Peptic Ulcer

Peptic ulcer is usually a non-malignant ulcer of the stomach (called gastric ulcer) or duodenum (called duodenal ulcer). About 4 % of gastric ulcers are caused by malignant tumour, which is why ulcers of stomach are controlled. Duodenal ulcers are non-malignant. By far most instances are now known to be due to Helicobacter pylori, a spiral-shaped bacterium that lives in the acid environment of the stomach. These ulcers can also be caused or worsened by drugs such as Aspirin and other NSAIDs.

Signs and symptoms
Symptoms of a peptic ulcer can be:

Abdominal pain;
Hematemesis (vomiting blood);
Melena (tarry feces due to oxidised iron from hemoglobin);
Weight loss;
Rarely, an ulcer can lead to a gastric or duodenal perforation. This is extremely painful and requires immediate surgery.
A history of heartburn, gastroesophageal reflux disease (GERD) and use of certain forms of medication can raise the suspicion for peptic ulcer. Medicines associated with peptic ulcer are NSAID (non-steroid anti-inflammatory drugs) that inhibit cyclooxygenase 1, and most glucocorticoids (e.g. dexamethasone).

In patients over 45 with more than 2 weeks of the above symptoms the odds for peptic ulceration are high enough to warrant rapid investigation by EGD (see below).

The timing of the symptoms in relation to the meal may differentiate between gastric and duodenal ulcers: A gastric ulcer would give epigastric pain during the meal, as gastric acid is secreted, or after the meal, as the alkaline duodenal contents reflux into the stomach. Symptoms of duodenal ulcers would manifest mostly before the meal — when acid (production stimulated by hunger) is passed into the duodenum.

Diagnosis
In patients in whom peptic ulcer is suspected, esophagogastroduodenoscopy (EGD, a form of endoscopy) is indicated. By direct visual identification, the location and severity of an ulcer can be described. Moreover, if no ulcer is present, EGD can often provide an alternative diagnosis.

The diagnosis of Helicobacter pylori can be by:

Biopsy during EGD;
Breath testing (does not require EGD);
Direct culture from an EGD biopsy specimen;
Direct detection of urease activity in a biopsy specimen;
Measurement of antibody levels in blood (does not require EGD). It is still slightly controversial whether a positive antibody without EGD is enough to warrant eradication therapy.
The possibility of other causes of ulcers, notably malignancy (gastric cancer) needs to be kept in mind. This is especially true in ulcers of the large curvature of the stomach; most are also a consequence of chronic H. pylori infection.

Treatment
Younger patients with ulcer-like symptoms are often treated with antacids or H2 antagonists before EGD is undertaken. Bismuth compounds may actually reduce or even clear organisms.

When H. pylori infection is present, the most effective treatments are combinations of 2 antibiotics (e.g. Erythromycin, Ampicillin, Amoxicillin, Tetracycline, Metronidazole) and 1 proton pump inhibitor (PPI). An effective combination would be Amoxicillin + Metronidazole + Pantoprazole (a PPI). In the absence of H. pylori, long-term higher dose PPIs are often used.

Treatment of Helicobacter usually leads to clearing of infection, relief of symptoms and eventual healing of ulcers. Recurrence of infection can occur and retreatment may be required, if necessary with other antibiotics. However, there is mounting evidence of the fact that H. pylori may be protective against certain diseases of the esophagus and cardia, including GERD, Barrett's esophagus, and esophageal adenocarcinoma (a particularly deadly form of cancer). Therefore, a more cautious approach to its eradication may be necessary.