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Dr. Sakshi Sharma
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MD Pharmacology, MBBS
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Peptic ulcer disease

Peptic ulcer disease

Also known as Peptic ulcer, PUD, Stomach ulcer, Gastric ulcer, Duodenal ulcer and Esophageal ulcer

Overview

Peptic ulcer disease (PUD) is a condition in which one or more sores or ulcers develop on the lining of the stomach, beginning of the small intestine (duodenum) or lower part of the food pipe (esophagus). Normally, a thick layer of mucus protects the digestive tract from the erosive effect of digestive acids. But many factors can reduce or damage this protective lining, allowing stomach acid to dissolve this lining, and thereby causing ulcers.

Peptic ulcers are fairly common. Worldwide, it is estimated that up to 10 percent of adults are affected by it at least once in their lifetime. In most cases, PUD occurs due to a bacterial infection (H. pylori)  or due to the excessive use of non-steroidal anti-inflammatory drugs (NSAIDs) that damage the digestive system. Symptoms of peptic ulcers include stomach ache, indigestion, nausea, vomiting, loss of appetite and unexplained weight loss.

Treatment of peptic ulcers is focussed on lowering stomach acid levels to aid in healing of ulcer, or eliminating the H. pylori infection. The medications include proton pump inhibitors (PPIs) to help reduce stomach acid and antibiotics to help fight infections.

Key Facts

Usually seen in
  • Adults between 30 to 50 years of age
Gender affected
  • Both men and women but more common in women
Body part(s) involved
  • Stomach
  • Intestine
Prevalence
Mimicking Conditions
Necessary health tests/imaging
Treatment
Specialists to consult
  • Gastroenterologist
  • Gastrointestinal surgeon
  • General physician
  • Pediatrician

Symptoms Of Peptic Ulcer Disease


The symptoms of peptic ulcer disease may vary from person to person, depending on the site of the ulcer and age. Ulcer in the stomach is called a gastric ulcer whereas the ulcer in the duodenum (part of the small intestine) is called a duodenal ulcer.

One of the most common symptoms of peptic ulcer disease is gnawing pain in the abdomen. However, not everyone with this condition experience symptoms. Some people do not notice any signs of the disease until complications such as internal bleeding or abdominal perforation develop.

The tell-a-tale signs and symptoms of peptic ulcer disease include the following:


Pain in the stomach

Peptic ulcer-related pain radiates from the middle of your stomach and travels to the neck region and down to the naval area or your back. It is characterized by a gnawing or burning sensation.

One can differentiate between gastric ulcer and duodenal ulcer based on the timing of the appearance of their symptoms on meal consumption. Pain occurs shortly after meals in case of gastric ulcer and 90-180 minutes after meals in case of duodenal ulcer. People with duodenal ulcers also often experience nocturnal pain (pain during the night). 


Bloating

Bloating can make you feel like your stomach is full of air or gas. It can be a very uncomfortable feeling.


Blood in vomit

Also known as hematemesis, it is a severe condition that requires immediate medical attention. 


Blood in stool

If your stools are black, it might indicate gastrointestinal bleeding.

Other gastric ulcer symptoms include:

  • A feeling of fullness in the abdomen

  • Vomiting and nausea

  • Weight loss

The warning symptoms that require urgent medical care include:

  • Unexplained weight loss

  • Deficiency of iron

  • Gastrointestinal bleeding 

  • Dysphagia or difficulty swallowing

  • Excessive vomiting


Here’s more on the common causes of a stomach ache and when to consult a doctor for a stomach ache. 

Causes Of Peptic Ulcer Disease


Peptic ulcers develop when digestive acid works against the defense mechanism of the stomach and eats up the protective lining covering it. The common causes of peptic ulcers are helicobacter pylori (bacteria) infection and excessive consumption of NSAIDs. 


H. pylori Infection

H. pylori can affect people of all ages and is one of the most common causes of PUD. The infection can go unnoticed as it doesn’t cause any symptoms in its early course of infection. The bacteria is present in the stomach lining. It generally causes no problems; however, in some cases, it can irritate the lining and make it weak and prone to stomach acid to get through the stomach lining leading to the development of ulcers.


Non-steroidal anti-inflammatory drugs (NSAIDs)

Although doctors prescribe these medications to treat pain, inflammation, and fever; some take them without symptoms. Unnecessary consumption of NSAIDs for a long time or in high doses can lead to side effects such as stomach ulcers.


Lifestyle factors 

Some lifestyle factors may also lead to the formation of ulcers in your stomach or duodenum. These include:

  • Eating spicy food

  • Drinking alcohol

  • Stress

Did you know?
A Cushing ulcer, named after Harvey Cushing, is a type of gastrointestinal ulcer associated with stressful medical conditions of the brain like accidents, operations, or strokes.
Did you know?

Risk Factors For Peptic Ulcer Disease

The risk factors of peptic ulcer disease include the following:

  • H. pylori infection

  • Advanced age

  • Frequent and unnecessary intake of NSAIDs

  • Long term use of glucocorticoids and anticoagulant medications

  • Health conditions such as lung, kidney, or liver disease

  • Smoking

  • Heavy alcohol consumption

  • Family history of peptic ulcers

  • Hispanic or African American ethnicity

Diagnosis Of Peptic Ulcer Disease


To begin with, your doctor will ask you about your symptoms and whether you have been taking NSAIDs. They may also test you for H. pylori infection. 

Medical examination for H. pylori infection

If your doctor suspects you have an H. pylori infection, they will suggest taking the following tests.

  • Urea breath test: It is a breath test in which your doctor will ask you to have a special drink containing urea and then analyze your breath for the bacteria based on the amount of carbon dioxide you exhale after drinking the solution.
  • Stool antigen test: In this test, the doctor will test your stool sample for the bacteria.
  • Helicobacter pylori IgG test: Your doctor will take your blood sample and test it for antibodies against the H. pylori bacteria.


Gastroscopy

During this procedure, your doctor uses an endoscope (flexible and thin) with a camera fitted on its end. They will administer a mild sedative and spray a local anesthesia and then insert this tube inside your mouth to see the inside pictures of your stomach and intestine. As it is usually an outpatient procedure, you can go home the same day as the test.

In addition to permitting direct visualization of the gastric mucosa, endoscopy facilitates photographic documentation of any mucosal defect and tissue biopsy to rule out malignancy or H. pylori infection.

Did you know?
Two Australian researchers, Barry James Marshall and Robin Warren, discovered the Helicobacter pylori bacterium in 1982. They have also been awarded the Nobel Prize in Physiology or Medicine. Here’s more on why the H. pylori test is recommended and what it might indicate.
Did you know?

Prevention Of Peptic Ulcer Disease

Prevention of peptic ulcers can be difficult sometimes. We still don’t completely know the mechanism of how the bacteria spread and how some people develop peptic ulcers without H. pylori infection. Researchers and medical experts from all over the world are working on developing a vaccine to cure peptic ulcer disease. Some preventive measures you may practice include the following:

Avoid irritants

The food you eat goes straight to your stomach. Therefore, make sure to avoid the food items that can irritate it. Especially, stay away from common food items you know can upset your stomach such as spicy foods, oily foods and citrus fruits.

Quit smoking

If you are a heavy smoker, your risk of developing duodenal ulcers is higher compared to a person who does not smoke. Therefore, you should quit smoking. If you are unable to stop smoking even after making deliberate attempts, you may consider consulting a counselor.

Tobacco is injurious to health. Explore our range of smoking cessation products.  

Control alcohol consumption

Heavy intake of alcohol can lead to the development of peptic ulcers and many other health complications. Therefore, you should drink alcohol in moderation. And, if you can stop drinking, there could be nothing better.

Limit intake on painkillers

Many people take pain killers, especially NSAIDs, unnecessarily. Some people take these medications without food, which increases their risk of developing peptic ulcers. To prevent the condition from damaging the protective lining of your stomach, take NSAIDs with food and only when necessary.

Control stress

Practice guided meditation and exercise regularly to relax your mind and body. This will also help you cope with increasing stress levels.

Is stress affecting your work-life balance? Try out our mind care products for a healthy mind and body. 

Also, lifestyle modifications such as eating the right food at the right time, keeping yourself hydrated, and having quality sleep, are some other ways that can prevent peptic ulcers.

Specilaist To Visit

If you experience the signs and symptoms of peptic ulcers, make sure not to ignore them and consult your doctor. If you take acid blockers and over-the-counter (OTC) antacids for relief from the pain, but the pain keeps coming back, seek immediate medical attention. 

Specialists you should visit include the following:

  • General physician

  • Gastroenterologist

  • Gastrointestinal surgeon

  • Pediatrician (in case of children)


Consult India’s best doctors from the comfort of your place.

Treatment Of Peptic Ulcer Disease


If you are diagnosed with a peptic ulcer disease, your doctor will decide the treatment plan based on the cause of the disease. With the appropriate treatment, it may take around a month or two to heal.

If Helicobacter pylori infection or/and taking NSAIDs is the reason for your ulcer, your doctor is likely to prescribe a course of antibiotics and proton pump inhibitor (PPI)

If the use of NSAIDs is the only cause for your peptic ulcer, your doctor is likely to recommend a course of PPI medicine. Occasionally, the doctor may also prescribe H2-receptor antagonists instead of proton pump inhibitors. For short-term relief from ulcer symptoms, your doctor might prescribe antacids.

Your doctor may also recommend another gastroscopy procedure, 4 to 6 weeks after treatment to check whether your ulcer has healed.

Medicines


Antibiotics

If H. pylori infection has caused the ulcer in your stomach, your doctor will probably prescribe antibiotics. Antibiotics may cause mild side effects, including diarrhea, not feeling well, and a metallic taste in your mouth. These medications kill the bacteria to help you heal faster. Some widely prescribed antibiotics include:

Proton pump inhibitor (PPI)

This class of medication helps reduce the amount of acid production by your stomach to prevent more damage to the ulcer. The course of treatment generally lasts for 4 to 8 weeks.

Some examples of protein pump inhibitors include:


Although PPIs do not have any severe side effects, they may include the following:


Long term intake of PPIs may lead to development of the following potential adverse effects:

  • Acute kidney disease

  • Chronic kidney disease

  • Hypomagnesemia

  • Clostridium difficile infections

H2-receptor antagonists

H2-receptor antagonists, also known as histamine H2-receptor antagonists and H2 blockers, are a group of medications that help reduce the amount of acid production in the stomach as PPIs do. 

Some examples of H2 blockers include:


Although not very common, some of its side effects that can occur include:

Antacids

As the medications mentioned above generally start their action after several hours of administration, your doctor may recommend antacids to get short-term but immediate relief. 

Antacids help neutralize the acid present in your stomach to provide relief from acidity. Some antacids may also contain alginate, a drug that creates a protective coating over your stomach's lining. 

You can get these medications as over-the-counter (OTC) drugs. Some side effects of these drugs include the following:

  • Feeling sick

  • Flatulence

  • Constipation (caused by aluminum containing preparations)

  • Diarrhea (caused by magnesium containing preparations)

  • Stomach cramps


Note: If taking NSAIDs is the reason for your stomach ulcer, your doctor is likely to review how you use these medicines. They might suggest you take an alternative painkiller like paracetamol, as it is not associated with ulcers. Your doctor may also prescribe another class of NSAIDs known as a COX-2 inhibitor.

If you have been taking a course of low-dose aspirin to minimize the possibility of blood clots, inform your doctor. Your doctor is the right person to tell you if you should keep taking it.


Surgery

If you are unresponsive to the treatment options given above or not compliant, your doctor may prescribe surgery to heal the peptic ulcer. Surgical procedures include:

  • Vagotomy: It is a surgical procedure which involves cutting off one or more branches of the vagus nerve to reduce the rate of gastric secretion. 

  • Antrectomy: This procedure involves surgical removal of the walls of the gastric or pyloric tantrum in the stomach. 

  • Pyloroplasty: It is a procedure to widen the opening in the lower part of the stomach to allow the food to empty directly in the small intestine. 

  • Artery tying off: If an ulcer in the stomach is bleeding, your doctor may cut off an artery to stop the blood supply to the region.

Did you know?
The Food and Drug Administration (FDA) requested removing all forms of OTC and prescription ranitidine, a widely used drug for treating peptic ulcers. The reason behind this move was the presence of unacceptable amounts of N-nitrosodimethylamine (NDMA) in ranitidine. NDMA is a possible cancer-causing chemical. If you are still taking this medicine, make sure to stop right away and get in touch with your doctor.
Did you know?

Home-care For Peptic Ulcer Disease


What you eat and how you eat play a crucial role in peptic ulcer management at home. Here are some do's and don'ts for people with peptic ulcer disease.


Do's

  • Make sure to eat food at regular intervals. For example, eat small meals in small portions every 3 hours.

  • Have your meal 2 to 3 hours before hitting the bed.

  • Make sure to chew your fluid slowly and properly.

  • Eat fresh fruits and vegetables.

  • Drink lots of water.

Don'ts

  • Do not eat too much of sour, fried, and spicy foods.

  • Avoid caffeinated beverages such as tea and coffee, excessively.

  • Do not drink alcohol, chew tobacco, or smoke.

  • Never self-medicate.

  • Avoid painkillers such as NSAIDs.

Complications Of Peptic Ulcer Disease

Usually, peptic ulcer disease do not cause any complications. However, the condition, if not diagnosed and treated on time, can cause severe complications. Following are the possible complications with peptic ulcer disease.


Internal bleeding 

It is the most prevalent complication of PUD. It mainly occurs if you have got an ulcer near a blood vessel. Internal bleeding is of two types:
  • Long-term and slow bleeding: It can lead to many other complications including anemia, pale skin, breathlessness, increased heartbeat, and fatigue.
  • Rapid bleeding: It can lead to blood in vomit and passing black stools.


Perforation

Although rare, it can be painful. It happens when the protective lining of your stomach perforates and breaks, allowing bacteria to live in your stomach and infect the peritoneum (lining of your abdomen). The condition is known as peritonitis. This health condition, if not treated on time, can spread into the blood and cause sepsis. It can also lead to multiple organ failures.


Gastric outlet obstruction

Sometimes, a scarred or swollen ulcer can block the passage of food in your digestive system leading to gastric outlet obstruction. The symptoms include:

  • Feeling bloated or full all the time

  • Bouts of vomiting contain undigested food 

  • Unexplained weight loss

Cancer

Helicobacter pylori as the etiological factor increases the chances of getting stomach cancer from the ulcer.

Alternative Treatments For Peptic Ulcer Disease

Here are some quick home remedies for peptic ulcers:


Fenugreek (Methi): Fenugreek seeds are enriched with antioxidants that help in reducing the severity of gastric ulcers. Boil a cup of fenugreek leaves in water. Add salt to taste. Drink this concoction two times a day. Here are few more health benefits of fenugreek seeds.

Cabbage (Bandha gobi) juice: Cabbage juice strengthens the lining of your stomach and aids in healing the condition. You may drink fresh cabbage juice before going to bed regularly.

Banana (Kela): Bananas are loaded with antibacterial benefits that slow down the progression of the PUD. Eat a banana after breakfast every day.

Honey (Shehed/Madhu): Honey has antimicrobial properties, and it is a natural healer. It keeps inflammation at bay and keeps your stomach healthy. Have one tablespoon of honey before your breakfast, or add it to the food you eat to let it work wonders.

Garlic (Lehsun): Garlic has antibacterial and antimicrobial properties that help fight infections. Have 2 to 3 cloves of garlic every day early in the morning to get the best possible benefits.

Slippery elm (Indian elm): The bark of the slippery elm plant helps calm the mucus membranes lining the stomach and the duodenum. Take the bark of slippery elm and grind it to powder. Add one cup of warm water to the powder, mix, and drink the concoction thrice a day.

Yoga for peptic ulcers

Practicing yoga asanas helps improve blood circulation in your digestive organs. Therefore, these can help you heal properly from stomach ulcers. Some common yoga poses for peptic ulcers include the following:

  • Mandukasana

  • Sasakasana

  • Yoga Mudrasana

  • Ardhamatyendrasana

  • Vakrasana

  • Pawan Muktasan

  • Gomukhasana

Living With Peptic Ulcer Disease

With adequate treatment and care, PUD heals over time. However, you need to monitor your diet and habits to reduce the chances of relapse. 

Determine your personal tolerance

There is no proof that spicy or citrus foods influence ulcer disease. However, some people report worsened symptoms after consuming these kinds of foods. It is critical to discover what works best for you. If you discover that specific foods make your symptoms worse, restrict or avoid them so you can feel your best, but don't remove an entire food category.


Take care of your mental health

Peptic ulcers can be caused indirectly by stress, worry, and depression. Ulcers can be exacerbated by poor eating habits and harmful lifestyle choices that might occur as a result of mental health issues.


Change your diet

In addition to medicines, physicians frequently advise patients with ulcers to make lifestyle and dietary modifications until complete healing occurs. Although patients were previously recommended to eat a bland diet, recent evidence does not support this dietary adjustment to be useful. Although spicy foods might aggravate ulcers in certain people, medical practitioners are increasingly emphasizing a high-fiber diet rich in vegetables and fruits. The following can be added to the diet:

  • Fiber and Vitamin A: Liver, carrots, broccoli, sweet potatoes, kale, spinach, and collard greens are all high in Vitamin A.

  • Flavonoid-rich foods and green tea: Garlic, onions, and colorful fruits and vegetables including cranberries, strawberries, blueberries, broccoli, carrots, and snap peas, have high flavonoid content.

  • Cranberry juice: Only two 250 ml cups of cranberry juice each day may lower the risk of H. pylori proliferation in the stomach. Cranberry aids in preventing inflammation by either not allowing bacteria to adhere to it or disengaging it from the body after it has attached. 


Individuals suffering from ulcers should avoid or limit coffee and alcohol.

  • Coffee: Caffeinated and decaffeinated coffee can both increase acid production and aggravate symptoms in people with peptic ulcers.
  • Alcoholic beverages: Alcoholic drinks can damage the protective mucosal lining of the gastrointestinal system, resulting in further inflammation and bleeding. 

Frequently Asked Questions

References

  1. Malik TF, Gnanapandithan K, Singh K. Peptic Ulcer Disease. [Updated 2021 Jul 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan.External Link
  2. Ankolekar C, Johnson D, Pinto Mda S, et al. Inhibitory potential of tea polyphenolics and influence of extraction time against Helicobacter pylori and lack of inhibition of beneficial lactic acid bacteria. J Med Food. 2011 Nov;14(11):1321-9.External Link
  3. Lee SY, Shin YW, Hahm KB. Phytoceuticals: mighty but ignored weapons against Helicobacter pylori infection. J Dig Dis. 2008 Aug;9(3):129-39.External Link
  4. Cohen S, Booth GH Jr. Gastric acid secretion and lower-esophageal-sphincter pressure in response to coffee and caffeine. N Engl J Med. 1975 Oct 30;293(18):897-9. External Link
  5. Zhang L, Ma J, Pan K, Go VL, Chen J, You WC. Efficacy of cranberry juice on Helicobacter pylori infection: a double-blind, randomized placebo-controlled trial. Helicobacter. 2005 Apr;10(2):139-45.External Link
  6. Aldoori WH, Giovannucci EL, Stampfer MJ, Rimm EB, Wing AL, Willett WC. Prospective study of diet and the risk of duodenal ulcer in men. Am J Epidemiol. 1997 Jan 1;145(1):42-50.External Link
  7. Garrigues-Gil V. Antacids in the treatment of peptic ulcer disease. Methods Find Exp Clin Pharmacol. 1989;11 Suppl 1:73-7. PMID: 2657291. External Link
  8. Zhang L, Ma J, Pan K, Go VL, Chen J, You WC. Efficacy of cranberry juice on Helicobacter pylori infection: a double-blind, randomized placebo-controlled trial. Helicobacter. 2005 Apr;10(2):139-45. External Link
  9. Mandal MD, Mandal S. Honey: its medicinal property and antibacterial activity. Asian Pac J Trop Biomed. 2011;1(2):154-160.External Link
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