THE PATIENT’S ILLNESS

A. DEFINITION OF THE DISEASE

Peptic ulcers are open sores that develop on the inside lining of your
stomach, upper small intestine or esophagus. The most common symptom of a
peptic ulcer is abdominal pain.
It wasn't too long ago that lifestyle factors, such as a love of spicy foods or
a stressful job, were thought to be at the root of most peptic ulcers. Doctors now
know that a bacterial infection or some medications — not stress or diet — cause
most peptic ulcers.
Peptic ulcers are common, affecting as many as 10 percent of Americans at
some point in their lives. The good news is that successful treatment of peptic
ulcers is possible.

Depending on their location, peptic ulcers have different names:

 Gastric ulcer. This is a peptic ulcer that occurs in your stomach.
 Duodenal ulcer. This type of peptic ulcer develops in the first part of the small
intestine (duodenum).
 Esophageal ulcer. An esophageal ulcer is usually located in the lower section
of your esophagus. It's often associated with chronic gastroesophageal reflux
disease (GERD).

B. SIGNS AND SYMPTOMS

Burning pain is the most common peptic ulcer symptom. The pain is caused by
the ulcer and is aggravated by stomach acid coming in contact with the ulcerated
area. The pain typically may:
 Be felt anywhere from your navel up to your breastbone
 Last from a few minutes to several hours
 Be worse when your stomach is empty
 Flare at night
 Often be temporarily relieved by eating certain foods that buffer stomach acid
or by taking an acid-reducing medication
 Disappear and then return for a few days or weeks
Less often, ulcers may cause severe signs or symptoms such as:
 The vomiting of blood — which may appear red or black
 Dark blood in stools or stools that are black or tarry
 Nausea or vomiting
 Unexplained weight loss
 Appetite changes

When to see a doctor

An ulcer isn't something that you should treat on your own, without a doctor's
help. Over-the-counter antacids and acid blockers may relieve the gnawing pain,
but the relief is short-lived. If you have signs or symptoms of an ulcer, see your
doctor for treatment.

C. PRECIPITATING AND PREDISPOSING FACTORS

a. PRECIPITATING FACTORS
Although stress and spicy foods were once thought to be the main causes
of peptic ulcers, doctors now know that the cause of most ulcers is the
corkscrew-shaped bacterium Helicobacter pylori (H. pylori).

H. pylori lives and multiplies within the mucous layer that covers and
protects tissues that line the stomach and small intestine. Often, H. pylori causes
no problems. But sometimes it can disrupt the mucous layer and inflame the
lining of your stomach or duodenum, producing an ulcer.

H. pylori is a common gastrointestinal infection. In the United States, one

in five people younger than 30 and half the people older than 60 are infected.
Although it's not clear exactly how H. pylori spreads, it may be transmitted from
person to person by close contact, such as kissing. People may also contract H.
pylori through food and water.
 H. pylori is the most common, but not the only, cause of peptic ulcers.
b. PREDISPOSING FACTORS
 Regular use of pain relievers. Nonsteroidal anti-inflammatory drugs (NSAIDs)
can irritate or inflame the lining of your stomach and small intestine. These
medications, which are available both by prescription and over-the-counter,
include aspirin, ibuprofen (Advil, Motrin, others), naproxen (Aleve), ketoprofen
and others. To help avoid digestive upset, take NSAIDs with meals. If you have
been diagnosed with an ulcer, make sure your doctor knows this when
prescribing any pain reliever. Other medications that contain NSAIDs are Alka-
Seltzer and bismuth subsalicylate (Pepto-Bismol, others). Unfortunately, some
people take these medications for symptoms of peptic ulcer, but they can make
the condition worse. Other prescription medications that can also lead to ulcers
include medications used to treat osteoporosis called bisphosphonates
(Actonel, Fosamax and others).

NSAIDs inhibit production of an enzyme (cyclooxygenase) that produces

prostaglandins. These hormone-like substances help protect your stomach
lining from chemical and physical injury. Without this protection, stomach acid
can erode the lining, causing bleeding and ulcers.

 Smoking. Nicotine in tobacco increases the volume and concentration of

stomach acid, increasing your risk of an ulcer. Smoking may also slow healing
during ulcer treatment.

 Excessive alcohol consumption. Alcohol can irritate and erode the mucous
lining of your stomach and increases the amount of stomach acid that's
produced. It's uncertain, however, whether this alone can progress into an ulcer
or if it just aggravates the symptoms of an existing ulcer.

 Stress. Although stress per se isn't a cause of peptic ulcers, it's a contributing
factor. Stress may aggravate symptoms of peptic ulcers and, in some cases,
 delay healing. You may undergo stress for a number of reasons — an
emotionally disturbing circumstance or event, surgery, or a physical trauma,
such as a burn or other severe injury.

D. HEALTH PROMOTION AND MANAGEMENT

a. TREATMENT AND DRUGS
Because many ulcers stem from H. pylori bacteria, doctors use a two-
pronged approach to peptic ulcer treatment:
 Kill the bacteria.
 Reduce the level of acid in your digestive system to relieve pain and
encourage healing.

Accomplishing these two goals requires the use of at least two, and sometimes
three or four, of the following medications:
 Antibiotic medications. Doctors use combinations of antibiotics to treat
H. pylori because one antibiotic alone isn't always sufficient to kill the
organism. For the treatment to work, follow your doctor's instructions
precisely. Antibiotics prescribed for treatment of H. pylori include
amoxicillin (Amoxil), clarithromycin (Biaxin) and metronidazole (Flagyl).
Combination drugs that include two antibiotics together with an acid
suppressor or cytoprotective agent (Helidac, Prevpac) have been
designed specifically for the treatment of H. pylori infection. You'll likely
need to take antibiotics for two weeks, depending on their type and
number. Other medications prescribed along with antibiotics generally are
taken for a longer period.

 Acid blockers. Acid blockers — also called histamine (H-2) blockers —

reduce the amount of hydrochloric acid released into your digestive tract,
which relieves ulcer pain and encourages healing. Acid blockers work by
keeping histamine from reaching histamine receptors. Histamine is a
substance normally present in your body. When it reacts with histamine
 receptors, the receptors signal acid-secreting cells in your stomach to
release hydrochloric acid. Available by prescription or over-the-counter
(OTC), acid blockers include the medications ranitidine (Zantac),
famotidine (Pepcid), cimetidine (Tagamet) and nizatidine (Axid).

 Antacids. Your doctor may include an antacid in your drug regimen. An

antacid may be taken in addition to an acid blocker or in place of one.
Instead of reducing acid secretion, antacids neutralize existing stomach
acid and can provide rapid pain relief.

 Proton pump inhibitors. Another way to reduce stomach acid is to shut

down the "pumps" within acid-secreting cells. Proton pump inhibitors
reduce acid by blocking the action of these tiny pumps. These drugs
include the prescription and over-the-counter medications omeprazole
(Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex) and
esomeprazole (Nexium). The drug pantoprazole (Protonix) can be taken
orally or administered intravenously in the hospital. Doctors frequently
prescribe proton pump inhibitors to promote the healing of peptic ulcers. If
you're admitted to the hospital with a bleeding ulcer, taking intravenous
proton pump inhibitors decreases the chance that bleeding will recur.
Proton pump inhibitors also appear to inhibit H. pylori. However, long-term
use of proton pump inhibitors, particularly at high doses, may increase
your risk of hip fracture. Ask your doctor if you need a calcium supplement
while taking these medications.

 Cytoprotective agents. In some cases, your doctor may prescribe these

medications that help protect the tissues that line your stomach and small
intestine. They include the prescription medications sucralfate (Carafate)
and misoprostol (Cytotec). Another nonprescription cytoprotective agent is
bismuth subsalicylate (Pepto-Bismol).
 If H. pylori isn't identified in your system, then it's likely that your ulcer is
due to NSAIDs — which you should stop using, if possible — or acid reflux,
which can cause esophageal ulcers. In both cases, your doctor will try to reduce
acid levels — through use of acid blockers, antacids or proton pump inhibitors —
and may also have you use cytoprotective drugs.

Ulcers that fail to heal

Peptic ulcers that don't heal with treatment are called refractory ulcers.
There are many reasons why an ulcer may fail to heal. These reasons may
include:
 Not taking medications according to directions.
 The fact that some types of H. pylori are resistant to antibiotics.
 Regular use of tobacco.
 Regular use of alcohol.
 Regular use of nonsteroidal anti-inflammatory drugs (NSAIDs).
Sometimes the problem is accidental: People may be unaware that
a medication they're taking contains an NSAID.

Less often, refractory ulcers may be a result of:

 Extreme overproduction of stomach acid, such as occurs in
Zollinger-Ellison syndrome
 An infection other than H. pylori
 Stomach cancer
 Other diseases, including cirrhosis and chronic obstructive
pulmonary disorder (COPD)

Treatment for refractory ulcers generally involves eliminating factors that may
interfere with healing, along with stronger doses of ulcer medications.
Sometimes, additional medications may be included. Surgery to help heal an
ulcer is necessary only when the ulcer doesn't respond to aggressive drug
treatment.
b. LIFESTYLE AND HOME REMEDIES
Before the discovery of H. pylori, doctors often advised people with ulcers to
eat a restricted diet and reduce the amount of stress in their lives. Now that food
and stress have been eliminated as direct causes of ulcers, these factors are no
longer of as much importance.

However, while an ulcer is healing, it's still advisable to watch what you
eat and to control stress. Acidic or spicy foods may increase ulcer pain. The
same is true for stress because stress may increase acid. If stress is severe, it
may delay the healing of an ulcer.

Your doctor may also give you these helpful suggestions:

 Don't smoke. Smoking may interfere with the protective lining of the
stomach, making your stomach more susceptible to the development of an
ulcer. Smoking also increases stomach acid.

 Limit or avoid alcohol. Excessive use of alcohol can irritate and erode the
mucous lining in your stomach and intestines, causing inflammation and
bleeding.

 Avoid nonsteroidal anti-inflammatory drugs (NSAIDs). If you use pain

relievers regularly, use acetaminophen (Tylenol, others).

 Control acid reflux. If you have an esophageal ulcer — usually associated

with acid reflux — you can take several steps to help manage acid reflux.
These include avoiding spicy and fatty foods, avoiding reclining after meals,
raising the head of your bed and reducing your weight. Avoiding smoking,
alcohol and NSAIDs also may help to control acid reflux.
E. COMPLICATIONS
Left untreated, peptic ulcers can result in:
 Internal bleeding. Bleeding can occur as slow blood loss that leads to
anemia or as severe blood loss that may require hospitalization or a blood
transfusion.
 Infection. Peptic ulcers can eat a hole through the wall of your stomach or
small intestine, putting you at risk of serious infection of your abdominal cavity
(peritonitis).
 Scar tissue. Peptic ulcers can also produce scar tissue that can obstruct
passage of food through the digestive tract, causing you to become full
easily, to vomit and to lose weight.

F. TEST AND DIAGNOSTICS

In order to detect an ulcer, you may have to undergo diagnostic tests, such as:
 Blood test. This test checks for the presence of H. pylori antibodies. A
disadvantage of this test is that it sometimes can't differentiate between
past exposure and current infection. Additionally, a false-negative is
possible if you've recently been taking certain drugs, such as antibiotics or
proton pump inhibitors.

 Breath test. This procedure uses a radioactive carbon atom to detect H.

pylori. For the test, you drink a small glass of clear, tasteless liquid. The
liquid contains radioactive carbon as part of a substance (urea) that will be
broken down by H. pylori. Less than an hour later, you blow into a bag,
which is then sealed. If you're infected with H. pylori, your breath sample
will contain the radioactive carbon in the form of carbon dioxide.

The advantage of the breath test is that it can monitor the effectiveness of
treatment used to eradicate H. pylori, detecting whether the bacteria have been
killed or eradicated.
  Stool antigen test. This test checks for H. pylori in stool samples. It's
useful both in helping to diagnose H. pylori infection and in monitoring the
success of treatment.
 Upper gastrointestinal (upper GI) X-ray. This test outlines your
esophagus, stomach and duodenum. During the X-ray, you swallow a
white, metallic liquid (containing barium) that coats your digestive tract and
makes an ulcer more visible. An upper GI X-ray can detect some ulcers,
but not all.

 Endoscopy. This procedure may follow an upper GI X-ray if the X-ray

suggests a possible ulcer, or your doctor may perform endoscopy first. In
this more sensitive procedure, a long, narrow tube with an attached
camera is threaded down your throat and esophagus into your stomach
and duodenum. With this instrument, your doctor can view your upper
digestive tract and identify an ulcer. Your doctor will perform this test if you
have other signs or symptoms, such as difficulty swallowing, weight loss,
vomiting (particularly vomiting red or black material that looks like coffee
grounds), black stools or anemia.
If your doctor detects an ulcer, he or she may remove small tissue samples
(biopsy) near the ulcer. These samples are examined under a microscope to rule
out cancer. A biopsy can also identify the presence of H. pylori in your stomach
lining. Depending on where the ulcer is found, your doctor may recommend a
repeat endoscopy after two to three months to confirm that the ulcer is healing.