Peptic Ulcer Disease (PUD)
While much of our digestive tract is alkaline, the stomach is an exception, containing hydrochloric acid which is important for initial digestion and killing of many bacteria. When the stomach and small intestine lining (mucosa) is damaged, this acid may cause injury resulting in a peptic ulcer. The word ‘peptic’ describes the acidic component of the digestive tract, while ‘ulcer’ refers to an eroded area in the mucosa.
Peptic ulcers may be gastric ulcers or duodenal ulcers. If the ulcer occurs in the stomach, it is called a gastric ulcer. If it occurs just after the stomach, in the first part of the small intestine (duodenum), it is called a duodenal ulcer.
In the majority of cases, a bacteria called helicobacter pylori (HP) infects the mucosal lining, causing inflammation which weakens the lining and leads to ulceration.
Another cause is the class of painkillers called NSAIDs (non-steroidal antiinflammatory drugs) which affects the action of prostaglandins, a protective substance produced by the mucosa. Many painkillers (apart from paracetamol, codeine and tramadol) belong to this group. Examples include diclofenac, naproxen, ketoprofen, indomethacin and celecoxib. Check with your doctor if your painkillers are NSAIDS. Aspirin used for heart and stroke patients is also in this group. Doctors often prescribe an antiulcer drug when prescribing these medications. With the exception of aspirin, NSAIDs should not be taken continuously.
- Upper abdominal pain
- Pain on hunger
- Pain at night
- Pain relieved by food
- Nausea, loss of appetite, fullness after eating can occur.
PUD is proven by undergoing endoscopy of the stomach, called oesophago-gastro-duodenoscopy (OGD), where a fibre-optic tube with a camera attachment is passed, after a local anaesthetic spray, via the mouth through the oesophagus to the stomach and into the duodenum. This enables the viewing and photography of abnormal portions and the taking of biopsies - tiny mucosal samples of tissue, which are tested for helicobacter pylori (HP)and to exclude more sinister diagnoses like cancer.
Although OGD takes less than five minutes, patients can choose to be sedated with a short-acting intravenous drug so that they can be asleep during the procedure.
Is there any other way to diagnose peptic ulcer?
Barium meal, where a drink containing barium salt is used to outline the stomach lining before taking x-rays of the stomach and duodenum. It is done when OGD is not performed for various reasons.
NSAIDs must be discontinued. If HP has been identified, a three antibiotic regimen lasting two weeks is often necessary to eradicate the bacteria. To demonstrate that HP has been eliminated, a repeat OGD and biopsy or a breath test may be done. A blood test and stool test is also available.
Powerful drugs that reduce acid secretion either belong to the class ‘proton pump inhibitors’ like omeprazole or esomeprazole or ‘H2 blockers’ like ranitidine or famotidine. Maintenance with these drugs is required for six to eight weeks. Over-the-counter alkaline salts called antacids (chewable or liquid) can provide quick relief of symptoms. They may contain magnesium trisilicate, calcium carbonate or sodium bicarbonate. On their own they cannot heal ulcers.
Complications of Peptic Ulcers
Bleeding can occur from ulcers causing black stool (the appearance of blood after undergoing digestion) or even vomiting of blood. Perforation, is where the ulcer deepens and penetrates a hole right through the muscular wall of the stomach or duodenum, with spillage of stomach contents into the abdominal cavity causing infection. This requires emergency surgery. Sometimes the ulcer can heal with a scar causing deformity of the stomach outflow called gastric outlet obstruction. This also requires surgery. Fortunately, with prompt and effective treatment, these consequences are quite rare today.
Can my upper abdominal pain be caused by other possibilities?
Not all upper abdominal pain is due to peptic ulcer, gastritis or duodenitis. Your doctor can help you evaluate.
Avoidance of prolonged NSAIDs is important. Alcohol, smoking, stressful situations, delayed and irregular meals are often linked to gastritis and ulcers. By themselves these do not generally cause ulcers, but may affect promptness of recovery. Therefore, it is prudent to avoid these factors.