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• Highlights
• Introduction
• Causes
• Symptoms
• Complications
• Risk Factors
• Diagnosis
• Treatment
• Treatment for NSAID-Induced Ulcers
• Medications
• Treatment for Bleeding Ulcers
• Lifestyle Changes
• Resources
• References

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

Risk Factors

About 25 million American are expected to have peptic ulcers at some point in their lives. Peptic ulcer disease affects all age groups but is rare in children. Men have twice the risk for ulcers as women. The risk for duodenal ulcers tends to rise at around age 25 and continues until age 75; gastric ulcers peak in people between the ages of 55 and 65.

Peptic ulcers are less common than they once were. Research suggests that ulcer rates have even declined in areas with widespread H. pylori infection. The increased use of proton pump inhibitor drugs may be responsible for this trend.

Risk Factors for H. pylori

H. pylori grows and colonizes only in the intestinal tracts of primates and in no other animals. The bacteria is most likely transmitted directly from person to person. Still, little is yet known about its transmission.

Who is Infected with H. Pylori? About half of the world's adults are infected with H. pylori. The bacteria, however, are nearly always acquired during childhood and persist throughout life if not treated. The prevalence in children ranges from under 10% to over 80%, depending on where they live. The highest infection rates (3% - 10%) are in developing countries and the lowest (0.5%) are in industrialized nations, where the rates continue to decline. Even within industrialized countries, however, the infection rates in regions that have crowded unsanitary conditions are equal to those in developing countries.

How Does the Bacteria Pass from Person to Person? It is not entirely clear how the bacteria is transmitted. A 2001 Swedish study, for example, did not find that infected students posed any risk for their classmates. Transmission within families may be the most important route for H. pylori . A 2002 study reported that spouses of people with peptic ulcers are at significantly higher risk for ulcers, suggesting that the bacteria may be transmitted from intimate contact. Some evidence suggests that it is transmissible during GI tract illness, particularly when vomiting occurs. The bacteria also may be passed in stools. Since H. pylori can live in water, but not apparently in food, then the bacteria may also be spread by sewage-contaminated water.

Who is at Risk for Ulcers from H. Pylori? Although H. pylori infection is very common, ulcers are very rare in children and only a minority of infected adults develops ulcers. Some known risk factors include smoking, alcohol use, having a relative who has had peptic ulcers, being male, and the presence of the cytotoxin-associated gene A (CagA). Experts are unable to determine, however, any single factor or group of factors that could determine which infected patients are most likely to develop ulcers.

Risk Factors for NSAID-Induced Ulcers

Between 15% and 25% of patients who have taken NSAIDs regularly will have evidence of one or more ulcers, but in most cases they are very small. Given the widespread use of these drugs, however, the total number of people with serious problems may be considerable. Long-term NSAID use can cause damage to the stomach and possibly the small intestine.

In April 2005, the FDA asked drug manufacturers of prescription NSAIDs to include with their products the same boxed warning used for the COX-2 inhibitor celecoxib (Celebrex). This boxed warning emphasizes an increased risk for cardiovascular events and GI bleeding in people taking these drugs. The FDA also requested manufacturers of over-the-counter NSAIDs to revise their labels to include more specific language concerning potential cardiovascular and GI risks. Due to its proven heart benefits, aspirin was excluded from these labeling revisions

High-Users of NSAIDs. Anyone who uses NSAIDs regularly is at risk for gastrointestinal problems. Even low-dose aspirin (81 mg) used to protect the heart may pose some risk (although lower than standard doses). In one study, over a 4-year period, 4.5% of regular uses were hospitalized for GI bleeding. The highest risks, however, are in people who require long-term use of very high doses, notably people who suffer from arthritis, particularly rheumatoid arthritis. Other people who have a high intake of NSAIDs, include, but are not limited to, people with chronic low back pain, fibromyalgia, and repetitive stress.

Contributing Factor s. Certain factors add to the risk for ulcers in NSAID-users:

• People older than age 65.
• Anyone with a history of peptic ulcers or upper gastrointestinal bleeding.
• Those with other serious ailments, such as heart disease or congestive heart failure.
• NSAID users who also take certain other medications, such as the anticoagulant warfarin (Coumadin), corticosteroids, or the osteoporosis drug alendronate (Fosamax).
• Alcohol abusers. Excessive alcohol use may intensify the risk of bleeding in those who also take NSAIDs. (Some studies have shown that alcohol may actually protect against H. pylori.) In any case, everyone should avoid excessive use of alcohol.
• People who take NSAIDs and are infected with the H. pylori bacteria. A 2002 study reported that the combination poses a 3.5-fold greater risk of ulcers than either one of these factors. (Not all studies report the higher risk in infected patients.)

Other Risk Factors for Ulcers from Either H. Pylori or NSAIDs

Stress and Psychological Factors. Although stress is no longer considered to play a causal role in ulcers, studies still suggest that stress may predispose someone to ulcers or help sustain existing ulcers. Some experts, in fact, estimate that social and psychological factors play a contributory role in 30% to 60% of peptic ulcer cases, whether they are caused by H. pylori or NSAIDs. In any case, some experts believe that the anecdotal relationship between stress and ulcers is so strong that attention to psychological factors is still warranted.

Smoking. Smoking increases acid secretion, reduces prostaglandin and bicarbonate production, and decreases mucosal blood flow. Results of studies on the actual effect of smoking on ulcers, however, are mixed. Some evidence suggests that smoking delays the healing of gastric and duodenal ulcers. One study reported that after ulcers healed, about half of nonsmokers relapsed after a year, but that all heavy smokers relapsed after 3 months. Other studies have found no increased risk for ulcers in smokers. In any case, any impact of smoking on ulcers does not seem to be affected by the presence of H. pylori . This should not give smokers any comfort, however, given the other proven dangers from smoking.

• 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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