During normal digestion, food moves from the mouth down the esophagus into the stomach. The stomach produces hydrochloric acid and an enzyme called pepsin to digest the food. From the stomach, food passes into the upper part of the small intestine, called the duodenum, where digestion and nutrient absorption continue.

An ulcer is a sore or lesion that forms in the lining of the stomach or duodenum where acid and pepsin are present. Ulcers in the stomach are called gastric or stomach ulcers. Those in the duodenum are called duodenal ulcers. In general, ulcers in the stomach and duodenum are referred to as peptic ulcers. Ulcers rarely occur in the esophagus or in the first portion of the duodenum, the duodenal bulb.

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Who has ulcers?

Ulcers can develop at any age, but they are rare among teenagers and even more uncommon in children. Duodenal ulcers occur for the first time usually between the ages of 30 and 50. Stomach ulcers are more likely to develop in people over 60. Duodenal ulcers occur more frequently in men than women; stomach ulcers develop more often in women than men.


What causes ulcers?

For almost a century, doctors believed lifestyle factors such as stress and diet caused ulcers. Later, researchers discovered that an imbalance between digestive fluids (hydrochloric acid and pepsin) and the stomach ability to defend itself against these powerful substances resulted in ulcers.

Today, research shows that most (80%-90%) of ulcers develop as a result of infection with bacteria called Helicobacter pylori (H. pylori). While all three of these factors- lifestyle, acid and pepsin, and H. pylori- play a role in ulcer development, H. pylori is now considered the primary cause.

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Risk factors for ulcers

Lifestyle
While scientific evidence refutes the old belief that stress and diet cause ulcers, several lifestyle factors continue to be suspected in playing a role. These factors include cigarettes, food and beverages containing caffeine, alcohol, and physical stress.

Smoking
Studies show that cigarette smoking increases one's chances of getting an ulcer. Smoking slows the healing of existing ulcers, and also contributes to ulcer recurrence.

Caffeine
Coffee, tea, colas, and food that contain caffeine seem to stimulate acid secretion in the stomach, aggravating the pain of an existing ulcer. However, the amount of acid secretion that occus after drinking decaffeinated coffee is the same as that produced after drinking regular coffee. Thus the stimulation of the stomach acid cannot be attributed solely to caffeine.

Alcohol
Research has not found a link between alcohol consumption and peptic ulcers. However, ulcers are more common in people who have cirrhosis of the liver, a disease often linked to heavy alcohol consumption.

Stress
Although emotional stress is no longer thought to be a cause of ulcers, people with ulcers often report that emotional stress increases ulcer pain. Physical stress, however, increases the risk of developing ulcers, particularly in the stomach. For example, people with injuries such as severe burns and people undergoing major surgery often require rigorous treatment to prevent ulcers and ulcer complications.

Acid and pepsin
Researchers believe that the stomach's inability to defend itself against the powerful digestive fluids, acid and pepsin, contributes to ulcer formation. The stomach defends itself from the fluids in several ways. One way is by producing a mucous- a lubricant-like coating that shields the stomach tissues. Another way is by producing a chemical called bicarbonate. The chemical neutralizes and breaks down digestive fluids into substances less harmful to the stomach tissue. Finally, blood circulation to the stomach lining, cell renewal, and cell repair also help to protect the stomach.

Nonsteriodal anti-inflammatory drugs
Nonsteroidal anti-inflammatory drugs (NSAIDs) make the stomach vulnerable to the harmful effects of acid and pepsin. NSAIDs such as aspirin, ibuprofen, and naproxen sodium are present in many non-prescription medications used to treat fever, headaches, and minor aches and pains. These, as well as prescription NSAIDs, used to treat a variety of arthritic conditions, interfere with the stomach's ability to produce mucous and bicarbonate and affect blood flow to the stomach and cell repair. They call all cause the stomach's defense mechanisms to fail, resulting in an increased chance of developing stomach ulcers. In most cases, these ulcers disappear once the person stops taking NSAIDs.

Helicobacter pylori
H. pylori is a spiral-shaped bacterium found in the stomach. Research shows that the bacteria (along with acid secretion) damage the stomach and duodenal tissue, causing inflammation and ulcers.

Review the H. pylori page for a full discussion of this risk factor for peptic ulcer disease.

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Symptoms of ulcers

The most common symptom of ulcers is a gnawing or burning pain in the abdomen between the breastbone and the naval. The pain often occurs between meals and in the early hours of the morning. It may last from a few minutes to a few hours and may be relieved by eating or taking antacids.

Less common ulcer symptoms include nausea, vomiting, and loss of appetite and weight. Bleeding from ulcers may occur in the stomach and duodenum. Sometimes people are unaware that they have a bleeding ulcer, because the blood loss is slow and blood may not be obvious in stool. Stool containing blood appears tarry or black.

It important to test for and treat peptic ulcer disease because ulcers increase the risk of stomach perforation (hole in the stomach) and peritonitis (inflammation of the abdominal cavity).

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Testing and treatment of ulcers

Ulcers can be detected with certain types of x-ray tests, and with endoscopy.

X-ray tests
A barium meal and upper G.I. series are both X-ray examinations and involve drinking barium, a contrast solution which allows the esophagus, stomach and intestines to show up against your other internal organs.

Endoscopy
Endoscopy involves swallowing a thin flexible tube with a video camera on the end. In upper endoscopy, your doctor can visualize the duodenum, the stomach and the esophagus and can take small biopsy (tissue) samples to diagnose disease that may only be detected under a microscope

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Treatment

The way peptic ulcer disease is treated depends on its cause and severity.

If you have an ulcer as a result of an H. pylori infection, clearing the infection, with a combination of antibiotic and antacid medication, usually results in curing peptic ulcer disease.

For those who develop ulcers as a result of the over-use or sensitivity to NSAIDs, these medication are commonly substitued with those that will not irritate the stomach lining.

When ulcers have resulted in complications and pharmaceutical treatments have been ineffective surgery can be an option. The different types if surgeries used to treat ulcers include; vagotomy, anterectomy and pyroplasty.

Vagotomy
A vagotomy involves cutting the vagus nerve, which is the nerve that transmits messages from the brain to the stomach. Interrupting the messages sent through the vagus nerve reduces acid secretion. This surgery may also interfere with the stomach emptying. The newest variation of the surgery involves cutting only those parts of the nerve that control the acid-secreting cells of the stomach, and avoiding those that control stomach emptying.

Antrectomy
An antrectomy involves removing the lower part of the stomach (antrum) which produces a hormone that stimulates the stomach to secrete digestive juices, and sometimes an adjacent part of the stomach which secretes pepsin and acid. This procedure is usually done in conjunction with a vagotomy.

Pyroplasty
Pyloroplasty is also sometimes done along with a vagotomy and involves enlarging the (pylorus) opening into the duodenum and small intestine enabling contents to pass more freely from the stomach.


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