Risk Factors:

About 25 million people in the U.S. are expected to develop 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 of ulcers as women. The risk of duodenal ulcers tends to rise, beginning around age 25, and continues until age 75. The risk of gastric ulcers peaks at ages 55 - 65.

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

Risk Factors for H. pylori

H. pylori bacteria are most likely transmitted directly from person to person. Yet little is known about exactly how these bacteria are transmitted.

Who Is Infected with H. pylori? About 20% of people under age 40 and 50% of those over age 60 are infected with H. pylori. The bacteria are nearly always acquired during childhood and persist throughout life if not treated. The prevalence in children is around 0.5% in industrialized nations, where rates continue to decline. Even in industrialized countries, however, infection rates in regions with crowded, unsanitary conditions are equal to those in developing countries.

How Do the Bacteria Pass from Person to Person? It is not entirely clear how the bacteria are transmitted. Suggested, but not clearly proven methods of transmission include: intimate contact, GI tract illness (particularly when vomiting occurs), and contact with oral secretions. The bacteria may also be passed in stools. Because H. pylori can live in water, but apparently not in food, the bacteria may also be transmitted through sewage-contaminated water.

Who Is at Risk for Ulcers from H. pylori? Although H. pylori infection is common, ulcers in children are very rare, and only a small percentage of infected adults develop ulcers. Some known risk factors include smoking, alcohol use, having a relative with peptic ulcers, being male, and having the cytotoxin-associated gene A (CagA). Experts do not know of any single factor or group of factors that can determine which infected patients are most likely to develop ulcers.

Risk Factors for NSAID-Induced Ulcers

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

The FDA has asked manufacturers of prescription NSAIDs and the COX-2 inhibitor celecoxib (Celebrex) to include with their products a boxed warning emphasizing the increased risk for cardiovascular events and GI bleeding in people taking these drugs. (Pharmaceutical companies are trying to develop new COX-2 inhibitors without these dangerous side effects. Early safety studies of the new COX-2 inhibitor CS-706 showed it to have the same effects on gastric mucosa as a placebo.)

The FDA also requested that manufacturers of over-the-counter NSAIDs 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.

Frequent Users

NSAIDs. Anyone who uses NSAIDs regularly is at risk for gastrointestinal problems. Even low-dose aspirin (81 mg) may pose some risk, although the risk is lower than with standard doses. The highest risk is among people who require long-term use of very high-dose NSAIDs, especially patients with rheumatoid arthritis. Other people who take high doses of NSAIDs include those with chronic low back pain, fibromyalgia, and chronic stress.

The use of COX-2 inhibitors may decrease the risk of uncomplicated ulcers, but these medications do not seem to reduce the risk of more serious events, such as bleeding or perforation.

Contributing Factors. Certain factors may increase the risk for ulcers in NSAID users:

• Age 65 and older
• History of peptic ulcers or upper gastrointestinal bleeding
• Other serious ailments, such as congestive heart failure
• Use of other medications, such as the anticoagulant warfarin (Coumadin), corticosteroids, or the osteoporosis drug alendronate (Fosamax)
• Alcohol abuse
• H. pylori infection

Other Risk Factors for Ulcers from H. pylori or NSAIDs

Stress and Psychological Factors. Although stress is no longer considered a cause of ulcers, studies still suggest that stress may predispose a person to ulcers or prevent existing ulcers from healing. Some even believe that the anecdotal relationship between stress and ulcers is so strong that people with ulcers should be treated for psychological conditions.

Smoking. Smoking increases acid secretion, reduces prostaglandin and bicarbonate production, and decreases mucosal blood flow. However, the results of studies on the actual effect of smoking on ulcers are mixed. Some evidence suggests that smoking delays the healing of gastric and duodenal ulcers. Other studies have found no increased risk for ulcers in smokers. In any case, H. pylori does not seem to affect the impact of smoking on ulcers.

Tobacco use and exposure may accelerate coronary artery disease and peptic ulcer disease. It is also linked to reproductive problems, esophageal reflux, hypertension, fetal illness and death, and delayed wound healing.