Stomach and Duodenal Ulcers
During normal digestion, food moves from the mouth down the esophagus into
the stomach. The stomach produces hydrochloric acid and an enzyme called
pepsin to digest the food. From the stomach, food passes into the upper
part of the small intestine, called the duodenum, where digestion and
nutrient absorption continue.
An ulcer is a sore or lesion that forms in the lining of the stomach or
duodenum where acid and pepsin are present. Ulcers in the stomach are
called gastric or stomach ulcers. Those in the duodenum are called
duodenal ulcers. In general, ulcers in the stomach and duodenum are
referred to as peptic ulcers. Ulcers rarely occur in the esophagus or in
the first portion of the duodenum, the duodenal bulb.
Who Has Ulcers?
|About 20 million Americans develop at least one
ulcer during their lifetime. Each year:
- Ulcers affect about 4 million people.
- More than 40,000 people have surgery because of persistent symptoms
or problems from ulcers.
- About 6,000 people die of ulcer-related complications.
Ulcers can develop at any age, but they are rare among teenagers and
even more uncommon in children. Duodenal ulcers occur for the first time
usually between the ages of 30 and 50. Stomach ulcers are more likely to
develop in people over age 60. Duodenal ulcers occur more frequently in
men than women; stomach ulcers develop more often in women than men.
What Causes Ulcers?
|For almost a century, doctors believed lifestyle
factors such as stress and diet caused ulcers. Later, researchers
discovered that an imbalance between digestive fluids (hydrochloric acid
and pepsin) and the stomach's ability to defend itself against these
powerful substances resulted in ulcers. Today, research shows that most
ulcers develop as a result of infection with bacteria called Helicobacter
pylori (H. pylori). While all three of these factors--lifestyle, acid and
pepsin, and H. pylori--play a role in ulcer development, H. pylori is now
considered the primary cause.
While scientific evidence refutes the old belief that stress and diet
cause ulcers, several lifestyle factors continue to be suspected of
playing a role. These factors include cigarettes, foods and beverages
containing caffeine, alcohol, and physical stress.
Studies show that cigarette smoking increases one's chances of getting
an ulcer. Smoking slows the healing of existing ulcers and also
contributes to ulcer recurrence.
Coffee, tea, colas, and foods that contain caffeine seem to stimulate
acid secretion in the stomach, aggravating the pain of an existing ulcer.
However, the amount of acid secretion that occurs after drinking
decaffeinated coffee is the same as that produced after drinking regular
coffee. Thus, the stimulation of stomach acid cannot be attributed solely
Research has not found a link between alcohol consumption and peptic
ulcers. However, ulcers are more common in people who have cirrhosis of
the liver, a disease often linked to heavy alcohol consumption.
Although emotional stress is no longer thought to be a cause of ulcers,
people with ulcers often report that emotional stress increases ulcer
pain. Physical stress, however, increases the risk of developing ulcers
particularly in the stomach. For example, people with injuries such as
severe burns and people undergoing major surgery often require rigorous
treatment to prevent ulcers and ulcer complications.
Acid and pepsin
Researchers believe that the stomach's inability to defend itself
against the powerful digestive fluids, acid and pepsin, contributes to
ulcer formation. The stomach defends itself from these fluids in several
ways. One way is by producing mucus--a lubricant-like coating that shields
stomach tissues. Another way is by producing a chemical called
bicarbonate. This chemical neutralizes and breaks down digestive fluids
into substances less harmful to stomach tissue. Finally, blood circulation
to the stomach lining, cell renewal, and cell repair also help protect the
Nonsteroidal anti-inflammatory drugs (NSAIDs) make the stomach
vulnerable to the harmful effects of acid and pepsin. NSAIDs such as
aspirin, ibuprofen, and naproxen sodium are present in many
non-prescription medications used to treat fever, headaches, and minor
aches and pains. These, as well as prescription NSAIDs used to treat a
variety of arthritic conditions, interfere with the stomach's ability to
produce mucus and bicarbonate and affect blood flow to the stomach and
cell repair. They can all cause the stomach's defense mechanisms to fail,
resulting in an increased chance of developing stomach ulcers. In most
cases, these ulcers disappear once the person stops taking NSAIDs.
H. pylori is a spiral-shaped bacterium found in the stomach.
Research shows that the bacteria (along with acid secretion) damage
stomach and duodenal tissue, causing inflammation and ulcers. Scientists
believe this damage occurs because of H. pylori's shape and
H. pylori survives in the stomach because it produces the enzyme
urease. Urease generates substances that neutralize the stomach's
acid--enabling the bacteria to survive. Because of their shape and the way
they move, the bacteria can penetrate the stomach's protective mucous
lining. Here, they can produce substances that weaken the stomach's
protective mucus and make the stomach cells more susceptible to the
damaging effects of acid and pepsin.
The bacteria can also attach to stomach cells further weakening the
stomach's defensive mechanisms and producing local inflammation. For
reasons not completely understood, H. pylori can also stimulate the
stomach to produce more acid.
Excess stomach acid and other irritating factors can cause inflammation
of the upper end of the duodenum, the duodenal bulb. In some people, over
long periods of time, this inflammation results in production of
stomach-like cells called duodenal gastric metaplasia. H. pylori then
attacks these cells causing further tissue damage and inflammation, which
may result in an ulcer.
Within weeks of infection with H. pylori, most people develop
gastritis--an inflammation of the stomach lining. However, most people
will never have symptoms or problems related to the infection. Scientists
do not yet know what is different in those people who develop H.
pylori-related symptoms or ulcers. Perhaps, hereditary or environmental
factors yet to be discovered cause some individuals to develop problems.
Alternatively, symptoms and ulcers may result from infection with more
virulent strains of bacteria. These unanswered questions are the subject
of intensive scientific research.
Studies show that H. pylori infection in the United States varies with
age, ethnic group, and socioeconomic class. The bacteria are more common
in older adults, African Americans, Hispanics, and lower socio- economic
groups. The organism appears to spread through the fecal-oral route (when
infected stool comes into contact with hands, food, or water). Most
individuals seem to be infected during childhood, and their infection
lasts a lifetime.
|The History of Helicobacter pylori
In 1982, Australian researchers Barry Marshall and Robin Warren
discovered spiral-shaped bacteria in the stomach, later named
Helicobacter pylori (H. pylori). After closely
studying H. pylori's effect on the stomach, they proposed
that the bacteria were the underlying cause of gastritis and peptic
Marshall and Warren came to this conclusion because in their
studies all patients with duodenal ulcers and 80 percent of patients
with stomach ulcers had the bacteria. The 20 percent of patients
with stomach ulcers who did not have H. pylori were those who
had taken NSAIDs such as aspirin and ibuprofen, which are a common
cause of stomach ulcers.
Although their findings seem conclusive, Marshall and Warren's
theory was hotly debated and remained in dispute. The debate
continued even after Marshall and a colleague performed an
experiment in which they infected themselves with H. pylori
and developed gastritis.
Evidence linking H. pylori to ulcers mounted over the next
10 years as numerous studies from around the world confirmed its
presence in most people with ulcers. Moreover, researchers from the
United States and Europe proved that using antibiotics to eliminate
H. pylori healed ulcers and prevented recurrence in about 90
percent of cases.
To further investigate these findings, the National Institutes of
Health (NIH) established a panel to closely review the link between
H. pylori and peptic ulcer disease. At the February 1994
Consensus Development Conference, the panel concluded that H.
pylori plays a significant role in the development of ulcers and
that antibiotics with other medicines can cure peptic ulcer disease.
What Are the Symptoms of Ulcers?
|The most common ulcer symptom is a gnawing or
burning pain in the abdomen between the breastbone and the navel. The pain
often occurs between meals and in the early hours of the morning. It may
last from a few minutes to a few hours and may be relieved by eating or by
Less common ulcer symptoms include nausea, vomiting, and loss of
appetite and weight. Bleeding from ulcers may occur in the stomach and
duodenum. Sometimes people are unaware that they have a bleeding ulcer,
because blood loss is slow and blood may not be obvious in the stool.
These people may feel tired and weak. If the bleeding is heavy, blood will
appear in vomit or stool. Stool containing blood appears tarry or black.
How Are Ulcers Diagnosed?
|The NIH Consensus Panel emphasized the
importance of adequately diagnosing ulcer disease and H. pylori
before starting treatment. If the person has an NSAID-induced ulcer,
treatment is quite different from the treatment for a person with an H.
pylori-related ulcer. Also, a person's pain may be the result of
nonulcer dyspepsia (persistent pain or discomfort in the upper abdomen
including burning, nausea, and bloating), and not at all related to ulcer
disease. Currently, doctors have a number of options available for
diagnosing ulcers, such as performing endoscopic and x-ray examinations,
and for testing for H. pylori.
Locating and monitoring ulcers
Doctors may perform an upper GI series to diagnose ulcers. An upper GI
series involves taking an x-ray of the esophagus, stomach, and duodenum to
locate an ulcer. To make the ulcer visible on the x-ray image, the patient
swallows a chalky liquid called barium.
An alternative diagnostic test is called an endoscopy. During this
test, the patient is lightly sedated and the doctor inserts a small
flexible instrument with a camera on the end through the mouth into the
esophagus, stomach, and duodenum. With this procedure, the entire upper GI
tract can be viewed. Ulcers or other conditions can be diagnosed and
photographed, and tissue can be taken for biopsy, if necessary.
Once an ulcer is diagnosed and treatment begins, the doctor will
usually monitor clinical progress. In the case of a stomach ulcer, the
doctor may wish to document healing with repeat x-rays or endoscopy.
Continued monitoring of a stomach ulcer is important because of the small
chance that the ulcer may be cancerous.
Testing for H. pylori
Confirming the presence of H. pylori is important once the
doctor has diagnosed an ulcer because elimination of the bacteria is
likely to cure ulcer disease. Blood, breath, and stomach tissue tests may
be performed to detect the presence of H. pylori. While some of the
tests for H. pylori are not approved by the U.S. Food and Drug
Administration (FDA), research shows these tests are highly accurate in
detecting the bacteria. However, blood tests on occasion give false
positive results, and the other tests may give false negative results in
people who have recently taken antibiotics, omeprazole (Prilosec®), or bismuth (Pepto-Bismol®).
Blood tests such as the enzyme-linked immunosorbent assay (ELISA) and
quick office-based tests identify and measure H. pylori antibodies.
The body produces antibodies against H. pylori in an attempt to
fight the bacteria. The advantages of blood tests are their low cost and
availability to doctors. The disadvantage is the possibility of false
positive results in patients previously treated for ulcers since the
levels of H. pylori antibodies fall slowly. Several blood tests
have FDA approval.
Breath tests measure carbon dioxide in exhaled breath. Patients are
given a substance called urea with carbon to drink. Bacteria break down
this urea and the carbon is absorbed into the blood stream and lungs and
exhaled in the breath. By collecting the breath, doctors can measure this
carbon and determine whether H. pylori is present or absent. Urea breath
tests are at least 90 percent accurate for diagnosing the bacteria and are
particularly suitable to follow-up treatment to see if bacteria have been
eradicated. These tests are awaiting FDA approval.
If the doctor performs an endoscopy to diagnose an ulcer, tissue
samples of the stomach can be obtained. The doctor may then perform one of
several tests on the tissue. A rapid urease test detects the bacteria's
enzyme urease. Histology involves visualizing the bacteria under the
microscope. Culture involves specially processing the tissue and watching
it for growth of H. pylori organisms.
How Are Ulcers Treated?
In the past, doctors advised people with ulcers to avoid spicy, fatty,
or acidic foods. However, a bland diet is now known to be ineffective for
treating or avoiding ulcers. No particular diet is helpful for most ulcer
patients. People who find that certain foods cause irritation should
discuss this problem with their doctor. Smoking has been shown to delay
ulcer healing and has been linked to ulcer recurrence; therefore, persons
with ulcers should not smoke.
Doctors treat stomach and duodenal ulcers with several types of
medicines including H2-blockers, acid pump inhibitors, and mucosal
protective agents. When treating H. pylori, these medications are used in
combination with antibiotics.
Currently, most doctors treat ulcers with acid-suppressing drugs known
as H2-blockers. These drugs reduce the amount of acid the stomach produces
by blocking histamine, a powerful stimulant of acid secretion.
H2-blockers reduce pain significantly after several weeks. For the
first few days of treatment, doctors often recommend taking an antacid to
Initially, treatment with H2-blockers lasts 6 to 8 weeks. However,
because ulcers recur in 50 to 80 percent of cases, many people must
continue maintenance therapy for years. This may no longer be the case if
H. pylori infection is treated. Most ulcers do not recur following
successful eradication. Nizatidine (Axid®)
is approved for treatment of duodenal ulcers but is not yet approved for
treatment of stomach ulcers. H2-blockers that are approved to treat both
stomach and duodenal ulcers are:
- Cimetidine (Tagamet®)
- Ranitidine (Zantac®)
- Famotidine (Pepcid®).
Acid pump inhibitors
Like H2-blockers, acid pump inhibitors modify the stomach's production
of acid. However, acid pump inhibitors more completely block stomach acid
production by stopping the stomach's acid pump--the final step of acid
secretion. The FDA has approved use of omeprazole for short-term treatment
of ulcer disease. Similar drugs, including lansoprazole, are currently
Mucosal protective medications
Mucosal protective medications protect the stomach's mucous lining from
acid. Unlike H2-blockers and acid pump inhibitors, protective agents do
not inhibit the release of acid. These medications shield the stomach's
mucous lining from the damage of acid. Two commonly prescribed protective
- Sucralfate (Carafate®). This
medication adheres to the ulcer, providing a protective barrier that
allows the ulcer to heal and inhibits further damage by stomach acid.
Sucralfate is approved for short-term treatment of duodenal ulcers and
for maintenance treatment.
- Misoprostol (Cytotec®). This
synthetic prostaglandin, a substance naturally produced by the body,
protects the stomach lining by increasing mucus and bicarbonate
production and by enhancing blood flow to the stomach. It is approved
only for the prevention of NSAID-induced ulcers.
Two common non-prescription protective medications are:
- Antacids. Antacids can offer temporary relief from ulcer pain
by neutralizing stomach acid. They may also have a mucosal protective
role. Many brands of antacids are available without prescription.
- Bismuth Subsalicylate. Bismuth subsalicylate has both a
protective effect and an antibacterial effect against H. pylori.
The discovery of the link between ulcers and H. pylori has
resulted in a new treatment option. Now, in addition to treatment aimed at
decreasing the production of stomach acid, doctors may prescribe
antibiotics for patients with H. pylori. This treatment is a
dramatic medical advance because eliminating H. pylori means the
ulcer may now heal and most likely will not come back.
The most effective therapy, according to the NIH Panel, is a 2-week,
triple therapy. This regimen eradicates the bacteria and reduces the risk
of ulcer recurrence in 90 percent of people with duodenal ulcers. People
with stomach ulcers that are not associated with NSAIDs also benefit from
bacterial eradication. While triple therapy is effective, it is sometimes
difficult to follow because the patient must take three different
medications four times each day for 2 weeks.
In addition, the treatment commonly causes side effects such as yeast
infection in women, stomach upset, nausea, vomiting, bad taste, loose or
dark bowel movements, and dizziness. The 2-week, triple therapy combines
two antibiotics, tetracycline (e.g., Achromycin® or Sumycin®) and
metronidazole (e.g., Flagyl ®) with
bismuth subsalicylate (Pepto-Bismol ®).
Some doctors may add an acid-suppressing drug to relieve ulcer pain and
promote ulcer healing. In some cases, doctors may substitute amoxicillin
(e.g., Amoxil® or Trimox ®) for tetracycline or if they expect bacterial
resistance to metronidazole, other antibiotics such as clarithromycin
As an alternative to triple therapy, several 2-week, dual therapies are
about 80 percent effective. Dual therapy is simpler for patients to follow
and causes fewer side effects. A dual therapy might include an antibiotic,
such as amoxicillin or clarithromycin, with omeprazole, a drug that stops
the production of acid.
Again, an accurate diagnosis is important. Accurate diagnosis and
appropriate treatment prevent people without ulcers from needless exposure
to the side effects of antibiotics and should lessen the risk of bacteria
developing resistance to antibiotics.
Although all of the above antibiotics are sold in the United States,
the FDA has not yet approved the use of antibiotics for treatment of H.
pylori or ulcers. Doctors may choose to prescribe antibiotics to their
ulcer patients as "off label" prescriptions as they do for many
|Typical 2-week, triple therapy
Typical 2-week, dual therapy
- Metronidazole 4 times a day
- Tetracycline (or amoxicillin) 4 times a day
- Bismuth subsalicylate 4 times a day
- Amoxicillin 2 to 4 times a day, or clarithromycin
- Omeprazole 2 times a day
When Is Surgery Needed?
|In most cases, anti-ulcer medicines heal ulcers
quickly and effectively. Eradication of H. pylori prevents most
ulcers from recurring. However, people who do not respond to medication or
who develop complications may require surgery. While surgery is usually
successful in healing ulcers and preventing their recurrence and future
complications, problems can sometimes result.
At present, standard open surgery is performed to treat ulcers. In the
future, surgeons may use laparoscopic methods. A laparoscope is a long
tube-like instrument with a camera that allows the surgeon to operate
through small incisions while watching a video monitor. The common types
of surgery for ulcers--vagotomy, pyloroplasty, and antrectomy--are
A vagotomy involves cutting the vagus nerve, a nerve that transmits
messages from the brain to the stomach. Interrupting the messages sent
through the vagus nerve reduces acid secretion. However, the surgery may
also interfere with stomach emptying. The newest variation of the surgery
involves cutting only parts of the nerve that control the acid-secreting
cells of the stomach, thereby avoiding the parts that influence stomach
Another surgical procedure is the antrectomy. This operation removes
the lower part of the stomach (antrum), which produces a hormone that
stimulates the stomach to secrete digestive juices. Sometimes a surgeon
may also remove an adjacent part of the stomach that secretes pepsin and
acid. A vagotomy is usually done in conjunction with an antrectomy.
Pyloroplasty is another surgical procedure that may be performed along
with a vagotomy. Pyloroplasty enlarges the opening into the duodenum and
small intestine (pylorus), enabling contents to pass more freely from the
What Are the Complications of Ulcers?
|People with ulcers may experience serious
complications if they do not get treatment. The most common problems
include bleeding, perforation of the organ walls, and narrowing and
obstruction of digestive tract passages.
As an ulcer eats into the muscles of the stomach or duodenal wall,
blood vessels may also be damaged, which causes bleeding. If the affected
blood vessels are small, the blood may slowly seep into the digestive
tract. Over a long period of time, a person may become anemic and feel
weak, dizzy, or tired.
If a damaged blood vessel is large, bleeding is dangerous and requires
prompt medical attention. Symptoms include feeling weak and dizzy when
standing, vomiting blood, or fainting. The stool may become a tarry black
color from the blood.
Most bleeding ulcers can be treated endoscopically--the ulcer is
located and the blood vessel is cauterized with a heating device or
injected with material to stop bleeding. If endoscopic treatment is
unsuccessful, surgery may be required.
Sometimes an ulcer eats a hole in the wall of the stomach or duodenum.
Bacteria and partially digested food can spill through the opening into
the sterile abdominal cavity (peritoneum). This causes peritonitis, an
inflammation of the abdominal cavity and wall. A perforated ulcer that can
cause sudden, sharp, severe pain usually requires immediate
hospitalization and surgery.
Narrowing and obstruction
Ulcers located at the end of the stomach where the duodenum is
attached, can cause swelling and scarring, which can narrow or close the
intestinal opening. This obstruction can prevent food from leaving the
stomach and entering the small intestine. As a result, a person may vomit
the contents of the stomach. Endoscopic balloon dilation, a procedure that
uses a balloon to force open a narrow passage, may be performed. If the
dilation does not relieve the problem, then surgery may be necessary.
Points to Remember|
- An ulcer is a sore or lesion that forms in the lining of the
stomach or duodenum where the digestive fluids acid and pepsin are
- Recent research shows that most ulcers develop as a result of
infection with bacteria called Helicobacter pylori (H.
pylori). The bacteria produce substances that weaken the
stomach's protective mucus and make the stomach more susceptible
to damaging effects of acid and pepsin.H. pylori can also
cause the stomach to produce more acid. Although acid and pepsin
and lifestyle factors such as stress and smoking cigarettes play a
role in ulcer formation,H. pylori is now considered the
- Nonsteroidal anti-inflammatory drugs such as aspirin make the
stomach vulnerable to the harmful effects of acid and pepsin,
leading to an increased chance of stomach ulcers.
- Ulcers do not always cause symptoms. When they do, the most
common symptom is a gnawing or burning pain in the abdomen between
the breastbone and naval. Some people have nausea, vomiting, and
loss of appetite and weight.
- Bleeding from an ulcer may occur in the stomach and duodenum.
Symptoms may include weakness and stool that appears tarry or
black. However, sometimes people are not aware they have a
bleeding ulcer because blood may not be obvious in the stool.
- Ulcers are diagnosed with x-ray or endoscopy. The presence of
H. pylori may be diagnosed with a blood test, breath test,
or tissue test. Once an ulcer is diagnosed and treatment begins,
the doctor will usually monitor progress.
- Doctors treat ulcers with several types of medicines aimed at
reducing acid production, including H2-blockers, acid pump
inhibitors, and mucosal protective drugs. When treating H.
pylori, these medications are used in combination with
- According to an NIH panel, the most effective treatment for
H. pylori is a 2-week, triple therapy of metronidazole,
tetracycline or amoxicillin, and bismuth subsalicylate.
- Surgery may be necessary if an ulcer recurs or fails to heal
or if complications such as bleeding, perforation, or obstruction
|Although ulcers may cause discomfort, rarely are
they life threatening. With an understanding of the causes and proper
treatment, most people find relief. Eradication of H. pylori
infection is a major medical advance that can permanently cure most peptic
Recommended Ulcer Resources
Zantac 150 Tablets, Cool Mint, 65-Count Bottle
Living with Ulcers/GERD (Home Use) DVD
Why Zebras Don't Get Ulcers, Third Edition
The Doctors Book of Food Remedies: The Latest Findings on the Power of Food to Treat and Prevent Health Problems - From Aging and Diabetes to Ulcers and Yeast Infections
Healthy Digestion the Natural Way: Preventing and Healing Heartburn, Constipation, Gas, Diarrhea, Inflammatory Bowel and Gallbladder Diseases, Ulcers, Irritable Bowel Syndrome, and More
Contemporary Diagnosis And Management of H Pylori-Associated Gastrointestinal Diseases
|DeCross AJ, Peura DA. Role of H. Pylori
in peptic ulcer disease. Contemporary Gastroenterology, 1992; 5(4):
Fedotin MS. Helicobacter pylori and peptic ulcer disease:
Reexamining the therapeutic approach. Postgraduate Medicine, 1993;
Gilbert G, Chan CH, Thomas E. Peptic ulcer disease: How to treat it
now. Postgraduate Medicine, 1991; 89(4): 91-98.
Larson DE, Editor-in-Chief. Mayo Clinic Family Health Book. New
York: William Morrow and Company, Inc., 1990. General medical guide with
sections on stomach problems and ulcers.
National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD 20892-3570
E-mail: National Digestive
Diseases Information Clearinghouse
The National Digestive Diseases Information Clearinghouse (NDDIC) is a
service of the National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK). The NIDDK is part of the National Institutes of Health
under the U.S. Public Health Service. Established in 1980, the
clearinghouse provides information about digestive diseases to people with
digestive disorders and to their families, health care professionals, and
the public. NDDIC answers inquiries; develops, reviews, and distributes
publications; and works closely with professional and patient
organizations and Government agencies to coordinate resources about
Publications produced by the clearinghouse are reviewed carefully for
scientific accuracy, content, and readability.
This e-text is not copyrighted. The clearinghouse encourages users of
this e-pub to duplicate and distribute as many copies as desired.
NIH Publication No. 95-38