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Reviewed by Dr Stephen C P Collins, GP
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What is an ulcer?
An ulcer is damage to the inner lining (the mucosa) of the
stomach or the upper part of the intestine (duodenum). A bacterium,
Helicobacter pylori, is the main cause of ulcers in this
area.
Why do people get ulcers?
The most common cause is infection with Helicobacter
pylori
bacteria and this is
responsible for up to 90 per cent of all cases of peptic
ulceration.
The second most common cause is damage inflicted by
aspirin (eg Disprin)
or
non-steroidal anti-inflammatory drugs
(NSAIDs, such as
diclofenac (eg Voltarol)
or
naproxen (eg Synflex)) used by
many for
arthritis,
rheumatism,
backache,
headaches and
period
pain.
Ulcers can also occur in people weakened by severe disease (such
as chronic respiratory disease or major trauma). This is thought to result from
poor oxygenation to the lining of the stomach.
Occasionally (in Europeans), a stomach ulcer is caused by cancer
and rarely, some other specific illness is found to be responsible. Such
conditions include:
-
excessive production of hydrochloric acid in the stomach
(Zollinger-Ellison syndrome)
-
Crohn's disease
(an inflammatory condition affecting any part of the gut).
What does an ulcer feel like?
This varies greatly from person to person. Many people never
realise that they have an ulcer. Others feel pain or a burning sensation in
their upper abdomen.
The symptoms are often described as indigestion,
heartburn, hunger
pangs or dyspepsia.
Some sufferers find that eating actually helps settle their
discomfort for a while, others find it makes them worse. Citrus drinks, spicy
and smoked foods can make the pain worse.
Finally, it is important to stress that most people with a
stomach ache do not have ulcers.
An ulcer is potentially dangerous - the warning signs
are:
-
difficulty swallowing or regurgitation
-
persistent nausea and vomiting
-
vomiting blood or vomit with the appearance of coffee
grounds
-
black or tar-like stools
-
unintended weight loss
-
anaemia (paleness and fatigue)
-
sudden, severe and incapacitating abdominal pains.
What can I do to help myself?
-
Smoking and drinking
alcohol puts you at greater risk of developing an ulcer. It's a good idea
to
stop smoking and
moderate your
alcohol
intake.
-
If for any reason you have an increased risk of ulcers, it is
important to seek advice before considering NSAIDs or aspirin.
-
If you experience the symptoms of an ulcer, consult your
doctor. You may need a thorough examination in hospital with a
gastroscopy. This is
a safe and commonly performed procedure that will help your doctor decide
whether your symptoms are due to an ulcer or something else.
How does the doctor make a diagnosis?
The diagnosis can only be definitely confirmed or excluded by a
gastroscopy. A
gastroscopy (or upper
GI endoscopy) involves the visualisation of the lining of your gullet
(oesophagus), stomach and duodenum with a small fibre-optic camera that can be
swallowed.
The gastroscopy is more helpful in diagnosis if it is performed
before you take any
acid-reducing medication.
An
X-ray examination
(involving a Barium meal) can also be used, but it is not quite as reliable or
helpful a diagnostic tool as a gastroscopy. It does not offer any opportunity
to take tissue samples (biopsies) for
microscopic diagnosis of tissue abnormalities and infection.
What is Helicobacter pylori?
Helicobacter pylori is a minute
bacteria living
inside and under the lining of the stomach. The groups most often affected
are:
-
elderly people
-
people in developing countries.
Those who carry this bacteria today have most probably been
infected during childhood. The risk of acquiring infection for an adult is
modest - less than 1 per cent every year.
Helicobacter pylori in itself does not
usually cause any ulcer symptoms. Nevertheless, this bacteria is the most
common cause of ulcers in the stomach and the duodenum.
The bacteria may also have a role in the development of
cancer of the
stomach. Helicobacter pylori infection can be
eliminated by taking antibiotics. There is about an 80 per cent chance of
successful treatment of the infection and a cure for the ulcer.
If the bacteria is not eliminated, most people get a recurrence
of their ulcer after a short period of time.
How to detect an infection by Helicobacter pylori
-
Gastroscopy, followed by biopsy of the lining of the stomach
(the mucosa) can allow the bacteria, inflammation, and tissue abnormalities to
be assessed under a microscope. From a biopsy, tissue from the mucosa can be
cultured and an indicator fluid (a urease test) can verify the presence of
bacteria.
-
'Breath test' examination: the expired air is tested,
after ingestion of a small amount of labelled urea (in crystalline
form).
-
Blood sample: if you have, or have had, Helicobacter
pylori, it can be detected by the presence of antibodies in your
blood.
-
Stool sample: this technique is not yet perfected. But the
method involves tracing bacterial DNA in stool samples.
Who should be screened and treated for Helicobacter
pylori?
These questions continue to be debated.
-
All patients with a proven ulcer of the stomach or duodenum
should be tested, and treated if the bacteria is found.
-
People under the age of 45 with ulcer-like symptoms can avoid
gastroscopy by choosing the breath test. If it is positive for
Helicobacter pylori infection the patient should be
treated with
antibiotics.
-
People with diagnosed
lymphatic cancer of
the stomach (very rare) should be examined and, if the bacteria are present,
treated.
-
People with diagnosed early stages of
cancer of the stomach
should be examined and treated if the bacteria are present.
-
Almost everyone with a past history of proven ulcers in the
duodenum has Helicobacter pylori and, therefore, it has
been proposed that these people could be treated without testing.
-
Anyone with ulcer-like symptoms, but a normal gastroscopy, will
not benefit from testing or treatment.
Which types of medicine can cause ulcers and ulcer
complications?
Aspirin (eg Disprin) and
non-steroidal anti-inflammatory drugs
(NSAIDs such as diclofenac or naproxen) can cause ulcers, but only a small
proportion of the people taking these drugs develop an ulcer. However, because they are so widely used, hundreds
of people in the UK die each year as a result of ulcer complications associated
with these drugs.
Some people have a very high sensitivity to aspirin and NSAIDs
and such people should not take this sort of medication.
If you have previously had a bleeding ulcer, you must not take
medicine that includes aspirin (acetylsalicylic acid) or NSAIDs.
Who is at risk from treatment with aspirin (acetylsalicylic acid)
and NSAIDs?
-
People older than 60 - the risk increases with age.
-
If you have had a previous ulcer, the risk is high.
-
If you are taking
anticoagulants (blood-thinning
treatment) at the same time, bleeding is more likely and more serious when it
occurs.
-
Oral
corticosteriods (such as
prednisolone (eg Precortisyl))
increase the chances of gastric irritation and ulcers.
-
The larger the dose of aspirin or NSAIDs the greater the
risk.
-
The longer duration of the treatment, the greater the
risk.
Can I reduce the risk from aspirin or NSAIDs?
If you are predisposed to this problem, the risk is not
diminished by taking the medication:
-
on a full stomach
-
as a dissolved or glazed tablet ('enteric
coated')
-
through other routes, such as suppositories or
injections.
However, acid-reducing medication (H2 inhibitors,
such as
ranitidine (eg Zantac)
or
nizatidine (Axid)) does
diminish the ulcer risk associated with aspirin and NSAIDs.
Treatment with another medicine called misoprostol (eg Cytotec) offers protection for the mucosa and is also potentially beneficial.
Misoprostol can cause diarrhoea but this tendency varies from person to
person.
Can you avoid treatment with NSAIDs?
Pain can often be alleviated by medication that does not
predispose to peptic ulceration.
Paracetamol (eg Panadol)
may be
worth trying in this respect, as it is not associated with peptic
ulceration.
Headaches,
migraine and chronic
abdominal pain are conditions for which NSAIDs can easily be substituted by
other painkillers.
In the case of
gout, acute attacks can be treated
with other drugs such as
colchicine instead
of NSAIDs.
For arthritis, traditional NSAIDs can be replaced with a new
sub-group of NSAIDS called cox-2 selective inhibitors, eg
celecoxib (Celebrex)
or etoricoxib (Arcoxia). These
have a lower risk of serious gastrointestinal side effects and can be used for
people at high risk, eg people over 65 years of age or those taking other
medicines that increase the risk of ulcers. However, as these medicines can
still cause ulcers, they should not be used in people with an active ulcer, and
only after careful consideration in people with a history of
ulcers.
Can you avoid treatment with aspirin?
In many cases, aspirin can be substituted with other medication,
such as paracetamol, which will not predispose to peptic ulcers and yet offer
the same therapeutic effect. In the case of aspirin, paracetamol is equally
effective with no ulcer risk. When low dose aspirin (eg Caprin 75mg)
is prescribed for
the reduction of cardiovascular risk (complications arising from
'hardening of the arteries' -
atherosclerosis), a
balance needs to be struck between the risk of heart/arterial disease and the
risk of peptic ulceration.
If you have a history of peptic ulcers, your cardiovascular risk
can be reduced with alternatives to aspirin, such as
dipyridamole (Persantin) or
Clopidogrel (Plavix).
The relative risk of each of these conditions and their
management varies from person to person, so it is always worth talking it over
with your doctor.
Good advice
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Ways to quit smoking
Go cold turkey and use willpower - not the easiest
method.
Use nicotine replacement therapy combined with
willpower.
Use a stop smoking plan.
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If you think you have an ulcer, see a doctor as the disease is
quite easy to detect (gastroscopy or screening for ulcer bacteria) and is
easily cured.
If you have a history of indigestion or stomach trouble, only
take aspirin and NSAIDs after discussion with your doctor or pharmacist. If you
have previously had bleeding from a peptic ulcer, you should avoid aspirin and
NSAIDs completely.
If you smoke,
QUIT.
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Based on a text by Dr Torben Nathan, Dr Carl J Brandt and Dr Ove Schaffalitzky de Muckadell, professor of internal medicine
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Last updated 06.07.2005
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