Starting the fire: causes of PUD

There are two major causes of peptic ulcer disease (PUD): Helicobacter pylori bacteria and use of ASA (Aspirin®) and other nonsteroidal anti-inflammatory drugs (NSAIDs).

Helicobacter pylori (H. pylori) bacteria are responsible for the majority of ulcers (about 50% to 70% of duodenal ulcers and 30% to 50% of gastric ulcers). It is estimated that the bacteria is found in the stomach of approximately one-half of the world’s population. The bacteria can spread into the protective mucus lining of the stomach and small intestine, causing damage. Not all people infected with these bacteria will actually develop ulcers.

Use of ASA (Aspirin®) and other nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen can cause PUD. NSAIDs block natural chemicals called prostaglandins that can help repair damaged cells in the protective mucus layer. This makes the mucus layer weaker and less able to protect the delicate stomach and intestine lining. Using ASA and NSAIDs regularly for a long time (such as for arthritis pain) increases the risk of developing PUD. Since NSAIDs are painkillers, they can mask the discomfort of ulcers.

Smoking also contributes to PUD, poor ulcer healing, and ulcer complications (such as bleeding). It is not known exactly how this happens, but smoking is believed to block prostaglandins that can help repair damaged cells in the protective mucus layer. It may also make it easier for H. pylori to cause PUD. Excessive alcohol use can put people at higher risk for PUD.

Some people have certain risk factors that make them more vulnerable to peptic ulcers caused by NSAIDs. If you are taking an NSAID and have one of these risk factors, your doctor may recommend a stomach protective medication (e.g., misoprostol) or an acid-suppressing medication (e.g., esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole). These risk factors are:

  • being older than 50 years
  • a history of previous ulcers (including a family history)
  • using high doses of NSAIDs or multiple NSAIDs
  • using corticosteroids (for example, prednisone)
  • using blood thinners such as ASA or warfarin
  • blood clotting disorders (e.g., hemophilia)
  • chronic health problems with major organs (e.g., heart disease)
  • heavy cigarette smoking (more than 10 cigarettes per day)
  • H. pylori infection
  • poor general health

Putting out the fire: managing PUD

Peptic ulcer disease (PUD) is a medical condition that should be evaluated by your doctor or health care professional. Depending on the cause, different treatments will be recommended. For ulcers related to H. pylori infection, the doctor can recommend a course of treatment with a three- or four-drug combination of antibiotics and anti-ulcer medications. For ulcers related to NSAID use, the usual treatment is to stop the NSAID or decrease the dose. Anti-ulcer medications may also be recommended if symptoms do not go away after stopping the NSAID. If the NSAID cannot be stopped, then anti-ulcer medications and medications to protect the stomach lining may be recommended.

To complement the treatment recommended by your doctor, there are ways you can reduce or eliminate some risk factors associated with ulcers through changes to your lifestyle:

  • Stop smoking, or at least smoke less.
  • Reduce or eliminate alcohol intake.
  • Avoid or consume less of foods and beverages that trigger "heartburn" symptoms (e.g., coffee, tea, cola, alcohol, mints or peppermint, onions, garlic, chocolate).
  • Avoid eating spicy and fried foods, as well as acidic foods such as oranges, grapefruits, and tomato juice.
  • Eat smaller, low-fat meals.
  • Do not eat late at night close to bedtime.
  • Take antacids to relieve occasional severe symptoms. It is not recommended to take antacids all the time. Consult your pharmacist or doctor rather than try to control chronic symptoms with antacids.
  • Probiotics and some foods like cranberry juice may decrease inflammation, which may help improve healing of ulcers caused by H. pylori infections.
  • Take the medications prescribed by your doctor, and continue to do so until he or she tells you it is safe to stop.

It may also be useful for your doctor or pharmacist to reassess all of your current medications. In some cases, people with ulcers may need surgery to correct the problems caused by the ulcer (such as tearing of the stomach lining or blockages in the stomach or intestines).

A burning sensation: ulcers

Peptic ulcer disease (also known as PUD) occurs when the strong acids and digestive juices normally present in the stomach damage the inside of the stomach or small intestine. This can happen when the protective mucus layer wears away in certain areas, causing ulcers (sores or lesions). There are two main types of peptic ulcers, named according to their location:

  • Gastric ulcers are sores in the stomach. This type of ulcer occurs equally among men and women and develops most commonly between the ages of 55 and 65. Pain from gastric ulcers is usually worst after eating a meal. Antacids can relieve the pain of gastric ulcers.
  • Duodenal ulcers occur in the upper part of the small intestine, called the duodenum. This type of ulcer was once more common in men, but is now equally prevalent in both genders. It is more common with age. Pain from duodenal ulcers typically occurs when the stomach is empty (e.g., at night or between meals). It may last a number of weeks and then temporarily go away. Food and antacids can often relieve this kind of pain.

The most common symptom of PUD is a gnawing or burning pain in the abdomen, between the breastbone and navel, sometimes passed off as "heartburn." An ulcer can also feel like a dull ache or strong hunger pangs with belching and bloating. The pain may be worse when you are hungry and may improve with a small meal. More serious PUD (typically poorly treated or untreated PUD) can lead to nausea, vomiting, lack of appetite, weight loss, bloody vomit, or black, tarry stools. Some people, especially the elderly, may not feel any pain from an ulcer. Other medical conditions, including gastroesophageal reflux disease (GERD) and cancers of the stomach or esophagus, can also cause similar symptoms.

Five-alarm blaze: when PUD is an emergency

There are 5 ulcer-related alarm features that signal an urgent need for medical evaluation. If you experience any of the following symptoms, visit your doctor immediately or go to the emergency department of a hospital:

  • persistent vomiting  
  • bloody vomit or black, tarry stools. Sometimes ulcers can bleed. Although the blood loss is usually too slow to be noticed, it might be enough to make you tired, pale, and weak from anemia. Your doctor will do a blood test to determine whether you are anemic.
  • weight loss with no apparent cause
  • a lump in the abdomen
  • difficulty swallowing

Your doctor has a variety of tests to diagnose peptic ulcer disease (PUD). Endoscopy involves inserting a thin tube with a tiny camera on its end into the mouth and down the throat to get close-up pictures of the esophagus, stomach, and duodenum. Endoscopy is not performed on all patients with PUD, and your doctor may decide to treat your ulcer without doing this test first. To detect Helicobacter pylori bacteria, a breath test (drinking a fluid and exhaling into a tube) or blood test can be used.

The most serious complications of PUD are bleeding, perforation (tearing of the stomach or intestine lining), and obstruction (where scarring or swelling related to the ulcer causes blockages in the stomach or intestines). These complications may be life threatening. The alarm symptoms listed above are warning signs that these complications may be occurring. Get medical attention immediately if you notice any of these symptoms.
Cancers of the esophagus and stomach become more of a concern when people reach the age of 50. If you are 50 or older and have PUD, consult a doctor or health care professional to ensure that cancer is not the cause of your symptoms. Your doctor may do a biopsy (take a small piece of tissue to examine under the microscope) for confirmation.