How do peptic ulcers arise?

Most peptic ulcers are caused by one of two things: a Helicobacter pylori infection or anti-inflammatory painkillers known as NSAIDs. Helicobacter pylori are bacteria which can infect mucous membranes, causing an inflammation. The inflammation damages the membranes lining the stomach or duodenum and leads to an increase in stomach acid production. Over time, this can damage the protective barrier usually provided by the membrane lining.

The other main cause of peptic ulcers is the (usually long-term) use of painkillers known as non-steroidal anti-inflammatory drugs, or NSAIDs. These include acetylsalicylic acid (the drug in medicines like Aspirin), diclofenac, ibuprofen and naproxen. They decrease the production of the hormone prostaglandin, which is responsible for regulating the production of gastric (stomach) mucus and substances that neutralize stomach acid. If there is too little prostaglandin, the stomach lining becomes more susceptible to damage from stomach acid and germs. Taking painkillers together with steroids can make this harmful effect worse.

What are the possible complications?

A peptic ulcer can lead to serious complications. The most common type of complication is bleeding. So it's important to see a doctor as soon as possible if you have any of the following symptoms:

• Black-colored stool (bowel movements)
• Vomit with blood in it (red or black vomit)
• Anemia symptoms such as exhaustion, feeling short of breath during physical activity, and pale skin.

In rare cases, ulcers can lead to perforation of the stomach wall (perforated ulcer). This complication is associated with sudden and very strong stomach pain. It is a life-threatening condition, so these symptoms should be taken seriously and the emergency services should be called immediately.

How are ulcers diagnosed and treated?

If it is thought that someone has a peptic ulcer, they will usually have an examination using a gastroscope. A sample of tissue can be taken during this procedure. The sample is then checked for Helicobacter pylori bacteria, signs of inflammation or other abnormal tissue, such as cancer cells.

Stomach ulcers are usually treated with proton pump inhibitors such as omeprazole or pantoprazole. Proton pump inhibitors reduce the production of stomach acid. This medication is taken for 4 to 8 weeks.

How are Helicobacter pylori infections treated?

If a peptic ulcer is being caused by a Helicobacter pylori infection, a combination of three medications is generally used to treat it:

• one proton pump inhibitor (PPI),
• one antibiotic drug containing the active ingredient clarithromycin, and
• another antibiotic drug containing the active ingredient metronidazole or amoxicillin.

Sometimes quadruple therapy is used instead. This approach involves taking four drugs: all three above-mentioned antibiotics and one proton pump inhibitor. In both triple and quadruple therapy, the drugs are taken together over a period of 7 to 10 days. If you still have symptoms after that, treatment with the proton pump inhibitor can be continued.

Once the Helicobacter treatment is finished, doctors wait at least four weeks before checking whether it was successful. They will usually do a special breath test to find out whether you still have Helicobacter pylori bacteria in your stomach. If the treatment wasn't effective, it can be repeated using a different combination of antibiotics and a proton pump inhibitor.

How can peptic ulcers be prevented?

It's not clear whether factors such as your diet, smoking or chronic stress can contribute to the development of peptic ulcers. But it can still be helpful to observe for yourself whether things like fatty or spicy foods cause stomach problems, or whether these problems tend to occur during stressful times.

If you notice that something is triggering your stomach problems, you can try to avoid it. This may include things like alcohol and cigarettes. It can also be worth trying to change your diet and reduce stress in everyday life.

If you have long-term treatment with anti-inflammatory painkillers such as acetylsalicylic acid (the drug in medicines like Aspirin), ibuprofen, diclofenac or naproxen, it's best to talk with your doctor about whether to also take acid-lowering medication.

Sources

• Fischbach W, Malfertheiner P, Hoffmann JC, Bolten W, Bornschein J, Götze O et al. S3-guideline "helicobacter pylori and gastroduodenal ulcer disease" of the German society for digestive and metabolic diseases (DGVS) in cooperation with the German society for hygiene and microbiology, society for pediatric gastroenterology and nutrition, German society for rheumatology. AWMF-Registernr.: 021-001. Z Gastroenterol 2009; 47(12): 1230-1263. [PubMed: 19960402]
• Fischbach W, Malfertheiner P, Lynen Jansen P, Bolten W, Bornschein J, Buderus S et al. S2k-Leitlinie Helicobacter pylori und gastroduodenale Ulkuskrankheit. AWMF-Registernr.: 021-001. Z Gastroenterol 2016; 54: 327-363. [PubMed: 27512738]
• Ford AC, Gurusamy KS, Delaney B, Forman D, Moayyedi P. Eradication therapy for peptic ulcer disease in Helicobacter pylori-positive people. Cochrane Database Syst Rev 2016; (4): CD003840. [PMC free article: PMC7163278] [PubMed: 27092708]
• Hawkey CJ, Langman MJ. Non-steroidal anti-inflammatory drugs: overall risks and management. Complementary roles for COX-2 inhibitors and proton pump inhibitors. Gut 2003; 52(4): 600-608. [PMC free article: PMC1773617] [PubMed: 12631678]
• Levenstein S, Rosenstock S, Jacobsen RK, Jorgensen T. Psychological stress increases risk for peptic ulcer, regardless of Helicobacter pylori infection or use of nonsteroidal anti-inflammatory drugs. Clin Gastroenterol Hepatol 2015; 13(3): 498-506. [PubMed: 25111233]
• Robert Koch-Institut (RKI), Statistisches Bundesamt (Destatis). Gastritis, Magen- und Zwölffingerdarmgeschwüre. Berlin: RKI; 2013. (Gesundheitsberichterstattung des Bundes; Heft 55).

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