Who Has Ulcers?
About 20 million Americans develop at least one ulcer during their lifetime. Each year:

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.

What Causes Ulcers?
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.

What Are the Symptoms of Ulcers?
The most common ulcer symptom is a gnawing or burning pain in the abdomen between the breastbone and the naval. The pain often occurs between meals and in the early hours of the morning. It may last from a few minutes to a few hours and may be relieved by eating or by taking antacids. Less common ulcer symptoms include nausea, vomiting, and loss of appetite and weight. Bleeding from ulcers may occur in the stomach and duodenum. Sometimes people are unaware that they have a bleeding ulcer, because blood loss is slow and blood may not be obvious in the stool. These people may feel tired and weak. If the bleeding is heavy, blood will appear in vomit or stool. Stool containing blood appears tarry or black.

Testing for H. pylori
Confirming the presence of H. pylori is important once the doctor has diagnosed an ulcer because elimination of the bacteria is likely to cure ulcer disease. Blood, breath, and stomach tissue tests may be performed to detect the presence of H. pylori. While some of the tests for H. pylori are not approved by the U.S. Food and Drug Administration (FDA), research shows these tests are highly accurate in detecting the bacteria. However, blood tests on occasion give false positive results, and the other tests may give false negative results in people who have recently taken antibiotics, omeprazole (Prilosec), or bismuth (Pepto-Bismol). Blood tests--Blood tests such as the enzyme-linked immunosorbent assay (ELISA) and quick office based tests identify and measure H. pylori antibodies. The body produces antibodies against H. pylori in an attempt to fight the bacteria. The advantages of blood tests are their low cost and availability to doctors. The disadvantage is the possibility of false positive results in patients previously treated for ulcers since the levels of H. pylori antibodies fall slowly.

Breath tests--Breath tests measure carbon dioxide in exhaled breath. Patients are given a substance called urea with carbon to drink. Bacteria break down this urea and the carbon is absorbed into the blood stream and lungs and exhaled in the breath. By collecting the breath, doctors can measure this carbon and determine whether H. pylori is present or absent. Urea breath tests are at least 90 percent accurate for diagnosing the bacteria and are particularly suitable to follow-up treatment to see if bacteria have been eradicated. These tests are awaiting FDA approval.

Tissue tests--If the doctor performs an endoscopy to diagnose an ulcer, tissue samples of the stomach can be obtained. The doctor may then perform one of several tests on the tissue. A rapid urease test detects the bacteria's enzyme urease. Histology involves visualizing the bacteria under the microscope. Culture involves specially processing the tissue and watching it for growth of H. pylori organisms.

Points to Remember
An ulcer is a sore or lesion that forms in the lining of the stomach or duodenum where the digestive fluids acid and pepsin are present.

Recent research shows that most ulcers develop as a result of infection with bacteria called Helicobacter pylori (H. pylori). The bacteria produce substances that weaken the stomach's protective mucus and make the stomach more susceptible to damaging effects of acid and pepsin. H. pylori can also cause the stomach to produce more acid. Although acid and pepsin and lifestyle factors such as stress and smoking cigarettes play a role in ulcer formation, H. pylori is now considered the primary cause.

Nonsteroidal anti-inflammatory drugs such as aspirin make the stomach vulnerable to the harmful effects of acid and pepsin, leading to an increased chance of stomach ulcers.

Ulcers do not always cause symptoms. When they do, the most common symptom is a gnawing or burning pain in the abdomen between the breastbone and naval. Some people have nausea, vomiting, and loss of appetite and weight.

Bleeding from an ulcer may occur in the stomach and duodenum. Symptoms may include weakness and stool that appears tarry or black. However, sometimes people are not aware they have a bleeding ulcer because blood may not be obvious in the stool.

Ulcers are diagnosed with x-ray or endoscopy. The presence of H. pylori may be diagnosed with a blood test, breath test, or tissue test. Once an ulcer is diagnosed and treatment begins, the doctor will usually monitor progress.

Surgery may be necessary if an ulcer recurs or fails to heal or if complications such as bleeding, perforation, or obstruction develop.

Conclusion
Although ulcers may cause discomfort, rarely are they life threatening. With an understanding of the causes and proper treatment, most people find relief. Eradication of H. pylori infection is a major medical advance that can permanently cure most peptic ulcer disease.