Stomach ulcer

A stomach or gastric ulcer is a break in the tissue lining of the stomach. The term “peptic ulcer” covers ulcers that occur either in the stomach or in the first part of the small intestine that leads out of the stomach, called the duodenum.

It was once widely believed that stress, smoking and diet were the main causes of stomach ulcers. We now know that most are caused by infection with the Helicobacter pylori (H. pylori) bacterium or by anti-inflammatory medication. H. pylori also produces many of the symptoms of indigestion (dyspepsia). Treatment usually involves antibiotics to clear the infection together with acid-suppressing drugs.

Symptoms#

Some stomach ulcers produce no symptoms at all. When symptoms do occur, they can include:

• abdominal pain, usually just below the ribcage
• indigestion
• nausea
• loss of appetite
• vomiting
• weight loss
• bright or altered (dark) blood in vomit or in bowel motions
• symptoms of anemia, such as light-headedness
• shock due to blood loss, which is a medical emergency

How the stomach works#

The stomach is a muscular organ of the digestive system. Swallowed food is squeezed down the esophagus and pushed through a sphincter (a small ring of muscle) into the stomach, where it is mixed with powerful gastric juices containing enzymes and hydrochloric acid.

Because the stomach is a muscular bag, it can churn the food and break it down mechanically as well as chemically. Once the food has the consistency of a smooth paste, it is squeezed through a second sphincter into the duodenum. The stomach lining, known as the mucosa or gastric epithelium, is arranged in multiple folds. Ulcers form in this lining.

Causes#

A stomach ulcer can be caused by several factors:

• H. pylori infection is thought to be responsible for around 60% of stomach ulcers and at least 90% of duodenal ulcers.
• Anti-inflammatory medications (NSAIDs), such as aspirin and drugs used for arthritis, are thought to cause around two-fifths of stomach ulcers.
• Cancer can sometimes present as an ulcer, particularly in older people.

H. pylori, the main cause of peptic ulcers#

The discovery of this micro-organism in 1983 transformed many aspects of gastroenterology, including the treatment of stomach ulcers. Infection is uncommon in young adults and occurs in about 15 to 20% of people aged over 25.

The bacteria live on the surface cells of the stomach beneath a layer of mucus. They cause irritation by invading these surface cells, which then release chemicals (cytokines) that promote inflammation. H. pylori directly causes about one-third of stomach ulcers and is a contributing factor in around three-fifths of cases. It can also lead to inflammation of the stomach (gastritis) and dyspepsia.

H. pylori is also the main environmental cause of stomach cancer. Transmission may occur through sharing food or utensils, coming into contact with infected vomit, or sharing water (such as well water).

Complications#

Ulcer bleeding#

Bleeding is a serious complication of ulcer disease and can be particularly dangerous in older people or those with several other medical problems. It is more common in people taking blood-thinning agents such as warfarin, aspirin or clopidogrel. People on these medications may need to take regular anti-ulcer medication to help prevent bleeding.

Perforated ulcer#

A severe, untreated ulcer can sometimes burn through the wall of the stomach, allowing digestive juices and food to leak into the abdominal cavity. This medical emergency is known as a perforated ulcer and generally requires immediate surgery.

Diagnosis#

A stomach ulcer can be diagnosed using several methods:

• Endoscopy – a thin, flexible tube is threaded down the esophagus into the stomach under light anesthesia. The endoscope carries a video camera that gives highly detailed images of the stomach lining. If a gastric ulcer is found, the endoscopy is repeated after treatment to confirm healing and rule out cancer.
• Biopsy – a small tissue sample is taken during the endoscopy and tested in a laboratory. This should always be done if a gastric ulcer is found.
• Carbon-14 (C14) breath test – H. pylori converts urea into carbon dioxide. For this test you swallow a small amount of radioactive carbon (C14), and the air you breathe out is then tested. A non-radioactive version is used for children and pregnant women.

Treatment#

Special diets are now known to have very little impact on preventing or treating stomach ulcers. Treatment options can include:

• Medication, including antibiotics, to destroy H. pylori. Several drugs are used in combination. Side effects can include rashes and diarrhea. Resistance to some of these antibiotics is becoming more common, but about 80% of treatment courses are successful.
• Acid-reducing drugs to help speed healing.
• Subsequent breath tests to make sure the H. pylori has been cleared.
• Changes to existing medication, such as reviewing anti-inflammatory or blood-thinning drugs.
• Lifestyle changes, including quitting smoking.

Key points#

• H. pylori and anti-inflammatory medications, not stress or diet, cause most stomach ulcers.
• The bacterium also produces many symptoms of indigestion (dyspepsia).
• Treatment includes antibiotics to clear the infection together with acid-suppressing drugs.
• Some stomach ulcers produce no symptoms, while others can bleed, which is a medical emergency.

Where to get help#