Definition of Ulcer

Ulcers are crater-like sores (generally 1/4 inch to 3/4 inch in diameter, but so
metimes 1 to 2 inches in diameter) which form in the lining of the stomach (call
ed gastric ulcers), just below the stomach at the beginning of the small intesti
ne in the duodenum (called duodenal ulcers) or less commonly in the esophagus (c
alled esophageal ulcers).
In general, ulcers in the stomach and duodenum are referred to as peptic ulcers.
Description of Ulcer
The stomach is a bag of muscle that crushes and mixes food with the digestive "j
uices" - hydrochloric acid and pepsin. If the lining of the stomach (or duodenum
) is damaged in one place or another, the acid and pepsin go to work on the lini
ng as they would on food, breaking it down as though to digest it.
An ulcer is the result of an imbalance between aggressive and defensive factors.
On one hand, too much acid and pepsin can damage the stomach lining and cause u
lcers. On the other hand (and more commonly), the damage comes first from some o
ther causes, making the stomach lining susceptible to even an ordinary level of
gastric acid.
If a person does not receive treatment for ulcers, it could lead to a bleeding u
lcer (the ulcer has eaten into blood vessels and the blood has seeped into the d
igestive tract), a perforated ulcer (the ulcer has eaten a hole in the wall of t
he stomach or duodenum and bacteria and partially digested food has spilled into
the hole, causing inflammation) or a narrowing and obstruction of the intestina
l opening preventing food from leaving the stomach and entering the small intest
ine.
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Causes and Risk Factors of Ulcer
The stomach defends itself from hydrochloric acid and pepsin by creating a mucus
coating (that shields stomach tissue), by producing bicarbonate and by circulat
ing blood to the stomach lining to aid in cell renewal and repair. If any of the
se functions are impaired it can lead to the formation of an ulcer.
The primary cause of ulcers is the bacterium called Helicobacter pylori (H. pylo
ri). H. pylori is a spiral-shaped bacterium found in the stomach. Unlike other b
acterium, H. pylori is able to twist through the layer of mucous that protects t
he stomach cavity and attach to cells on the surface of the stomach wall, where
it produces urease, an enzyme that generates ammonia.
Urease generates substances that neutralize the stomach's acid and allows H. pyl
ori to thrive. H. pylori weakens the stomach's defenses by thinning the mucous c
oating of the stomach, making it more susceptible to the damaging effects of aci
d and pepsin; inflaming the area; poisoning nearby cells and producing more stom
ach acid.
Although H. pylori is the primary cause of ulcers, there are other factors that
play a role in ulcer development. These factors are the use of nonsteroidal anti
-inflammatory drugs (NSAIDs), a person's lifestyle and the stomach's inability t
o defend itself against digestive fluids, hydrochloric acid and pepsin.
NSAIDs such as aspirin, ibuprofen (Motrin, Advil, Nuprin), naproxen (Naprosyn, A
naprox), or piroxicam (Feldene) interfere with the stomach's ability to produce
mucus and bicarbonate (a chemical produced in the stomach that neutralizes and b
reaks down the hydrochloric acid and pepsin into substances less harmful).
NSAIDs also affect blood flow to the stomach, hinder cell repair and cause the s
tomach's defense mechanisms to fail.
Lifestyle factors such as smoking, drinking caffeine, consuming alcohol and stre
ss are also associated with ulcers.
Smoking slows the healing of ulcers and makes them likely to recur.
Caffeine stimulates acid secretion in the stomach, thus aggravating the pain of
an existing ulcer.
Studies on alcohol consumption and ulcers have been less conclusive, although al
coholic cirrhosis has been linked to an increased risk of ulcers, and heavy drin
king has been shown to delay the healing of ulcers.
Although emotional stress is no longer thought to be a cause of ulcers, people w
ith ulcers often report that emotional stress increases ulcer pain. However, phy
sical stress increases the risk of developing gastric ulcers.
Symptoms of Ulcer
There may be no symptoms of ulcers or the individual may experience:
* A gnawing or burning pain in the abdomen between the breastbone and the na
vel. The pain is usually worse a couple of hours after a meal or in the middle o
f the night when the stomach is empty.
* Nausea
* Vomiting
* Loss of appetite
* Loss of weight
* Tiredness (a symptom of a bleeding ulcer)
* Weakness (a symptom of a bleeding ulcer)
* Blood in vomit or stool. When blood is in the stool, it appears tarry or b
lack (symptom of a bleeding ulcer).
Diagnosis of Ulcer
Doctors have a number of options available for diagnosing ulcers, such as perfor
ming endoscopic and x-ray examinations, as well as testing for H. pylori. Endosc
opy is a diagnostic procedure that gives the doctor a direct view of the upper d
igestive tract from within the body itself. By means of an instrument called a f
iber-optic endoscope, the doctor is able to illuminate and follow the same path
that food takes, examining the esophagus, stomach and duodenum from within. Alon
g the way, the doctor will look closely at inflamed, ulcerated or infected areas
, as well as growths and malformations.
If the doctor suspects ulcers, an upper GI (gastrointestinal) series (x-rays) of
the esophagus, stomach and duodenum will usually be performed. The patient will
swallow a chalky liquid that contains barium, which makes the ulcer visible on
the x-ray.
The doctor may also order a gastroscopy, in which a flexible tube-shaped device
with a special light-conducting properties will be put down the throat to enable
the doctor to see the ulcer and obtain tissue samples for microscopic examinati
on to determine if the ulcer is cancerous.
Confirming the presence of H. pylori is important in diagnosing an ulcer because
 elimination of H. pylori is likely to cure the ulcer. H. pylori can be detected
using a blood, breath or tissue test. The blood test uses a blood sample to ide
ntify and measure H. pylori antibodies. Approved in 1996, the Meretek UBT Breath
Test requires that a person first drink a liquid or swallow a capsule containin
g a small amount of a protein. The person is then asked to blow through a straw
into a balloon. A lab technician checks the exhaled air for evidence of the H. p
ylori bacteria. If the doctor previously performed an endoscopy, the tissue obta
ined through that procedure is cultured and watched for growth of H. pylori orga
nisms.
Treatment of Ulcer
Along with reducing stress and modifying lifestyle, doctors treat gastric and du
odenal ulcers with several types of medicines, including H2-blockers, proton-pum
p inhibitors and mucosal protective agents. When treating H. pylori, these medic
ations are used in combination with antibiotics. If medication is ineffective or
complications arise, surgery may be required.
Medications
H2-blockers reduce the amount of acid that the stomach makes. These medicines in
clude cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid) and nizatid
ine (Axid). A single bedtime dose starts healing a duodenal ulcer in four weeks
and a gastric ulcer in six to eight weeks.
Proton-pump inhibitors modify the stomach's production of acid by stopping the s
tomach's acid pump - the final step of acid secretion. The recently approved and
now available drug, omeprazole (Prilosec), is 10 times more powerful in suppres
sing stomach acid production than the H2-blockers, able to promote duodenal ulce
r healing in two to four weeks. This potent acid-inhibitor can suppress about 95
percent of stomach acid production. It is especially useful for treating people
whose ulcers fail to respond to H2-receptor blockers or other medications and t
hose with Zollinger-Ellison syndrome.
Mucosal protective agents protect the stomach's mucous lining from acid. The pre
scription medications are sucralfate (Sulcrate or Carafate) and misoprostol (Cyt
otec). The non-prescription medications are antacids (such as Tums and Rolaids)
and bismuth subsalicylate (Pepto-Bismol).
Antibiotics. With the discovery of the link between ulcers and H. pylori peptic
ulcers can be treated by a short course of combined high dose antibiotic therapy
rather than acid-suppression alone. Without antibacterial therapy, there is a 7
5 percent chance of the ulcer reoccurring. With antibacterial therapy, there is
a 1 percent chance of the ulcer reoccurring. There are two types of combination
therapies currenly being used: triple therapy and dual therapy.
Triple therapy involves:
* Metronidazole (Flagyl)*, an antibiotic taken four times a day
* Tetracycline (Achromycin or Sumycin)**, an antibiotic taken four times a d
ay
* Pepto-Bismol taken four times a day
This regimen lasts two weeks. This treatment is 90 percent effective in destroyi
ng the H. pylori bacteria and in reducing the risk of reoccurrence. (*doctor may
substitute amoxicillin (Amoxil or Trimox); **doctor may substitute clarithromyc
in (Biaxin))
Dual therapy involves:
 * Amoxicillin two to four times a day or Biaxin three times a day
* Prilosec two times a day
This regimen lasts two weeks. This treatment is 80 percent effective in destroyi
ng the H. pylori bacteria and in reducing the risk of reoccurrence.
Surgery
The most common types of surgery for ulcers are vagotomy, antrectomy and pylorop
lasty.
Vagotomy involves cutting the vagus nerve that transmits messages from the brain
to the stomach. This interruption reduces acid secretion.
Antrectomy removes the lower part of the stomach (antrum) which produces a hormo
ne that stimulates the stomach to secrete digestive juices. This enlarges the op
ening into the duodenum and small intestine (pyloris), enabling contents to pass
more freely from the stomach.
Pyloroplasty may be performed with a vagotomy.
Questions To Ask Your Doctor About Ulcer
Where is the ulcer located and how severe is it?
Will you be prescribing any medications?
What are the side effects?
How much of the over-the-counter antacids can be taken daily?
What are the best antacids to take?
Does diet affect the ulcer?
Are there some foods that should be?
Do you have any printed pamphlets on the foods to avoid?
Is milk helpful in relieving ulcer pain?
Are there any symptoms that may be serious and should be reported right away?
Will ulcers reoccur?