Upper gastrointestinal (upper GI) X-ray: If an individual has signs and symptoms of a peptic ulcer, the doctor may begin with an upper gastrointestinal x-ray, also known as an upper GI. An upper GI allows the doctor to visualize the esophagus, stomach, and duodenum. During the x-ray, the individual swallows a white, metallic liquid (containing barium) that coats the digestive tract and makes an ulcer more visible. An upper GI x-ray can detect some ulcers, but not all.
Endoscopy: An endoscopy may follow an upper GI X-ray if the x-ray suggests a possible ulcer. Doctors also may use the endoscopy as the first choice of diagnosis. In this more sensitive procedure, a long, narrow tube with a small attached camera is threaded down the throat and esophagus into the stomach and duodenum. With this instrument, the doctor can view the upper digestive tract and identify an ulcer. If the doctor detects an ulcer, they may remove small tissue samples 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 the stomach lining by using laboratory tests. Depending on where the ulcer is found, the doctor may recommend a repeat endoscopy after two to three months to confirm that the ulcer is healing. Possible complications of upper endoscopy include bleeding and puncture of the stomach lining. However, such complications are rare. Most people will probably have nothing more than a mild sore throat after the procedure. The procedure takes 20-30 minutes. Because the individual will be sedated, they will need to rest at the endoscopy facility for one to two hours until the medication wears off. It is recommended to have a friend or loved one drive.
Blood test: A blood test can check for the presence of H. pylori antibodies. The body's immune system produces antibodies specific for H. pylori when the bacteria exists in the body. A disadvantage of this test is that it sometimes cannot determine if the antibodies are from a past exposure to H. Pylori bacteria or a current infection. After H. pylori bacteria have been destroyed, the individual may still have a positive test result for many months.
Breath test: A breath test uses a harmless radioactive carbon atom to detect H. pylori. First, the individual blows into a small plastic bag, which is then sealed. Then, the person drinks a small glass of clear, tasteless liquid. The liquid contains radioactive carbon mixed with urea. This combination will be broken down by H. pylori if it is present in the body. Thirty minutes later, the person blows into a second bag, which is then also sealed. If the individual is infected with H. pylori, the second 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, such as antibiotics, used to eradicate H. pylori, detecting when the bacteria have been killed. With the blood test, H. pylori antibodies may sometimes still be present a year or more after the infection is gone.
Stool antigen test: The stool antigen test checks for H. pylori in stool samples. This test is useful both in helping to diagnose H. pylori infection and in monitoring the success of treatment.
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 the navel to the breastbone. The pain may last from a few minutes to many hours and may flare up a night. Peptic ulcers also tend to be worse when the stomach is empty. Ulcers are often temporarily relieved by eating certain foods that buffer stomach acid, such as milk, or by taking acid-reducing medications, such as calcium carbonate (Tums®). Burning pain may come and go for a few days or weeks. Ulcer pain may also return after years of absence.
Less often, ulcers may cause severe signs or symptoms, such as the vomiting of blood (which may appear red or black) and dark blood in stools or stools that are black or tarry. Other severe signs of an ulcer include nausea or vomiting, unexplained weight loss, and chest pain.
An ulcer is not generally something that should be treated at home. A doctor can help with prescribed medications or advise the individual the over-the-counter (OTC) medications that may be best. OTC antacids and acid blockers may relieve the burning pain, but the relief is usually temporary. When signs or symptoms of a peptic ulcer exist, a doctor should perform a physical examination to determine if a peptic ulcer exists.
risk factors and causes
Infection: 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 digestive tract. H. pylori usually does not cause problems, but sometimes the bacteria can disrupt the mucous layer and inflame the lining of the stomach or duodenum, producing an ulcer. Individuals who develop peptic ulcers may already have damage to the lining of the stomach or small intestine, making it easier for bacteria to invade and inflame tissues. H. pylori is a common digestive tract infection around the world. In the United States, one in five people younger than 30 and half the people older than 60 are infected with H. pylori. Although it's not clear exactly how H. pylori spreads, the bacteria may be transmitted from person to person by close contact, such as kissing. Individuals may also contract H. pylori through food and water. H. pylori is the most common, but not the only, cause of peptic ulcers.
Pain relievers: Pain-relieving drugs called non-steroidal anti-inflammatory drugs (NSAIDs) can irritate or inflame the lining of the stomach and small intestine. The medications are available both by prescription and over-the-counter. Nonprescription NSAIDs include aspirin, ibuprofen (Advil®, Motrin®), naproxen (Aleve®), and ketoprofen (Orudis KT®). Individuals vary in sensitivity to these medications. Some individuals may develop ulcer symptoms with occasional use of NSAIDs, others with long-term. To help avoid digestive upset, take NSAIDs with food. NSAIDs inhibit production of an enzyme that produces hormone-like substances called prostaglandins. Prostaglandins help protect the stomach lining from chemical and physical injury. Without this protection, stomach acid can erode the lining causing bleeding and ulcers.
Smoking and Caffeine: Individuals who smoke and those exposed to second hang smoke have an increased risk of developing an ulcer. Smoking may also slow healing during ulcer treatment. Caffeine stimulates acid secretion in the stomach, thus aggravating the pain of an existing ulcer. Drinking coffee or tea daily may also increase the chances of developing a peptic ulcer.
Excessive alcohol consumption: Alcohol can irritate and erode the mucous lining of the stomach and it increases the amount of stomach acid that is produced. It is uncertain, however, whether alcohol consumption alone can cause an ulcer or whether other contributing factors must be present, such as H. pylori bacteria or ulcer-causing medications.
Stress: Although stress is not a direct cause of peptic ulcers, it is a contributing risk factor. Stress may aggravate symptoms of peptic ulcers and, in some cases, delay healing. Stress can be caused by a number of reasons, including emotionally disturbing circumstances or events, surgery, or a physical injury, such as a severe burn. Stress ulcers can occur as a result of the stress of severe illness, skin burns, or trauma. Stress ulcers occur in the stomach and the duodenum.
Other conditions: Achalasia is a rare disease of a muscle of the esophagus, the body's swallowing tube. The term achalasia means "failure to relax" and refers to the inability of a ring of muscle between the lower esophagus and the stomach called the esophageal sphincter to open and let food pass into the stomach. As a result, patients with achalasia have difficulty swallowing food. Gastroesophageal reflux disease (GERD) can develop as a result.
Most ulcers can be cured without complications. However, in some rare cases, peptic ulcers can develop potentially life-threatening complications, such as penetration, perforation (holes), bleeding (hemorrhage), and obstruction. Depending upon the individual, life-threatening complications usually develop over time.
Penetration: An ulcer can penetrate (go through) the muscular wall of the stomach or duodenum and continue into a nearby organ, such as the liver or pancreas. This penetration causes an intense, piercing, persistent pain, which may be felt outside of the area involved. Sometimes the back may hurt when a duodenal ulcer penetrates the pancreas. The pain may intensify when the person changes position. If drugs do not heal the ulcer, surgery may be needed.
Perforation: Ulcers on the front surface of the duodenum, or less commonly the stomach, can perforate or go through the wall of the organ. Perforating ulcers create an opening to the free space in the abdominal cavity. The pain resulting from this perforation is sudden, intense, and steady, and rapidly spreads throughout the abdomen. The individual may also feel pain in one or both shoulders, which may intensify with deep breathing. Changing position worsens the pain, so the person often tries to lie very still. The abdomen is tender when touched, and the tenderness worsens if a doctor presses deeply and then suddenly releases the pressure. Symptoms may be less intense in older individuals, in individuals taking corticosteroids, or in very ill individuals. A fever indicates an infection in the abdomen. If the condition is not treated, shock may develop. This emergency situation requires immediate surgery and intravenous (IV) antibiotics.
Hemorrhage: Hemorrhage (bleeding) is a common complication of ulcers, even when they are not painful. Symptoms of a bleeding ulcer may include vomiting bright red blood or reddish brown clumps of partially digested blood that look like coffee grounds. Small amounts of blood in the stool may not be noticeable but, if persistent, can still lead to anemia, or the deficiency of hemoglobin (the oxygen-carrying component of the blood). Bleeding may result from other digestive conditions as well, but doctors begin their investigation by looking for the source of bleeding in the stomach and duodenum. Unless bleeding is massive, a doctor performs a procedure called an endoscopy. An endoscopy is an examination using a flexible viewing tube. If a bleeding ulcer is seen, the endoscope can be used to cauterize, which is the use of heat to close the bleeding opening. A doctor may also use the endoscope to inject a material that causes a bleeding ulcer to clot. If the source cannot be found and the bleeding is not severe, treatments include taking ulcer drugs, such as cimetidine (Tagamet®) or omeprazole (Prilosec®). The individual also receives intravenous (IV) fluids and takes nothing by mouth, so the digestive tract can rest. If these measures fail, surgery is needed.
Obstruction: Swelling of inflamed tissues around an ulcer or scarring from previous ulcer flare-ups can narrow some parts of the duodenum. An individual with this type of obstruction may vomit repeatedly, often regurgitating large volumes of food eaten hours earlier. A feeling of being unusually full after eating, being bloated, and a lack of appetite are symptoms of obstruction. Over time, vomiting may cause weight loss and dehydration. Treating the ulcers relieves the obstruction in most cases, but severe obstructions may require endoscopy or surgery.
Enteritis: Enteritis is an inflammation of the small intestine caused by a bacterial or viral infection. H. pylori infections can cause enteritis with symptoms including gas, bloating, and pain.
Zollinger-Ellison syndrome: Zollinger-Ellison syndrome (ZES) is a rare disorder that causes tumors in the pancreas and duodenum. ZES may also cause ulcers in the stomach and duodenum. The pancreas is a gland located behind the stomach. It produces enzymes that break down fat, protein, and carbohydrates from food and hormones such as insulin that break down sugar. The duodenum is the first part of the small intestine. ZES can occur sporadically or may be genetic. The tumors secrete a hormone called gastrin that causes the stomach to produce too much acid, which in turn causes peptic ulcers in the stomach and duodenum. The ulcers caused by ZES are less responsive to treatment than ordinary peptic ulcers. What causes people with ZES to develop tumors is unknown, but approximately 25% of ZES cases are associated with a genetic disorder called multiple endocrine neoplasia type 1. The symptoms of ZES include signs of peptic ulcers, including gnawing, burning pain in the abdomen, diarrhea, nausea, vomiting, fatigue (extreme tiredness), weakness, weight loss, and bleeding. Doctors diagnose ZES through blood tests to measure levels of gastrin and gastric acid secretion. They may check for ulcers by performing an endoscopy, which involves looking at the lining of the stomach and duodenum through a lighted tube.
Cancer: Individuals with ulcers caused by H. pylori have three to six times the chance of developing stomach cancer later in life. There is no increased risk of developing cancer from ulcers that have other causes. Some evidence also links H. pylori infection to gastric cancer, gastric mucosa-associated lymphoid tissue (MALT) lymphoma, and perhaps pancreatic cancer and cardiovascular disease.