What are they?

A peptic ulcer is a crater-like open sore in the lining of parts of the digestive tract. There are two types:

• Stomach ulcers, also called gastric ulcers, occur in the stomach.
• Duodenal ulcers occur in the duodenum, the uppermost part of the small intestine near the stomach.

What are the main symptoms?

The classic and most common symptom of peptic ulcers is pain. Ulcer pain is thought to affect at least 70% of people with duodenal ulcers and around 50% of those with stomach ulcers.

This pain may:

• Be a gnawing, burning sensation in the abdomen between the breastbone and navel.
• Feel like a constant hunger or sensation of pressure in the abdominal area.
• Range from a mild ache to severe discomfort.
• Come on after a meal, anywhere from 30 minutes to a couple of hours afterwards.
• Last anywhere from minutes to hours.
• Be felt in a wide area, radiating from the abdomen and spreading to the back and sides.
• Be relieved by eating or taking antacids (e.g. Rennies, Gaviscon or Milk of Magnesia).
• Develop at night, although this is more common with duodenal ulcers.
• Persist for days or weeks, then fade for months before recurring.

Other less common symptoms of peptic ulcers include:

• Nausea and vomiting, although this is more common with duodenal ulcers than stomach ulcers. Vomiting may relieve some of the pain.
• A loss of appetite, though this is more common in stomach ulcers.
• Unexplained weight loss.
• Bleeding, which may be vomited or noticed when passing black, tarry stools. These symptoms may indicate a silent ulcer.

What's the risk?

It's estimated that between 5% and 10% of the population will suffer a peptic ulcer at some time in their lives. Men are more susceptible than women. Ulcers are rare in children but more common with age.

• Duodenal ulcers are more common than stomach ulcers. They usually develop from the age of around 25 onwards, with the peak age being around 45.
• Stomach ulcers tend to occur later in life, especially in people who are over 60. Unlike duodenal ulcers, stomach ulcers can sometimes be malignant.

What causes them?

Peptic ulcers develop when naturally present acid and digestive enzymes break through the protective mucus lining of the stomach and duodenum and eat into the underlying tissues.

There are a number of factors that can increase the risk of developing a peptic ulcer:

• Infection with Helicobacter pylori (often referred to by doctors as H. pylori). This bacterium is now thought to be the most important contributory factor in the majority of peptic ulcers.
• Cigarette smoking. Smokers are about twice as likely to develop a peptic ulcers because of tobacco's effect on the mucus lining of the stomach and digestive tract. In addition, smoking slows down the rate of healing, even when someone is taking strong anti-ulcer medication. Smoking also increases the risk of a recurrence, even after successful treatment.
• Medications. Regular use of non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, can greatly increase the risk of peptic ulcers.
• Family history of peptic ulcer disease. The tendency towards peptic ulcers runs in families. Siblings of people with peptic ulcers are over two-and-a-half times as likely to develop them. It's also known that within families one type of ulcer tends to prevail over another. Initially it was thought that ulcer disease had a genetic link. Now, however, it is suspected that cross-infection with H. pylori is the key factor.
• There have been many studies looking at the effect of diet and stress on peptic ulcers. Although there's some evidence that certain foods and drink, or emotional stress, can make symptoms of an existing ulcer worse, there's no evidence that they have any effect on the development of the ulcer in the first place.

How can I prevent them?

There's little you can do to prevent the development of a peptic ulcer. However, you can:

• Avoid taking aspirin or other NSAIDs regularly. Use paracetamol which is not an NSAID and, If you do need NSAIDs for a chronic condition, discuss it with your doctor.
• Stop smoking. Smoking increases the risk of peptic ulcers and also increases the risk of recurrence.

Should I see a doctor?

Anyone with unexplained stomach or chest pain should see a doctor since there can be many causes, including indigestion, hiatus hernia or heart disease. Untreated ulcers may also lead to serious complications.

Your doctor may carry out one of the following tests to determine the cause of your symptoms:

• Barium meal X-ray. This procedure involves drinking barium sulfate, a substance which is visible on X-ray pictures. It coats the lining of the stomach and duodenum, showing up the craters or holes created by peptic ulcers. It's done on an outpatient basis and is painless. Barium meals aren't particularly effective at showing small ulcers or at pinpointing an ulcer's exact size or depth, however, and they can't detect H. pylori.
• Endoscopy. This is a method of looking directly at various internal areas of the body, including the digestive tract. An endoscope, a telescopic tube with a video chip on the tip, is inserted down the throat into the stomach and duodenum. Endoscopy is very accurate, providing images of any ulcer as well as its exact position, size and depth. During endoscopy, the doctor can also remove a biopsy, a small sample of tissue, from the ulcer and surrounding area. This can be examined for H. pylori as well as for any signs of malignancy. Endoscopy is performed on an outpatient basis and can be uncomfortable, although patients can opt for a mild sedative.
• H. pylori tests. Once a peptic ulcer is confirmed, your doctor may arrange for tests to check for H. pylori (if this was not done during an endoscopy). Blood tests are often used, but there is also an effective breath test. This involves swallowing urea, a harmless substance that's broken down in the stomach if there are bacteria present. The breakdown products can be detected in the breath. This test may be given before any treatment is started. It may also be used after treatment to determine whether the infection has been successfully eradicated.

What are the main treatments?

There are a number of effective medications for peptic ulcers:

• Antacids (e.g. Rennies, Gaviscon or Milk of Magnesia) are often the first line of treatment. They provide temporary relief from the pain by neutralising stomach acids. Antacids come in a number of forms, including liquids, tablets and gels, and are effective at relieving pain. When taken in high doses they can also help speed up the healing of ulcers.
• H2 antagonists work by reducing stomach acid secretion. H2 antagonists are very effective — when used properly, around 70—80% of ulcers will heal within four to eight weeks of treatment. H2 antagonists include cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid) and nizatidine (Axid).
• Proton pump inhibitors also inhibit acid production, but much more effectively than the H2 antagonists. The drugs include omeprazole (Losec), lansoprazole (Zoton), pantoprazole (Protium) and rabeprazole (Pariet).
• Drugs that help protect the stomach's mucus lining from acid, such as misoprostal (Cytotec) or sucralfate (Antepsin). These do not inhibit the release of the acid.
• If H. pylori is known to be present, treatment usually involves an acid-reducing drug in combination with antibiotics to eliminate the bacteria. "Triple therapy" is the most successful approach. This involves taking two antibiotics and an acid-suppressing drug for seven days. However, because of the need to take so many tablets, many people have difficulty sticking to the treatment. There are also common side-effects, such as stomach upsets, nausea and vomiting.

Although triple or dual therapy is clearly effective for the majority of ulcers caused by H. pylori, it isn't always the first line of treatment, particularly for younger sufferers. Part of the reason may be the cost of the drugs but it may also be unnecessary. Many peptic ulcers clear up even without treatment (though these often recur) while others can be effectively treated with cheaper, simpler treatments such as H2 antagonists. It's often only when these have been tried unsuccessfully that H. pylori eradication therapy is given.

How can I help myself?

You can help reduce the frequency and severity of attacks:

• Avoid spicy or rich foods if they make symptoms worse.
• Coffee or tea can increase acid production, so reduce your intake.
• Avoid excessive alcohol consumption, as alcohol can irritate the areas of inflammation.
• Drink milk and eat milk-based foods. Milk is thought to help coat the stomach and neutralise the effects of stomach acid, relieving any pain.
• Eating little and often may help reduce the build-up of stomach acid between meals.
• Don't smoke. Smoking impairs the healing process and increases the risk of an ulcer recurring.
• Learn some stress-reduction techniques. High stress levels may increase acid production and worsen symptoms.
• Avoid NSAIDs (non-steroidal anti-inflammatory drugs) if possible. Discuss alternatives with your doctor.

What's the outlook?

The modern treatments available for peptic ulcers are very effective. However, not all ulcers can be completely cured and recurrence is common.

• Treatment with antacids or H2 antagonists usually heals ulcers after four to eight weeks. However, around 80% of ulcers may recur within a year.
• Treatment with triple or dual therapy is very successful. If H. pylori is successfully eradicated the majority of people are cured for life. It's estimated that just 5—7% will have a recurrence.

People who have ulcers that do recur, or that are caused by NSAIDs rather than H. pylori, may need long-term therapy to avoid relapses. This includes treatment with H2 antagonists and other acid-reducing medications. However, fewer and fewer people are now on long-term therapy.

Who else can help?

CORE Charity: Fighting gut and liver disease

Tel: 020 7486 0341

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