An ulcer is defined as a hole, in the lining (or mucosa) of the alimentary tract, which extends through the muscular layer into the submucosa or deeper. Although ulcers may occur anywhere in the alimentary tract, none are as prevalent as the ulcers that occur in the upper intestine (duodenum) and stomach1. Ulcers occurring in the stomach are also termed gastric ulcers.
A peptic ulcer is an ulcer that arises in areas of the alimentary tract which are exposed to the digestive enzyme, pepsin. These are the same areas which are also exposed to gastric acid.
What causes stomach ulcers?
Peptic ulcers appear to be produced by an imbalance between the gastroduodenal mucosal defence mechanisms and damaging forces1. Ulcers are formed when the mucosa of the stomach or duodenum cannot resist the corrosive effects of acid on its surface.
The primary defect may not reflect any abnormality in acid secretion2. The two most common factors that predispose to ulcers are chronic gastric infection with a bacteria called helicobacter pylori and ingestion of non-steroidal anti-inflammatory drugs (NSAIDs)2,3,4 - such as aspirin, Disprin or Nurofen.
With the exception of gastric secretion of acid and pepsin, they do not appear to need any other co-factors to cause mucosal ulceration3. If NSAID induced ulcers are excluded, an infection with H.pylori is found in more than 95% of all individuals with gastric or duodenal ulcers5. On the other hand, only 15-20% of persons infected with H.pylori will develop in their lifetimes6.
Rarely ulcers can form as a result of tumors which cause excessive acid secretion (Zollinger-Ellison syndrome) also as a result of gastritis due to reflux of duodenal contents. Several other factors are associated with ulcer formation although this may be an indirect relationship. Such factors include hereditary, smoking, elevated blood calcium levels (hypercalcaemia) and alcohol. The role of stress or coffee is as yet unproven. Corticosteroids in high dose and with repeated use may promote ulcer formation1.
The great majority of peptic ulcers cause gnawing, burning or aching pain in the region of the stomach made worse by or unrelated to food. Pain tends to be worse at night and occurs usually 1 to 3 hours after food during the day. Additionally there may be food aversion, weight loss, nausea, belching or bloating. There is great individual variation and occasionally the pain may be referred to the back or the upper quadrant of the abdomen1,2,4.
Complications include bleeding, obstruction, perforation or intractable pain4.
In western industrialised countries, the risk of developing peptic ulcer depends on the date of birth. The risk for peptic ulcer was highest in generations born before the turn of the century and has declined in all subsequent generations3.
Age-adjusted mortality rates for men have fallen to 1.5 per 100 000 and in women have remained between 1.1 and 1.2 per 100 0002. About 15-20% of H.pylori infected individuals develop ulcers during their lifetime2,7. Eradication of this infection markedly decreases recurrence of peptic ulcers.
Low family income, old age, smoking, lower educational attainment and ethnicity act as significant and independent risk factors2,7.
- Physical examination - physical examination is not useful in establishing the diagnosis of uncomplicated peptic ulcer2. The physical examination can be useful to exclude other causes of pain.
- Clinical tests.
- Endoscopy- A flexible tube with a camera attached is passed into the stomach to allow direct visualisation.
- Barium Radiography- after swallowing a barium solution the stomach is x-rayed.