Gastric (Stomach) Ulcers
Stomach ulcers, also known as
gastric ulcers, are open sores that develop on the lining of the stomach. Similar ulcers can occur in bit of
intestine just beyond the stomach, known as duodenal ulcers. Both stomach and duodenal ulcers are
sometimes referred to as peptic ulcers. Here the term “stomach ulcer” will be
used, although the following information applies equally to duodenal ulcers.
The most common symptom of a stomach
ulcer is a burning or gnawing pain in the centre of the abdomen. Read more
about the symptoms of a stomach ulcer.
There are two main causes of stomach
ulcers:
- Helicobacter pylori (H. pylori) bacteria,
which can irritate the stomach or upper intestine lining, causing an ulcer
to form
- non-steroidal anti-inflammatory drugs
(NSAIDs), such as ibuprofen or aspirin, which can have a similar effect.
Stomach ulcers are common. In England,
it is estimated that about 1 in 10 people will have a stomach ulcer
during some point in their life. Stomach ulcers can affect people of any
age, including children, but mostly people aged 60 or over.
Medication can be used to treat stomach
ulcers. A type of medication known as a proton pump inhibitor is usually used
to reduce the amount of acid in your digestive system, allowing the ulcer to
heal. If an H. pylori infection is
responsible for the ulcers, a combination of antibiotics can be used to kill
the bacteria and this will prevent the ulcer coming back.
If the ulcers are related to the use of
NSAIDs, NSAIDs are usually stopped and the ulcer is healed using proton pump
inhibitors. In the case of aspirin-induced ulcers the aspirin sometimes needs
to be continued, depending on the reason it is being given. Your doctor will advise you on your
particular case.
Complications of a stomach ulcer are
uncommon, affecting around 1 in 50 people.
However, they can be serious and include:
However, they can be serious and include:
- bleeding at the site of the ulcer
- the stomach lining at the site of the ulcer
splitting open – this is known as perforation
- the ulcer blocking the movement of food
through the digestive system – this is known as gastric obstruction.
Some of these complications are
regarded as medical emergencies, although they are rarely life-threatening.
Older people aged over 70 are most at risk of experiencing a fatal
complications of a stomach ulcer.
If the underlying causes of a stomach
ulcer are addressed, the ulcer usually goes away after treatment. However,
new ulcers can sometimes form so it's important to address the
underlying cause of any ulcers.
Schematic diagram showing gastric (stomach) and duodenal (small intestine) ulcers.
Causes
Stomach ulcers are usually caused by
one of the following things:
- H. pylori bacteria
- non-steroidal anti-inflammatory drugs (NSAIDs).
The stomach produces acid to digest
food. The lining of the stomach is coated
with mucus, which protects the lining from the harmful effects of the acid. H. pylori and NSAIDs can break down the
stomach's defence against acid, allowing the acid to cause an ulcer. Even
though most people with ulcers are not producing too much acid, blocking the
acid will allow the ulcer to heal and then the cause of the ulcer can be removed
to prevent it coming back.
Helicobacter pylori (H. pylori)
infections are very common, and it's possible to be infected without realising
it because the infection doesn't usually cause symptoms. It is not known why some people are
vulnerable to the effects of H. pylori when the majority of people are not.
However, smoking is a major risk factor that people can do something about.
Also, stomach ulcers are known to run
in families, so there may be genetic factors that make certain people more
sensitive to H. pylori. Some strains of H.pylori are more damaging than others.
Schamatic diagram of Helicobacter Pylori.
Non-steroidal anti-inflammatory drugs
(NSAIDs) are medicines commonly used to treat:
- pain – such as toothache, headache, joint
pain and period pain
- high temperature (fever)
- inflammatory conditions – conditions that
cause painful inflammation of the joints, such as rheumatoid
arthritis.
Some people with cardiovascular
disease (conditions that affect the heart and the blood) also take aspirin on a
regular basis because it can reduce the risk of blood clots which can
cause heart attacks and strokes. NSAIDs that are available over the
counter include:
- ibuprofen
- aspirin
- naproxen
NSAIDs that are only available on
prescription include:
- diclofenac
- etodolac
- fenoprofen
Because of the risk of getting stomach
ulcers, you may be advised not to use NSAIDs if you currently have a stomach
ulcer or if you have had one in the past. Paracetamol can often be used as an alternative painkiller as it is safer.
However, there may be cases where the
benefits of taking NSAIDs is thought to outweigh the risk of developing stomach
ulcers. For example, if you have recently had a heart attack, low-dose aspirin
may be required to prevent you having another one. In such circumstances, a medication
called a proton pump inhibitor (PPI) can be used to reduce the amount of acid
in your digestive system, which should help prevent ulcers from forming and
reduce the risk of complications.
Diagnosing a stomach ulcer
Your family doctor may suspect that you have an
ulcer based on your symptoms. In most cases they will then either treat you
with an acid-suppressing medication or test for H. pylori and treat it, or
both. You may be referred for an endoscopy to
look inside your stomach directly to see whether you have a stomach ulcer.
The procedure (called a
diagnostic gastroscopy) is carried out in hospital and involves
passing a thin, flexible tube (an endoscope) with a camera at one end into your
mouth, through your gullet and into your stomach and duodenum. The images taken by the camera will
usually confirm or exclude an ulcer without the need for further tests. During the procedure the specialist may
also take a tissue sample from your stomach or duodenum. The sample can then be
tested for the H. pylori bacteria.
A diagnostic gastroscopy isn't painful
but some people find the experience uncomfortable. You can have your throat
numbed with a local anaesthetic spray or you can be sedated. Sedation makes you very drowsy so that
you have little or no awareness of the gastroscopy being carried out. If you
choose to have sedation, you will need to arrange for someone to give you a
lift home after the procedure and to stay with you for at least 12 hours
afterwards. If you decide to have a local
anaesthetic, you can leave hospital as soon as the procedure has been
completed. You can resume normal activities within one-to-two hours.
Schematic diagram showing an oesophago-gastro-duodeno-scopy (OGD).
If your doctor thinks that your symptoms
may be due to an H. pylori infection (which would usually be the case if you
don't have recent history of taking non-steroidal anti-inflammatory drugs), you
may need to have one of several possible further tests. These include:
- A urea breath test –
you will be given a special drink that contains a chemical that is
digested by H. pylori. Analysis of your breath after having the drink
indicates whether or not you have an H. pylori infection.
- A stool antigen test –
a pea-sized stool sample will be tested.
- A blood test – a sample of your blood
will be tested for antibodies to the H. pylori bacteria. Antibodies are
proteins that are produced naturally in your blood and help fight
infection.
If you test positive for H. pylori, you
will need treatment to clear the infection. This can heal the ulcer and, even
more importantly, prevent it from coming back.
Treating a stomach ulcer
If you have a stomach ulcer, your
treatment will depend on whether the cause is an H. pylori
infection, non-steroidal anti-inflammatory drugs (NSAIDs) or both. If your stomach ulcer is caused by an
H. pylori infection, a course of antibiotics is recommended. This is known as
eradication therapy because it will kill the bacteria.
If your stomach ulcer is caused by
NSAIDs and you don't have a H. pylori infection, a one-to two-month course of
proton pump inhibitors (PPIs) are recommended. Your use of NSAIDs will also
need to be reviewed and an alternative painkiller, such as paracetamol, may be
recommended. If it is thought that your stomach
ulcer is caused by a combination of NSAID use and an H. pylori infection, you
will be given a two-month course of PPIs and a course of eradication therapy. An alternative type of medication,
known as H2-receptor antagonists, are sometimes used instead of PPIs.
Eradication therapy involves taking a
combination of two or three different antibiotics and a proton pump inhibitor
(PPI), all at the same time. Taking one antibiotic alone is insufficient to
kill the germ.You will usually be asked to take each antibiotic twice a day for
7-14 days. The antibiotics most commonly used in eradication therapy are:
- amoxicillin
- clarithromycin
- metronidazole.
The side effects are usually mild and
include:
- feeling sick
- diarrhoea
- a metallic taste in your mouth
- grey colouring of saliva or your stools.
Try to persist with treatment if you
only have mild side effects. Stop if you have severe watery diarrhoea or an
obvious allergic reaction. You will be re-tested at least four
weeks after eradication therapy has been completed to see whether there are any
H. pylori bacteria left in your stomach. If there is, you will be given a
further course of eradication therapy using different antibiotics in
combination with PPIs.
Proton pump inhibitors (PPIs)
Proton pump inhibitors (PPIs) work by
blocking the actions of proteins called proton pumps, which are partially
responsible for producing stomach acid. Reducing the amount of stomach acid
prevents any further damage to your stomach ulcer, allowing it to heal
naturally. Lansoprazole and omeprazole are the two
PPIs most commonly used to treat stomach ulcers. Side effects of these are
usually mild but include:
- headache
- diarrhoea
- nausea
- abdominal pain
- constipation
- dizziness
- skin rashes.
These should pass once treatment has
been completed.
H2-receptor antagonists work by
blocking the actions of a protein called histamine, which is also responsible
for stimulating the production of acid. Ranitidine is the most widely used
H2-receptor antagonist for treating stomach ulcers. Side effects are uncommon but may
include:
- diarrhoea
- headaches
- dizziness
- skin rashes
- tiredness.
All of the treatments discussed above
can take several hours before they start to work, so it is likely that your doctor will recommend some additional medication to help provide short-term symptom
relief. Two types of medication that can be
used are:
- antacids – to help neutralise
stomach acid on a short-term basis
- alginates – which produce a
protective coating on the lining of your stomach.
Both antacids and alginates are
available to buy over the counter at pharmacies. Your pharmacist will be able
to advise you about the types of antacid and alginate most suitable for you. Antacids are best taken when you
experience symptoms or when you expect them, such as after meals or at bedtime.
Alginates are best taken after meals.
Do not take these medications within an
hour of taking proton pump inhibitors or ranitidine as they may block the
effects. Side effects for both medications are
uncommon but include:
- diarrhoea
- vomiting
- wind (flatulence).
Bananas are also thought to provide a
protective effect against stomach acid, so you may want to consider eating
these as an alternative way to relieve your symptoms, if you don't want to take
antacids or alginates.
If your stomach ulcer has been caused
by taking NSAIDs, your doctor will want to review your use of them. You will usually be advised to use an
alternative painkiller that is not linked to stomach ulcers, such as
paracetamol or a low-dose opiate-based painkiller.
If you are taking low-dose aspirin
to reduce your risk of getting blood clots, your doctor will help you decide
whether you need to continue taking it. In most cases it is continued or
only stopped for a few days. In these cases a PPI is given as well
as the aspirin to try to prevent further ulceration, and this is usually very
effective. If you or your doctor feel that the continued used of NSAIDs is
absolutely necessary, you will be prescribed a long-term course of a PPI or
H2-receptor antagonist.
It is important that you understand the
potential drawbacks and risks associated with continued NSAID use. You are more
likely to develop another stomach ulcer and the risks of experiencing serious
complications, such as internal bleeding, are higher.
Complications of stomach ulcer
The introduction of eradication therapy
means that complications of stomach ulcers related to H. pylori infections are
now uncommon. Complications are more common in
stomach ulcers that are associated with the use of non-steroidal
anti-inflammatory drugs (NSAIDs).
This is because these types of ulcers do not
always cause any obvious symptoms, so are left untreated. It is estimated that around 1 in 50
people with a NSAID-related stomach ulcer will develop a complication.
Internal bleeding is the most common
complication of stomach ulcers and is responsible for around 3,500 hospital
admissions in England each year. Internal bleeding can occur when an
ulcer develops at a site of a blood vessel. You are at an increased risk of
bleeding if you:
- are on continued use of non-steroidal
anti-inflammatory drugs (NSAIDs)
- are 60 years old or over.
Depending on the location and type of
blood vessel, you may have long-term bleeding which could lead to anaemia
(a condition where the body has a lack of oxygen-carrying red blood cells). Symptoms of anaemia include:
- fatigue
- breathlessness
- pale skin
- irregular heartbeats.
Alternatively, the bleeding can be
rapid and massive, causing you to vomit blood or pass stools that are black and
tar-like. People who have this sort of internal
bleeding always need an endoscopy to identify the cause of the bleeding. Often
bleeding can be stopped by treatment performed through the endoscope.
Patients receiving this are kept in
hospital and given injections of proton pump inhibitors (PPIs). Lowering the
amount of acid around the site of the bleeding is thought to make the blood
more likely to clot, which helps to stop the bleeding. Massive bleeding can be treated
using blood transfusions to replace any blood loss. Surgery is
occasionally needed to repair the blood vessels.
A rarer complication of stomach ulcers
is where the ulcer causes the lining of the stomach to split open (a
perforation). It affects around 1 in 350 people with a stomach ulcer. Perforation is potentially very serious
because it enables the bacteria that live in your stomach to escape and infect
the lining of your abdomen (peritoneum). This is known as peritonitis.
The most common symptom of peritonitis
is the sudden onset of abdominal pain, which gets steadily worse. In peritonitis, an infection can
rapidly spread into the blood (sepsis) before spreading to other organs. This carries
the risk of multiple organ failure, and can be fatal if left untreated.
Peritonitis is a medical emergency
because the peritoneum doesn't have an in-built defence mechanism for fighting
off infection. It requires admission to hospital so that the condition can be
treated with antibiotic injections to get rid of the infection. Surgery will
then be used to seal the hole in the stomach wall.
In some cases, an inflamed or
scarred stomach ulcer can obstruct the normal passage of food through your
digestive system. This is known as gastric outlet obstruction. Gastric outlet obstruction
is relatively uncommon. Each year, it affects around one in a 1,000 people
with a stomach ulcer.
Symptoms of gastric outlet obstruction
include:
- repeated episodes of vomiting, with large
amounts of vomit that contain undigested food
- a persistent feeling of bloating or fullness
- feeling very full after eating less food than
usual
- unexplained weight loss.
An endoscopy will confirm the type and
site of the obstruction. If the obstruction is caused by inflammation, PPIs or
H2-receptor antagonists can be used to help reduce it. If the obstruction is caused by scar
tissue, surgery may be needed to treat it, although sometimes it can be treated
by passing a small balloon through an endoscope and inflating it to widen the
site of the obstruction.
In more severe cases of scarring, it
may be necessary to surgically remove the affected section of stomach, before
reattaching the remainder of the stomach.
Source: NHS Choices.
Source: NHS Choices.