Ulcers and H-Pylori

Ulcers, also known as peptic ulcer disease, are a common condition that affects up to 10% of the population. Ulcers can be classified by their location as either ulcers within the stomach (gastric ulcers), or ulcers within the upper portion of the small intestine (duodenal ulcers). An ulcer is an open sore in the lining of the stomach or small intestine.

Upper abdominal pain is the most common sign of an ulcer, often described as a gnawing, burning, or boring pain in the "pit of the stomach." At times, the pain can improve with eating and at other times worsen with eating. Nausea or decreased appetite and weight loss can also occur.

A bleeding ulcer occurs when the ulcer sore burrows into a blood vessel causing leakage of blood into the stomach or intestine. When this occurs, the person may start vomiting fresh blood or vomiting material that looks like coffee grounds. The stools turn black and tarry (known as melena) and often contain a foul odor. Patients who have bleeding ulcers do not necessarily have pain preceding or during the bleeding episode.

Gastric Ulcer with central black spot indicating recent bleeding from this ulcer. This patient presented with a bleeding ulcer.

Gastritis and Duodenitis

Inflammation of the stomach is called gastritis. Inflammation of the duodenum is called duodenitis. Gastritis and duodenitis can be caused by the same factors as ulcers (see below). The injury to the stomach or small intestine is more superficial, and does not cause an open sore and thus does not appear as an ulcer crater. The symptoms and therapy of gastritis and duodenitis are similar to those of gastric and duodenal ulcers.

Actively bleeding ulcer spurting a stream of blood.

Causes of Ulcers

1. Acid: The stomach produces a strong acid (hydrochloric acid) which aids digestion and breakdowns food before it enters the small intestine. The stomach and intestine have mechanisms to protect from acid injury, but when these defenses break down an ulcer can develop.

2. Helicobacter Pylori: Helicobacter Pylori (H-Pylori) is a bacteria that is spiral shaped (giving the name helico) and can infect the superficial layer of the stomach and thereby reduce the defenses in the stomach and duodenum, allowing injury to occur. H-Pylori is present in the environment but it is still unclear how people acquire the infection. Most likely, it is ingested after exposure by touching and then eating. This organism should be perused and treated in most patients who have ulcers. Diagnosis and treatment are discussed below.

3. Stress: Stress is commonly thought to cause ulcers but research has shown that it plays only a minor role. Stress can bring out ulcer-type symptoms even if an actual ulcer is not present. Therefore, the ways stress interacts with the digestive tract should not be discounted.

4. Diet: No food, even greasy or spicy foods, cause ulcers. Similar to stress and emotional factors, certain foods, can bring out abdominal pain or discomfort mimicking an ulcer or gastritis. These symptoms may reflect heartburn or stimulation of intestinal contractions (spasm).

5. Heredity: Ulcers can occur in family members. This may reflect a genetic tendency or be related to other factors such as H-Pylori.

6. Medications: Certain medications can reduce defensive barriers and injure the tissues directly. Anti-inflammatory medications often used for aches, pains, headaches, and arthritis are common examples of medicines that can cause ulcers. Examples of these medications include Ibuprofen, Motrin, Aleve, Naprosyn, Indocin, Advil, and many others. Aspirin also falls into this category of potentially ulcer-producing medications. A new class of anti-inflammatory agents known as Cox-2 inhibitors (i.e. Celebrex), appear to have significantly less ulcer producing side effects.

7. Idiopathic: Idiopathic refers to ulcers that develop with no apparent cause. 

Diagnosis

The diagnosis of ulcers can be considered from the description of a patient’s symptoms. However, ulcer-type symptoms can occur as a response to stress, diet, medications or too much acid. In these cases, an actual ulcer sore has not developed. Thus, testing to determine if an ulcer is present is usually recommended. This is accomplished by performing an Endoscopy (see Endoscopy for more information) or an Upper GI X-ray series.

• Endoscopy allows careful and accurate inspection of the upper gastrointestinal tract, as well as the ability to obtain biopsies to directly test for H-Pylori and for possible tumors or other problems.

• An Upper GI X-ray series is performed to obtain a picture-type evaluation of possible ulcers. Biopsies cannot be performed with X-ray techniques.

• Blood can be drawn to test for antibodies to detect the presence of H-Pylori. It should be noted that once a patient has been evaluated for and treated for H-Pylori, this antibody test remains positive and thus cannot be used at a later point to determine if the person is still infected with H-Pylori. In certain circumstances, H-Pylori can be detected via a breath test using a low dose radioactive tracer.

Gastric ulcer with clean base. This patient presented with a painful ulcer.

Treatment

Medications to suppress stomach acid, such as H2 blockers (i.e. Pepcid, Zantac, Tagamet, Axid) or the more potent Proton Pump Inhibitors (i.e. Prilosec, Prevacid, Aciphex, Protonix, Nexium) are very effective forms of therapy for ulcers. If H-Pylori is present, therapy often requires a combination of antibiotics and acid inhibitors. There are several different treatment options available.

Avoiding non-steroidal anti-inflammatory (NSAIDs) medications, aspirin, and tobacco is often necessary to treat the ulcer and prevent it from recurring. Current medications are so effective in treating ulcers that strict dietary modifications are usually not needed. Avoidance of spicy food and significant amounts of caffeine may be helpful.

New therapies that offer higher cure rates and/or a reduced number of medications to treat the infection are under study. Participation in clinical research studies may be offered to help develop better therapies. For a list of available studies, please call (513) 872-4549 or visit www.ccrstudy.com

Related Sites

The Helicobacter Foundation, http://www.helico.com

National Digestive Diseases Information Clearinghouse (NDDIC), http://digestive.niddk.nih.gov

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