What is a stomach or duodenal ulcer?
An ulcer is an open sore, or lesion, usually found on the skin or mucous membrane areas of the body.

An ulcer in the lining of the stomach or duodenum, where hydrochloric acid and pepsin are present, is referred to as a peptic ulcer.

• When the ulcer is in the stomach, it is called a gastric ulcer.

• When the ulcer is in the duodenum, it is called a duodenal ulcer.

What causes gastric and duodenal ulcers?
In the past it was believed lifestyle factors, such as stress and diet caused ulcers. Later, researchers determined that stomach acids -- hydrochloric acid and pepsin -- contributed to ulcer formation.

Today, research shows that most ulcers (80 percent of gastric ulcers and 90 percent of duodenal ulcers) develop as a result of infection with a bacterium called Helicobacter pylori (H. pylori).

It is believed that, although all three of these factors -- lifestyle, acid and pepsin, and H. pylori -- play a role in ulcer development, H. pylori is considered to be the primary cause.

Factors in the development of peptic ulcers:
Factors suspected of playing a role in the development of stomach or duodenal ulcers include:

• Helicobacter pylori
  Research shows that most ulcers develop as a result of infection with bacterium called Helicobacter pylori (H. pylori). The bacterium produces substances that weaken the stomach's protective mucus and make it more susceptible to the damaging effects of acid and pepsin, as well as produce more acid.

• smoking
  Studies show smoking increases the chances of getting an ulcer, slows the healing process of existing ulcers, and contributes to ulcer recurrence.

• caffeine
  Caffeine seems to stimulate acid secretion in the stomach, which can aggravate the pain of an existing ulcer. However, the stimulation of stomach acid cannot be attributed solely to caffeine.

• alcohol
  Although no proven link has been found between alcohol consumption and peptic ulcers, ulcers are more common in people who have cirrhosis of the liver, a disease often linked to heavy alcohol consumption.

• stress
  Although emotional stress is no longer thought to be a cause of ulcers, people with ulcers often report that emotional stress increases ulcer pain.

During normal digestion, food moves from the mouth down the esophagus into the stomach. The stomach produces hydrochloric acid and an enzyme called pepsin to digest the food.

From the stomach, food passes into the upper part of the small intestine, called the duodenum, where digestion and nutrient absorption continue.

An ulcer is a sore or lesion that forms in the lining of the stomach or duodenum where hydrochloric acid and pepsin are present. These ulcers are referred to as peptic ulcers: gastric ulcers in the stomach and duodenal ulcers in the duodenum.

• About 1 in 10 Americans develop at least one ulcer during their lifetimes.

• Ulcers affect about 5 million people each year.

• More than 40,000 people a year have surgery because of persistent symptoms or problems from ulcers.

• Each year about 6,000 people die of ulcer-related complications.

• Ulcers can develop at any age, but they are rare among teenagers and even more uncommon in children.

• Duodenal ulcers occur for the first time usually between the ages of 30 and 50.

• Duodenal ulcers occur more frequently in men than women.

• Stomach ulcers are more likely to develop in people over age 60.

• Stomach ulcers develop more often in women than men.

Physical stress, however, may increase the risk of developing ulcers, particularly in the stomach. For example, people with injuries such as severe burns and people undergoing major surgery often require rigorous treatment to prevent ulcers and ulcer complications.

• acid and pepsin
  It is believed that the stomach's inability to defend itself against the powerful digestive fluids, hydrochloric acid and pepsin, contributes to ulcer formation.

• nonsteroidal anti-inflammatory drugs (NSAIDs)
  These drugs (such as aspirin, ibuprofen, and naproxen sodium) make the stomach vulnerable to the harmful effects of acid and pepsin. They are present in many non-prescription medications used to treat fever, headaches, and minor aches and pains.

What are the symptoms of gastric and duodenal ulcers?
The following are the most common symptoms for ulcers, however, each individual may experience symptoms differently.

Although ulcers do not always cause symptoms, the most common ulcer symptom is a gnawing or burning pain in the abdomen between the breastbone and the navel. The pain often occurs between meals and in the early hours of the morning. It may last from a few minutes to a few hours. Less common ulcer symptoms include:

• belching
• nausea
• vomiting
• poor appetite
• loss of weight
• feeling tired and weak

The symptoms of stomach and duodenal ulcers may resemble other digestive conditions or medical problems. Consult your physician for a diagnosis.

What are some complications from ulcers?
People with ulcers may experience serious complications if they do not get treatment. The most common problems include:

• bleeding
  As an ulcer eats into the muscles of the stomach or duodenal wall, blood vessels may also be damaged, causing bleeding.

• perforation
  Sometimes an ulcer eats a hole in the wall of the stomach or duodenum, and bacteria and partially digested food can spill through the opening into the sterile abdominal cavity (peritoneum) and cause peritonitis, an inflammation of the abdominal cavity and wall.

• narrowing and obstruction
  Ulcers located at the end of the stomach, where the duodenum is attached, can cause swelling and scarring, which can narrow or close the intestinal opening. This obstruction can prevent food from leaving the stomach and entering the small intestine, resulting in vomiting the contents of the stomach.

How are ulcers diagnosed?
Because treatment protocols may be different for different types of ulcers, it is important to adequately diagnose ulcer disease and H. pylori before starting treatment. For example, for an NSAID-induced ulcer, treatment is quite different from the treatment for a person diagnosed with an ulcer caused by the bacterium, H. pylori.

There are a number of options available for diagnosing ulcers, and for testing for the H. pylori bacterium. These diagnostic procedures include:

• upper GI (gastrointestinal) series - an x-ray of the esophagus, stomach, and duodenum to locate an ulcer, which is made visible on the x-ray image by swallowing a chalky liquid called barium.

• endoscopy - a small flexible instrument with a camera on the end is inserted through the mouth into the esophagus, stomach, and duodenum to view the entire upper GI tract.

• blood, breath, and stomach tissue tests - performed to detect the presence of H. pylori. Although, some of the tests for H. pylori are not approved by the US Food and Drug Administration (FDA) because they may occasionally give false positive results, and the other tests may give false negative results in people who have recently taken antibiotics, omeprazole, or bismuth, research shows these tests can be accurate in detecting the bacteria.

Treatment for stomach and duodenal ulcers:
Specific treatment will be determined by your physician(s) based on:

• your age, overall health, and medical history
• extent of the disease
• your tolerance for specific medications, procedures, or therapies
• expectations for the course of the disease
• your opinion or preference

Recommended treatment may include:

• lifestyle changes
  In the past, physicians advised people with ulcers to avoid spicy, fatty, or acidic foods. However, a bland diet is now known to be ineffective for treating or avoiding ulcers. No particular diet is helpful for most ulcer patients. People who find that certain foods cause irritation should discuss the problem with their physicians.

Smoking has been shown to delay ulcer healing and has been linked to ulcer recurrence; therefore, people with ulcers should not smoke.

• medications
  Physicians treat stomach and duodenal ulcers with several types of medications, including:

• H2-blockers to reduce the amount of acid the stomach produces by blocking histamine, a powerful stimulant of acid secretion.

• acid pump inhibitors to more completely block stomach acid production by stopping the stomach's acid pump -- the final step of acid secretion.

• mucosal protective agents to shield the stomach's mucous lining from the damage of acid, but do not inhibit the release of acid.

When treating H. pylori, these medications are often used in combination with antibiotics.

• antibiotics
  The discovery of the link between ulcers and H. pylori resulted in a probable new treatment option -- antibiotics for patients with H. pylori.

• surgery
  In most cases, anti-ulcer medicines heal ulcers quickly and effectively, and eradication of H. pylori prevents most ulcers from recurring. However, people who do not respond to medication or who develop complications may require surgery.

At present, standard open surgery is performed to treat ulcers. Types include:

• vagotomy - a procedure that involves cutting parts of the vagus nerve (a nerve that transmits messages from the brain to the stomach) to interrupt messages sent through it, therefore, reducing acid secretion.

• antrectomy - an operation to remove the lower part of the stomach (antrum), which produces a hormone that stimulates the stomach to secrete digestive juices. Sometimes a surgeon may also remove an adjacent part of the stomach that secretes pepsin and acid. A vagotomy is usually done in conjunction with an antrectomy.

• pyloroplasty - a surgical procedure that may be performed along with a vagotomy, in which the opening into the duodenum and small intestine (pylorus) are enlarged, enabling contents to pass more freely from the stomach.

In the future, laparoscopic methods may also be standard surgical treatments. A laparoscope is a long tube-like instrument with a camera that allows the surgeon to operate through small incisions while watching a video monitor.

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