all cases of bleeding from the upper digestive tract are caused by ulcers. The mortality rate from ulcer hemorrhage is 6-10%.
About 5% of ulcer patients develop perforations, which are holes in the duodenal or gastric wall through which the stomach contents can leak out into theabdominal cavity. The incidence of perforation is rising because of the increased use of NSAIDs, particularly among the elderly. The signs of an ulcer perforation are severe pain, fever, and tenderness when the doctor touches the abdomen. Most cases of perforation require emergency surgery. The mortality rate is about 5%.
The diagnosis of peptic ulcers is rarely made on the basis of a physical examination alone. The only significant finding may be mild soreness in the areaover the stomach when the doctor presses it. The doctor is more likely to suspect an ulcer if the patient has one or more of the following risk factors:
- Male sex
- Age over 45
- Recent weight loss, bleeding, recurrent vomiting, jaundice, back pain, or anemia
- History of using aspirin or other NSAIDs
- History of heavy smoking
- Family history of ulcers or stomach cancer.
An endoscopy is considered the best procedure for diagnosing digestive ulcersand for taking samples of stomach tissue for biopsies. An endoscope is a slender tube-shaped instrument that allows the doctor to view the tissues liningthe stomach and duodenum. Duodenal ulcers are rarely malignant.
Most doctors presently recommend treatment to eliminate H. pylori in order to prevent ulcer recurrences. Without such treatment, ulcers recur at the rate of 80% per year. The usual regimen used to eliminate the bacterium isa combination of tetracycline, bismuth subsalicylate (Pepto-Bismol), and metronidazole (Metizol).
The prognosis for recovery from ulcers is good for most patients. Very few ulcers fail to respond to the medications that are currently used to treat them.
Strategies for the prevention of ulcers or their recurrence include the following:
- Eradication of H. pylori in patients already diagnosed with ulcers
- Avoiding unnecessary use of aspirin and NSAIDs
- Giving up smoking
- Cutting down on alcohol, tea, coffee, and sodas containing caffeine.