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Peptic ulcers

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of stomach and GI ulcers.

Alternative Names

Duodenal ulcers; Gastric ulcers; H. pylori

Diagnosis

Peptic ulcers are always suspected in patients with persistent dyspepsia (e.g., bloating, belching, abdominal pain). Dyspepsia, however, occurs in 20% - 40% of people who live in industrialized nations, and only about 15% - 25% of these people actually have an ulcer. There are a number of steps needed to make an accurate diagnosis of ulcers.

Medical and Family History

The doctor will ask for a thorough report of a patient's dyspepsia and other important symptoms, such as weight loss or fatigue, any present and past medication use (especially chronic use of NSAIDs), family members with ulcers, and drinking and smoking habits.

Ruling Out Other Disorders

In addition to peptic ulcers, a number of conditions, notably gastroesophageal reflux disease (GERD and irritable bowel syndrome), cause dyspepsia. In most cases, however, no cause can be determined. (In such cases, the symptoms are referred to collectively as functional dyspepsia.)

Peptic ulcer symptoms, notably abdominal and chest pain, may resemble those of other conditions, such as gallstones, or even the chest pain of heart attack. Certain features may help to distinguish these different conditions. However, symptoms often overlap, and it is impossible to make a diagnosis based on symptoms alone. A number of tests are needed.

The following are some disorders that may be confused with peptic ulcers:

• GERD. About half of patients with GERD also have dyspepsia. With GERD or other problems in the esophagus (food pipe), however, the main symptom is usually heartburn, a burning pain that radiates up to the throat. It typically develops after meals and is often relieved by antacids. The patient may have difficulty swallowing, and there is often regurgitation or acid reflux. [See In-Depth Report #85 : Gastroesophageal Reflux Disease . ]
• Heart Events. Pain due to heart events, such as angina or a heart attack, is more likely to occur with exercise, and it may radiate to the neck, jaw, or arms. In addition, patients typically have distinct risk factors for heart disease, such as a family history, smoking, high blood pressure, obesity, and high cholesterol. [See In-Depth Report #12 : Heart Attack . ]
• Gallstones. The primary symptom in gallstones is typically a steady gripping or gnawing pain on the right side (under the rib cage), which can be quite severe and can radiate to the upper back. Some patients experience the pain behind the breast bone. The pain is often precipitated by a fatty or heavy meal, but gallstones almost never cause dyspepsia. [See In-Depth Report #10 : Gallstones and Gallbladder Disease . ]
• Irritable Bowel Syndrome. Irritable bowel syndrome can cause dyspepsia, nausea and vomiting, bloating, and abdominal pain. It occurs more often in women.

Dyspepsia may also occur with gastritis, stomach cancer, or as a side effect of certain drugs, including NSAIDs, antibiotics, iron, corticosteroids, theophylline, and calcium blockers used to treat high blood pressure.

Noninvasive Tests for Gastrointestinal (GI) Bleeding.

When ulcers are suspected, the doctor administers tests to detect any bleeding. They include a rectal exam, a complete blood count, and a fecal occult blood test (FOBT). The FOBT tests for hidden (called occult ) blood in stools. Typically, the patient is asked to supply up to six stool specimens in a specially prepared package. A small quantity of feces is smeared on specially treated paper, which reacts to hydrogen peroxide. If blood is present, the paper turns blue.

Noninvasive Screening Tests for H. Pylori

Simple blood, breath, and stool tests can now detect H. pylori with a fairly high degree of accuracy. It is not entirely clear, however, which individuals should be screened for H. pylori.

Candidates for Screening. Some doctors currently test for H. pylori only in individuals with dyspepsia who also have high-risk conditions, such as the following:

• Strong indications for ulcers, such as weight loss, anemia, or indications of bleeding.
• History of active ulcers.
• Risk factors for stomach cancer or other complications from ulcers.

Smokers and those who experience regular and persistent pain on an empty stomach may also be good candidates for screening tests. Some doctors argue that testing for H. pylori may be beneficial for patients with dyspepsia who are regular NSAID users. In fact, given the possible risk for stomach cancer in H. pylori infected people with dyspepsia, some experts now recommend that any patient with dyspepsia that lasts longer than 4 weeks should be given blood tests for H. pylori . This is a subject of considerable debate, however.

Specific Screening Tests for H. Pylori. The following are the screening tests used or under investigation for H. pylori.

• Breath Test. A simple test called the carbon isotope-urea breath test (UBT) can identify up to 99% of people who harbor H. pylori . Up to 2 weeks before the test the patient must be off any antibiotics, bismuth-containing agents (such as Pepto-Bismol), and proton-pump inhibitors (PPIs). As part of the test, the patient swallows a special substance containing urea (a compound in mammals metabolized from nitrogen) that has been treated with carbon atoms. If present, the H. pylori bacteria convert the urea into carbon dioxide, which is detected and recorded in the patient's exhaled breath after 10 minutes.
• Blood Tests. Blood tests are used to measure antibodies to H. pylori , with results available in minutes. Diagnostic accuracy is reported at 80% and 90%. One such important test is called enzyme-linked immunosorbent assay (ELISA). An ELISA test of the urine is also showing promise in children.
• Stool Test. A test to detect genetic fingerprints of H. pylori in the feces appears to be as accurate as the breath test for initial detection of the bacteria and for detecting recurrences after antibiotic therapy.

It should be noted that such tests are not as accurate as endoscopy, an invasive procedure, which is needed to confirm a diagnosis of H. pylori . The breath and stool tests, however, can be particularly useful after treatment to determine if patients are cured.

Managing the Test Results: Test and Tre at . Depending on the results of the screening tests, some doctors take the following steps:

• Approach for Noninfected Individuals. People who do not have evidence of H. pylori on a blood test or breath are typically given a 4-week course of acid-suppressing medication, usually PPIs, such as omeprazole (Prilosec).
• Approach for H-Pylori- Infected Individuals. Patients who have evidence of bacterial infection are given antibiotics. If this does not relieve symptoms, they are given another 6-week course of omeprazole (Prilosec). (Whether to give antibiotics to infected patients with non-ulcer dyspepsia is controversial, however, and discussed in the section What Are the Guidelines for Treating Peptic Ulcers Caused by H. pylori ?)

If symptoms persist, then usually panendoscopy, also know simply as endoscopy, is performed. This is an invasive procedure, but only endoscopy allows a biopsy of stomach tissue, making it the most accurate test.

Experts debate on whether endoscopy should be performed on all patients who do not respond to initial medication. It does not appear to add any useful information on treatment choices, however, unless there is evidence or suspicion of bleeding or serious complications.

Although endoscopy, an invasive test, is the gold standard for diagnosing upper GI disorders, three-dimensional CT imaging may be valuable, as well. Researchers in China recently compared the results of endoscopy to the results of noninvasive CT imaging performed to diagnose GI tract disease. They found that the CT imaging correctly diagnosed 50 of 52 cases, including 5 cases of peptic ulcer disease. Three-dimensional CT imaging clearly showed the GI tract lesions and currently is a valuable complementary technique to endoscopy. Still, endoscopy will remain the gold standard for diagnosis because it allows doctors to biopsy the stomach.

Panendoscopy

Panendoscopy (also called gastroscopy or, simply, endoscopy ) is a procedure that evaluates the esophagus, stomach, and duodenum using an endoscope (a long thin tube containing a tiny video camera). When used with biopsy, panendoscopy is the most accurate procedure for detecting the presence of peptic ulcers, bleeding, and stomach cancer. It can also be used to confirm a diagnosis of H. pylori .

Appropriate Candidates for Panendoscopy. Panendoscopy is invasive and expensive and not suitable for everyone with dyspepsia. Most individuals with these symptoms are managed effectively after simple screening methods.

Panendoscopy is usually reserved for patients with dyspepsia who also have risk factors for ulcers, stomach cancer, or both. Such factors include the following:

• Having so-called "alarm" symptoms (unexplained weight loss, gastrointestinal bleeding, vomiting, difficulty in swallowing, or anemia).
• Being over 45 (when the risk for stomach cancer increases).

There is some debate over whether patients under 45 with persistent dyspepsia and no alarm symptoms should have endoscopy.

The Procedure. Panendoscopy may be performed either in a hospital or in a doctor's office and typically involves the following.

• The doctor administers a local anesthetic using an oral spray and an intravenous sedative to suppress the gag reflex and to relax the patient.
• The doctor then places an endoscope (a thin, flexible plastic tube) into the patient's mouth and down the esophagus (food pipe) into the stomach.
• A tiny camera in the endoscope allows the doctor to see the surface of the esophagus, stomach, and duodenum and to search for abnormalities.
• The doctor will take about ten small tissue samples (biopsies), which will be used to test for H. pylori .

Note: Some evidence suggests that in patients who are taking them, PPIs should be discontinued 2 weeks before an endoscopy. Their use may mask ulcers.

Capsule Endoscopy. Capsule endoscopy involves swallowing a capsule the size of a large vitamin, which contains tiny camera, light source, and a radio transmitter. The device takes and records pictures as it passes through the intestinal tract. At this point, its benefits are limited to the small intestine, so it is unlikely to play a role in the diagnosis of peptic or gastric ulcers. However, it has the potential to be an important tool for the diagnosis of obscure upper GI bleeding. Patients who have used it have usually found it painless and preferable to conventional endoscopy.

Upper GI Series

The upper GI (gastrointestinal) series was the standard diagnostic method for peptic ulcers until the introduction of adequate tests for detecting H. pylori . The patient drinks a solution containing barium. Then x-rays are taken, which may reveal inflammation, active ulcer craters, or deformities and scarring due to previous ulcers. Endoscopy is more accurate, although more invasive and expensive.

Other Laboratory Tests

Stool tests may show traces of blood that are not visible, and blood tests may reveal anemia in those who have bleeding ulcers. If Zollinger-Ellison syndrome is suspected, blood levels of gastrin should be measured.

• Review Date: 7/14/2006
• Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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