Peptic ulcer disease, usually known as ‘ulcers’ is a condition in which there is erosion of the lining in the digestive tract, commonly in the stomach (called gastric ulcers) and duodenum which is the first part of the small intestines (duodenal ulcers).

Ulcers can sometimes heal spontaneously without treatment but these are bound to high recurrence rates, and others can worsen overtime leading to development of serious and life-threatening complications such as severe bleeding, perforation of the stomach/ duodenum ( when the ulcer leads to formation of a ‘hole’ through the wall of the stomach or duodenum)

Peptic ulcers develop when the acid secreted by the stomach erodes the lining of the digestive tract. Normally, the stomach and duodenum have mechanisms which help to protect them against erosion by the stomach. These include; mucous protective layer, foods and other substances produced by the intestines which neutralize the stomach acid, and if the mucous layer is damaged or the acid neutralizing substances are not adequate, there is exposure of the stomach or duodenal lining to the acids found in stomach digestive juices, which can lead to irritation and damage of the linings hence an ulcer can form.

The 2 mostly known causes of peptic ulcer disease are infection with bacteria called H. Pylori and the use of a group of painkillers called Non-Steroidal Anti-Inflammatory Drugs (NSAIDs).

H pylori infection is a common bacterial infection of the gastrointestinal tract, found in about 50% of the general population. Not everyone with H pylori infection suffers ulcers, but it increases the risk through; causing increase in acid levels in the stomach and intestines, causing inflammation of the lining of the stomach and duodenum, and destruction of the mucous protective layer.

NSAIDs are certain drugs which are commonly used to treat pain and inflammation. They include drugs like diclofenac, ibuprofen, lornoxicam and many others. These drugs interfere with the integrity of protective mucous layer of stomach and intestinal lining, increasing the risk of developing an ulcer. The risk of developing ulcers secondary to these drugs increases with increasing duration of use, higher dozes, and risk varies with each particular drug used.

There are other factors associated with a higher risk of peptic ulcer disease, and include; family history of ulcers, tobacco smoking, excess alcohol drinking, stress and anxiety. These can interfere with the healing mechanisms of the ulcers and increase the rates of recurrences.

Symptoms of peptic ulcer disease

Some people with peptic ulcers might not have symptoms, especially initially. Symptoms of peptic ulcers vary and may include; abdominal pain or discomfort which is often a burning sensation and felt mostly in upper belly (pain is usually at its worst immediately after food for stomach ulcers and 2-5 hours after food for duodenal ulcers and usually between 11pm to 2AM when acid secretion tends to be greatest), bloating, early sense of feeling full with eating, lack of appetite, heart burn, nausea, vomiting (may contain blood in severe form), passing blood in stools (usually appear as black stools).

Diagnosis of peptic ulcer disease

The diagnosis of peptic ulcer disease is made after taking the history from the patient, physically examining the patient, and some investigations can be done to confirm the disease and cause, since other conditions can present like peptic ulcer disease.

An upper endoscopy is a procedure which is usually performed to confirm an ulcer. A flexible thin tube with light and camera attached to its end is inserted through the mouth and throat down to the stomach and duodenum and the lining of the stomach and duodenum visualized on a screen and if an ulcer or abnormal structure is visualized, a small part of it is taken off (biopsy) during the procedure and taken to the laboratory to look out for H. Pylori bacteria or any cancer cells.

Tests for H pylori bacteria infection such as breath tests or stool analysis to look out for the bacteria can be done in addition to endoscopy to confirm presence of H pylori bacteria.

Less commonly, a barium swallow which involves drinking a thick substance containing barium (which allows the digestive tract to be seen more clearly) while X rays are taken can be done

Treatment of peptic ulcers

Most ulcers can be healed with medication. Surgery is usually reserved for the complications of the disease such as perforation, less commonly in severe bleeding and stomach outlet obstruction.

The hallmark of treating peptic ulcer lies in identifying the cause. The above class of drugs (NSAIDs) should be stopped irrespective of the initial cause of the ulcers

For the patients with ulcers and who test positive for H pylori bacteria infection, a combination of different types of antibiotics to eradicate the infection and drugs which reduce the release of acid by the stomach can be prescribed, and these should be taken as prescribed, for effective outcome.

In addition to medications, a number of lifestyle changes can help ones ulcers to heal and these can include; stop NSAID use (inform the clinicians that you have suffered from ulcers before so that alternative painkillers are always prescribed), quit smoking, reduce on or stop alcohol intake, take antacid medications for symptom relief, make an effort to reduce stress. Eating a healthy diet with plenty of fruits, vegetables, fiber and reducing on acidic, spicy, high fat rich diet can help in reducing the symptoms of ulcers.

Dr. Ian Shyaka is a General Practitioner at Rwanda Military Hospital