What is Peptic Ulcer Disease?

Peptic ulcer disease is a common condition in Singapore where open sores develop in the lining of the stomach (gastric ulcer) and upper portion of the small intestine (duodenal ulcer). According to a study done in 2019, the age-standardised global prevalence rate of peptic ulcer disease is approximately 99.4 per 100,000 population. 

Although the disease can affect anyone, it has been shown that the age-standardised rate for prevalence, incidence, and deaths were higher in males than females over 29 years old. One of the main causes of peptic ulcer disease is Helicobacter pylori (H. pylori) infection which affects about 50% of the world’s population. In Singapore, the seroprevalence is 31%. 

What is the difference between Peptic Ulcer and Gastritis? 

Gastritis is a differential diagnosis of peptic ulcer disease as they share very similar symptoms. Gastritis is the inflammatory process of the gastric mucosa while peptic ulcer disease is the development of open sores in the mucosa lining. 

Although both conditions cause inflammation in the stomach lining, gastritis indicates general inflammation while a peptic ulcer is a patch of inflamed stomach lining. Both conditions share similar symptoms such as upper abdominal pain, nausea, and vomiting.

What are the risk factors for Peptic Ulcer Disease?

• Smoking
• Alcohol
• Family history of ulcers
• Kidney, liver, or lung disease
• Frequent use of Non-steroidal anti-inflammatory drugs (NSAIDs)

What are the symptoms of Peptic Ulcer Disease?

The most common symptom for peptic ulcer disease is stomach pain. However, some people with peptic ulcer disease may be asymptomatic. 

The pain may worsen with an empty stomach, and can be relieved temporarily after consuming food or by taking medication to buffer the stomach acid. Do seek medical help if you experience any of the following symptoms which may indicate peptic ulcer disease.

Common symptoms include:

• Stomach pain
• Bloatedness
• Nausea

Less common severe symptoms include:

• Vomiting
• Blood in stools or dark stools
• Severe abdominal pain 
• Unexplained weight loss
• Intolerance of fatty food

What causes Peptic Ulcer Disease?

The stomach and small intestine are lined with a mucous layer that protects them against the digestive acid. However, an increased amount of acid or decreased amount of mucus may allow the stomach acid to damage the tissue, causing a painful open sore to develop. 

The predominant causes of peptic ulcer disease are H. pylori infection and the use of non-steroidal anti-inflammatory drugs (NSAIDs), which account for 48% and 24% of cases in the United States.

Common causes of peptic ulcer disease include:

Bacterial infection

H. pylori bacteria is commonly present in the mucous layer of the stomach and small intestine. It is often present without symptoms and does not cause any problems. However, the H. pylori bacteria can stick to the mucus and cause inflammation and breakdown of the mucous layer. Only about 10 to 15% of patients with H. pylori infection eventually develop peptic ulcer disease.

Long term use of NSAIDs

NSAIDs are a group of medications often prescribed to relieve pain. However, overuse of these drugs can cause erosion of the mucous layer in the digestive tract, resulting in the development of ulcers. In addition, NSAIDs inhibit cyclooxygenase, which is essential in prostaglandin formation and their protective effect on the mucus. Common NSAID medications include aspirin, naproxen, and ibuprofen.

Rare causes

Other rare causes that have the potential to cause peptic ulcer disease include being seriously ill from other infections, having surgery, and the intake of steroids.

I have Peptic Ulcer Disease. What foods should I eat/avoid?

There is no clear evidence for the types of food that should be avoided or encouraged to prevent the development of peptic ulcers. 

Contrary to popular belief, stress and spicy food do not cause peptic ulcer disease, although they may exacerbate the condition, making it harder to treat. In general, food rich in antioxidants may be beneficial in activating the immune system to fight the infection and lower your risk of stomach cancer. 

Food that may be beneficial:

• Cauliflower
• Blueberries
• Cherries
• Bell peppers
• Leafy vegetables such as kale
• Fermented probiotic food such as miso
• Olive oil
• Turmeric 

Food to avoid when you have peptic ulcer or acid reflux:

• Coffee
• Chocolate
• Spicy food
• Alcohol
• Acidic food such as citrus fruits

How is Peptic Ulcer Disease diagnosed? 

In order to detect a peptic ulcer, the doctor may choose to order the following tests:

Laboratory tests

Laboratory tests for the presence of helicobacter pylori bacteria can be done through blood, stool, or breath tests. In the breath test, you will be asked to consume something that contains radioactive carbon, which will be broken down by the bacteria in your stomach into carbon dioxide. You will then be asked to blow into a bag and the breath sample will be tested for carbon dioxide which will indicate the presence of the bacteria.

Upper gastrointestinal endoscopy

Endoscopy is a procedure that examines and inspects the upper gastrointestinal tract for any abnormalities such as peptic ulcers. It involves the insertion of an endoscope (a long flexible tube equipped with light and camera at the end) into the mouth and passed along the oesophagus, stomach, and small intestine. A biopsy of the ulcer may be obtained for further examination in the lab.

Barium meal

During this procedure, a series of X-ray images of the upper gastrointestinal tract are taken while a white liquid containing barium is swallowed. The barium helps to coat the digestive tract thus giving a clearer visualisation of the peptic ulcer. 

Can Peptic Ulcer Disease be cured? 

Most peptic ulcer disease can be cured completely by treating its underlying cause, such as a H. pylori infection or avoiding NSAIDs use. However, peptic ulcers can recur if the H. pylori is not completely eliminated from the gastrointestinal tract or with continual use of NSAIDs and smoking.

Peptic ulcers can be prevented by protecting yourself from helicobacter pylori infection. Although it is unclear how the bacteria spreads, it is believed to be transmitted from person to person, or through food and water. Hence, it is important to wash your hands frequently and avoid food that is not cooked completely. You can also reduce the risk of peptic ulcer disease by taking caution with NSAIDs intake. Try starting with the lowest dose possible and taking the medication with meals.

A note from Dr Benjamin Yip: Non-healing gastric ulcers deserve special attention and follow-ups as they may be the presenting sign of gastric cancers. Hence, if you are diagnosed with a gastric ulcer, your doctor should be asking you to go for a second endoscopy to ensure that your gastric ulcer has healed. 

How is Peptic Ulcer Disease Treated? 

Although peptic ulcers can sometimes heal on their own, it should not be ignored. Without proper and prompt treatment, peptic ulcers can lead to complications such as bleeding, gastric outlet obstruction, and perforation. 

Peptic ulcers are treated according to the cause. Generally, treatment will involve eliminating the helicobacter pylori bacteria, reducing the use of NSAIDs, and other medications to help the ulcer heal. For bleeding ulcers, the doctor may choose to treat via an endoscopy by administering injections, using a clamp, or cauterisation to stop the bleeding.

Medications for peptic ulcer include:

• Antibiotics — The doctor may prescribe antibiotics such as amoxicillin, clarithromycin, metronidazole, and tinidazole to kill the H. pylori bacteria.
  
• Medications that reduce acid production — Proton pump inhibitors (PPIs) help reduce stomach acid by inhibiting the action of the parts of the cells that produce acid. Histamine blockers, or antihistamines, work by reducing the amount of stomach acid released into the gastrointestinal tract to relieve ulcer pain.
  
• Antacids — Antacids are medications that neutralise the existing stomach acid to relieve pain, heartburn, and indigestion.
  
• Mucosal protective agents — The doctor may prescribe cytoprotective agents to protect tissues that line the stomach and small intestine. 

Treatment for peptic ulcers using medications are generally successful, leading to ulcer healing. However, if the symptoms persist despite treatment, the doctor may recommend another endoscopy to rule out other causes. Ulcers that fail to heal may be due to several reasons such as non-compliance to the medications, antibiotics resistance, and regular use of tobacco and NSAIDs. 

Refractory peptic ulcer disease is a condition that fails to heal after 8 to 12 weeks of therapy. Therapy options for refractory ulcers involve the treatment of its underlying causes, prolonged administration of PPI, and surgery. Refractory ulcers may be due to other underlying medical conditions such as:

• Zollinger-Ellison syndrome
• Stomach cancer
• Crohn’s disease
• Infection from other bacteria other than H. pylori

What complications can occur when Peptic Ulcer Disease is left untreated?

Untreated peptic ulcers can lead to several health complications such as:

• Bleeding — Upper gastrointestinal bleeding occurs in 15 to 20% of patients with peptic ulcer disease. Peptic ulcers can result in blood loss that leads to anaemia. Severe blood loss may cause bloody stools or vomit.
  
• Perforation — Perforation occurs in 2 to 10% of patients with peptic ulcer disease. Peptic ulcers can perforate the walls of the stomach or small intestine resulting in serious infection of the abdominal cavity. Chemical and bacterial peritonitis due to peritoneal perforation is a surgical emergency that causes sudden and severe upper abdominal pain.
  
• Obstruction — Gastric outlet obstruction occurs in less than 5 to 8% of patients with peptic ulcer disease. Recurrent peptic ulcers may lead to the development of pyloric stenosis as a result of inflammation and scarring.
  
• Gastric cancer — Patients with helicobacter pylori infection have an increased risk of gastric cancer.

Summary

Peptic ulcer disease is a common condition of the gastrointestinal tract characterised by the development of peptic ulcers due to the discontinuation of the mucous layer that lines and protects the stomach and small intestine. 

As peptic ulcer disease is mainly caused by H. pylori bacteria and the use of NSAIDs, treatment generally involves medication and refraining from NSAID use. If you suffer from peptic ulcer disease, or if your symptoms persist even after treatment, please consult a doctor immediately for further tests and treatment. 

References

1. Xie, X., Ren, K., Zhou, Z., Dang, C., & Zhang, H. (2022). The global, regional and national burden of peptic ulcer disease from 1990 to 2019: A population-based study. BMC Gastroenterology, 22(1). https://doi.org/10.1186/s12876-022-02130-2 
2. Chew, C. A., Lye, T. F., Ang, D., & Ang, T. L. (2017). The diagnosis and management of H. pylori infection in Singapore. Singapore Medical Journal, 58(5), 234–240. https://doi.org/10.11622/smedj.2017037 
3. Mayo Foundation for Medical Education and Research. (2020, August 6). Peptic ulcer. Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/peptic-ulcer/symptoms-causes/syc-20354223 
4. Peptic ulcer disease: Treatment, symptoms, causes, prevention. Cleveland Clinic. (n.d.). Retrieved from https://my.clevelandclinic.org/health/diseases/10350-peptic-ulcer-disease 
5. Ramakrishnan, K., & Salinas, R. C. (2007). Peptic Ulcer Disease. Am Fam Physician, 76, 1005–1012. 
6. Watson, K. (2020, August 21). Stomach ulcer diet: Foods to eat and foods to avoid. Healthline. Retrieved from https://www.healthline.com/health/stomach-ulcer-diet#what-to-eat 
7. Malik, T. F., Gnanapandithan, K., & Singh, K. (2021, July 29). Peptic ulcer disease. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK534792/