An ulcer is a sore or lesion that forms in the lining of the stomach or duodenum where acid and pepsin are present. Ulcers in the stomach are called gastric or stomach ulcers. Those in the duodenum are called duodenal ulcers. In general, ulcers in the stomach and duodenum are referred to as peptic ulcers. Ulcers rarely occur in the esophagus or in the first portion of the duodenum, the duodenal bulb.
About 20 million Americans develop at least one ulcer during their lifetime. Each year:
- Ulcers affect about 4 million people.
- More than 40,000 people have surgery because of persistent symptoms or problems from ulcers.
- About 6,000 people die of ulcer-related complications.
Ulcers can develop at any age, but they are rare among teenagers and even more uncommon in children. Duodenal ulcers occur for the first time usually between the ages of 30 and 50. Stomach ulcers are more likely to develop in people over age 60. Duodenal ulcers occur more frequently in men than women; stomach ulcers develop more often in women than men.
For almost a century, doctors believed lifestyle factors such as stress and diet caused ulcers. Later, researchers discovered that an imbalance between digestive fluids (hydrochloric acid and pepsin) and the stomach's ability to defend itself against these powerful substances resulted in ulcers. Today, research shows that most ulcers develop as a result of infection with bacteria called Helicobacter pylori (H. pylori). While all three of these factors--lifestyle, acid and pepsin, and H. pylori--play a role in ulcer development, H. pylori is now considered the primary cause.Lifestyle
While scientific evidence refutes the old belief that stress and diet cause ulcers, several lifestyle factors continue to be suspected of playing a role. These factors include cigarettes, foods and beverages containing caffeine, alcohol, and physical stress.
Smoking
Studies show that cigarette smoking increases one's chances of getting an ulcer. Smoking slows the healing of existing ulcers and also contributes to ulcer recurrence.
Caffeine
Coffee, tea, colas, and foods that contain caffeine seem to stimulate acid secretion in the stomach, aggravating the pain of an existing ulcer. However, the amount of acid secretion that occurs after drinking decaffeinated coffee is the same as that produced after drinking regular coffee. Thus, the stimulation of stomach acid cannot be attributed solely to caffeine.
Alcohol
Research has not found a link between alcohol consumption and peptic ulcers. However, ulcers are more common in people who have cirrhosis of the liver, a disease often linked to heavy alcohol consumption.
Stress
Although emotional stress is no longer thought to be a cause of ulcers, people with ulcers often report that emotional stress increases ulcer pain. Physical stress, however, increases the risk of developing ulcers particularly in the stomach. For example, people with injuries such as severe burns and people undergoing major surgery often require rigorous treatment to prevent ulcers and ulcer complications.
Acid and pepsin
Researchers believe that the stomach's inability to defend itself against the powerful digestive fluids, acid and pepsin, contributes to ulcer formation. The stomach defends itself from these fluids in several ways. One way is by producing mucus--a lubricant-like coating that shields stomach tissues. Another way is by producing a chemical called bicarbonate. This chemical neutralizes and breaks down digestive fluids into substances less harmful to stomach tissue. Finally, blood circulation to the stomach lining, cell renewal, and cell repair also help protect the stomach.
Nonsteroidal anti-inflammatory drugs (NSAIDs) make the stomach vulnerable to the harmful effects of acid and pepsin. NSAIDs such as aspirin, ibuprofen, and naproxen sodium are present in many non-prescription medications used to treat fever, headaches, and minor aches and pains. These, as well as prescription NSAIDs used to treat a variety of arthritic conditions, interfere with the stomach's ability to produce mucus and bicarbonate and affect blood flow to the stomach and cell repair. They can all cause the stomach's defense mechanisms to fail, resulting in an increased chance of developing stomach ulcers. In most cases, these ulcers disappear once the person stops taking NSAIDs.
Helicobacter pylori
H. pylori is a spiral-shaped bacterium found in the stomach. Research shows that the bacteria (along with acid secretion) damage stomach and duodenal tissue, causing inflammation and ulcers. Scientists believe this damage occurs because of H. pylori's shape and characteristics.
H. pylori survives in the stomach because it produces the enzyme urease. Urease generates substances that neutralize the stomach's acid--enabling the bacteria to survive. Because of their shape and the way they move, the bacteria can penetrate the stomach's protective mucous lining. Here, they can produce substances that weaken the stomach's protective mucus and make the stomach cells more susceptible to the damaging effects of acid and pepsin.
The bacteria can also attach to stomach cells further weakening the stomach's defensive mechanisms and producing local inflammation. For reasons not completely understood, H. pylori can also stimulate the stomach to produce more acid.
Excess stomach acid and other irritating factors can cause inflammation of the upper end of the duodenum, the duodenal bulb. In some people, over long periods of time, this inflammation results in production of stomach-like cells called duodenal gastric metaplasia. H. pylori then attacks these cells causing further tissue damage and inflammation, which may result in an ulcer.
Within weeks of infection with H. pylori, most people develop gastritis--an inflammation of the stomach lining. However, most people will never have symptoms or problems related to the infection. Scientists do not yet know what is different in those people who develop H. pylori-related symptoms or ulcers. Perhaps, hereditary or environmental factors yet to be discovered cause some individuals to develop problems. Alternatively, symptoms and ulcers may result from infection with more virulent strains of bacteria. These unanswered questions are the subject of intensive scientific research.
Studies show that H. pylori infection in the United States varies with age, ethnic group, and socioeconomic class. The bacteria are more common in older adults, African Americans, Hispanics, and lower socio- economic groups. The organism appears to spread through the fecal-oral route (when infected stool comes into contact with hands, food, or water). Most individuals seem to be infected during childhood, and their infection lasts a lifetime.
Vitamins and Minerals
Because many people with UC have vitamin and mineral deficiencies (due to decreased nutritional intake and absorption by the colon and excessive diarrhea), a multivitamin is recommended. Further research is needed to determine whether specific vitamin or mineral supplements may help treat the symptoms of UC.
Omega-3 Fatty Acids
At least one study has found that, compared to placebo, fish oil supplements containing omega-3 fatty acids may reduce symptoms of UC and prevent recurrence of the condition. The supplements are less effective than sulfasalazine, however, at reducing inflammation in people with mild to moderate UC. Some experts suggest that omega-3 fatty acids may prove particularly valuable when used in combination with sulfasalazine or other medications.
People with UC often have low levels of folate in their blood cells and some experts suggest that this may be due, at least in part, to sulfasalazine use. Some researchers speculate that folate deficiencies contribute to the risk of colon cancer in those with UC. Although preliminary studies suggest that folate supplements may help reduce tumor growths in people with UC, further research is needed to determine the precise role of folate supplementation in people with inflammatory bowel diseases.
N-acetyl glucosamine
Preliminary evidence suggests that N-acetyl glucosamine supplements or enemas may improve symptoms of UC in children with IBD who did not improve after using other treatments, but further research is needed to determine whether the substance is safe and effective for the treatment of UC.
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lysine
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flavonoids
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glutamine