Peptic Ulcer Disease: Symptoms, Causes & Treatment

Peptic ulcer disease is a common condition characterized by erosion in the protective lining (mucosa) of the stomach or the first part of the small intestine called the duodenum. This erosion occurs when stomach acid penetrates the protective barrier and damages the underlying tissue. The ulcer can be shallow or deep, causing a burning pain in the upper abdomen, especially between meals or at night.

The two main causes are: first, infection with Helicobacter pylori bacteria, which lives in the stomach and affects approximately half the world's population; and second, chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen. Peptic ulcer disease affects millions of people worldwide, and in the Middle East including Jordan, it is considered a common condition in gastroenterology clinics. Fortunately, modern treatments are very effective and cure most cases completely within 4-8 weeks if followed regularly.

It is important to understand that peptic ulcer disease is not always serious, but leaving it untreated can lead to serious complications such as bleeding or perforation. Therefore, it is necessary to consult a doctor when persistent symptoms such as burning abdominal pain or nausea appear.

Symptoms of peptic ulcer disease range from mild to severe and may vary depending on the ulcer location (stomach or duodenum) and severity. Some sufferers may feel no symptoms until complications occur. Symptoms are often worse when the stomach is empty or at night. Women may experience slightly different symptoms than men, such as more severe nausea or food intolerance.

• Burning pain in the upper abdomen: Between the navel and ribs (epigastric), may last from minutes to hours.
• Feeling of fullness and bloating: Especially after small meals or even drinking water.
• Acid reflux (heartburn): Stomach acid rising into the esophagus causes a burning sensation in the chest.
• Nausea and vomiting: May be accompanied by persistent vomiting urges; vomit may contain blood or coffee-ground material.
• Loss of appetite: Avoiding food because it increases pain.
• Feeling full quickly: Even with small amounts of food.
• Diarrhea or constipation: May alternate depending on the condition.
• Black stools: A sign of internal bleeding from the ulcer.
• Anemia and fatigue: Results from chronic mild bleeding from the ulcer.
• Dizziness or fainting: Especially with severe bleeding.
• Back pain: May occur if the ulcer is deep and affects adjacent tissues.
• Inability to tolerate certain foods: Especially spicy or fatty foods that increase pain.

• Helicobacter pylori (H. pylori) infection: Bacteria that live in the stomach lining and cause chronic inflammation leading to mucosa erosion, transmitted through contaminated food and water or direct contact.
• Nonsteroidal anti-inflammatory drugs (NSAIDs): Aspirin, ibuprofen, and naproxen reduce stomach-protective substances (prostaglandins) and increase stomach acid, weakening the protective barrier.
• Corticosteroids: Medications used to treat chronic inflammation may increase ulcer risk, especially when combined with NSAIDs.
• Excessive stomach acid production: In rare cases (such as Zollinger-Ellison syndrome), the body produces more acid than normal, leading to multiple and resistant ulcers.
• Smoking: Reduces bicarbonate and protective mucus secretion, increases stomach acid, and impairs ulcer healing.
• Alcohol: Irritates stomach lining and increases stomach acid, especially with heavy consumption.
• Severe psychological stress: Increases stomach acid secretion but does not directly cause ulcers without other contributing factors.
• Poor nutrition and spicy foods: May irritate the stomach and increase symptoms in susceptible individuals.

• Age and gender: More common in men than women, appears at any age but peaks around 40-60 years.
• Family history: Having relatives with peptic ulcers increases risk, especially if caused by H. pylori.
• Chronic NSAID use: Particularly in people over 60 or those taking high doses.
• Previous H. pylori infection: If not properly treated, may persist and cause ulcers.
• Heavy smoking: Smokers absorb nicotine which increases stomach acid and weakens protection.
• Heavy alcohol consumption: Irritates stomach lining and increases acidity.
• Continuous stress and psychological pressure: Increases stomach sensitivity and acid secretion.
• Chronic diseases: Such as liver or kidney disease may increase risk.
• Human immunodeficiency virus (HIV): Increases susceptibility to peptic ulcers.
• Other medications: Such as long-term proton pump inhibitors (PPIs) may alter digestive system balance.

Diagnosis of peptic ulcer disease requires a combination of clinical examination, tests, and imaging. The doctor will start by questioning the patient about symptoms, medical history, and medications used, then perform a physical examination including abdominal pressure to check for pain. Several reliable methods are available to confirm diagnosis, and the doctor chooses what suits the case.

• Urea Breath Test for H. pylori: A non-invasive test that measures the presence of pylori bacteria in the stomach through breath. The patient drinks a substance containing radioactive urea then breathes into a bag for analysis. Below 4 DPM is considered negative (normal).
• Stool Antigen Test: Detects the presence of H. pylori bacterial proteins in stool. A negative result means no infection (normal).
• Blood Test (Serology): Looks for antibodies against H. pylori. The presence of antibodies may indicate current or past infection.
• Upper Endoscopy (EGD): Considered the gold standard. The doctor inserts a thin tube with a camera through the mouth into the stomach and duodenum to directly visualize the ulcer and take samples for microscopic examination. Performed under light sedation.
• Barium X-ray: An older test but still sometimes used. The patient drinks barium solution that coats the stomach, making ulcers easier to see on images.
• Gastric Acid pH Test: Measures stomach acidity level. Normal average is around pH 2-3.
• Complete Blood Tests: To check hemoglobin levels (usually 12-16 g/dL for women and 13.5-17.5 g/dL for men), which may decrease due to chronic bleeding from the ulcer.

Medications

• Proton Pump Inhibitors (PPIs): Such as omeprazole and lansoprazole, reduce stomach acid secretion by 90%. Usual dose 20-40 mg daily. Given for 4-8 weeks in simple cases.
• H2 Receptor Blockers: Such as famotidine and ranitidine, reduce acid by 50-70%. Sometimes used instead of PPIs or with PPI in severe cases.
• Triple Antibiotic Therapy: Used when H. pylori is confirmed. Popular mixture is amoxicillin + clarithromycin + omeprazole, given for 7-14 days. Cure rate reaches 90% with adherence.
• Protective Agents: Such as sucralfate which forms a protective layer on stomach lining. Used 4 times daily.
• Antacids: Such as aluminum and magnesium, provide quick but temporary pain relief. Used as needed between meals.
• Probiotics: Some studies suggest beneficial bacteria may help healing and reduce antibiotic side effects, but not used as primary treatment.

Procedures and Surgery

• Therapeutic Endoscopy: When severe bleeding occurs from the ulcer, the doctor can use endoscopy to stop bleeding by injecting medications or placing metal clips on the bleeding vessel. Successful in 80-90% of cases.
• Surgery: Very rare now thanks to effective medications. Done only when medical treatment fails or perforation occurs. Options include vagotomy or partial gastrectomy in exceptional cases.
• Repeated Endoscopy: For resistant ulcers, patient may need multiple endoscopies to ensure complete healing.

Lifestyle Changes

• Avoid irritating foods: Such as spicy, acidic, fatty foods, chocolate, coffee, and tea. Replace with easy-to-digest foods like rice, boiled vegetables, and grilled chicken.
• Stop smoking and alcohol: Both impair healing and worsen symptoms. Quitting smoking within two weeks noticeably improves ulcer healing.
• Eat small frequent meals: Instead of 3 large meals, eat 5-6 small meals throughout the day to avoid stomach distension.
• Avoid other irritating medications: Especially NSAIDs. If necessary for another reason, take with PPI or with food.
• Manage stress: Practice yoga, meditation, or breathing exercises. Severe stress increases acidity.
• Eat slowly and chew well: Helps digestion and reduces excess acid secretion.
• Avoid eating before bedtime at least 2 hours: Reduces acid reflux and nighttime pain.
• Drink plenty of water: At least 8 glasses daily helps dilute acid and ease digestion.

• Gastrointestinal Bleeding: One of the most serious complications. The ulcer may penetrate a blood vessel causing mild (black stools) or severe bleeding (vomiting blood). Severe bleeding requires blood transfusion and urgent endoscopy and can be life-threatening if not treated quickly.
• Perforation: When the ulcer completely erodes through the stomach or duodenum wall, a complete opening occurs allowing stomach contents to leak into the abdominal cavity. This causes acute peritonitis and severe pain, requiring emergency surgery.
• Stenosis (Narrowing): Ulcer healing leaves scar tissue that may narrow the stomach opening or duodenum, obstructing food passage. Causes rapid fullness and repeated vomiting. May require endoscopic intervention or surgery.
• Adhesions: Chronic inflammation may cause stomach and intestinal tissues to stick together, obstructing food movement and causing recurring pain.
• Chronic Anemia: Slow continuous ulcer bleeding reduces blood hemoglobin levels, causing constant fatigue, weakness, and dizziness.
• Malnutrition: Inability to eat due to pain and nausea reduces absorption of essential nutrients, especially calcium, iron, and vitamin B12.
• Cancer: Very rare, but some studies suggest chronic H. pylori infection may increase stomach cancer risk over time, especially if untreated.

• Protection from H. pylori: Wash hands regularly especially before eating and after bathroom. Drink clean safe water (sterilized water is best), avoid food from unreliable sources. If a family member has H. pylori, use separate utensils and avoid direct kissing until treated.
• Avoid NSAIDs or use cautiously: If aspirin or ibuprofen is necessary, use the lowest possible dose for the shortest time. Take with food or with PPI to protect stomach.
• Stop smoking and alcohol: Both weaken stomach's protective barrier. Quitting or reducing them significantly decreases risk.
• Manage stress effectively: Exercise regularly (walk 30 minutes daily), meditate, or take yoga classes. Continuous stress increases acidity.
• Eat healthy balanced diet: Focus on fruits, vegetables, whole grains, and lean protein. Avoid spicy, fatty, and fried foods.
• Adequate and regular sleep: At least 7-8 hours nightly. Sleep deprivation increases stress and stomach acidity.
• Test and treat H. pylori if present: If you have symptoms or family history, ask your doctor for H. pylori testing. Early treatment prevents ulcer development.
• Regular follow-up with doctor: Especially if taking NSAIDs regularly or have previous ulcer history. Regular check-ups detect problems early.
• Use iodized salt cautiously: High salt may increase stomach acid secretion, so reduce salt added to food.
• Drink low-fat milk: Some studies suggest milk may help strengthen protective barrier, but avoid full-fat milk.