A peptic ulcer is ulceration of the intestinal mucosa either in the stomach
(gastric ulcer) or in the duodenum (duodenal ulcer).

For patients investigated by endoscopy for dyspepsia, gastric ulcer is seen
in 5-10% of cases, duodenal ulcer in 10-15% and gastric cancer in 2%.

Symptoms are similar to those of simple dyspepsia and/or heartburn due
to reflux.

Duodenal ulcer pain classically appears at night.

THE ROLE OF H.PYLORI;

There is strong evidence that Helicobacter pylori plays an important role in
causing duodenal ulcers not associated with NSAIDs, as well as evidence of a
role in benign gastric ulcers. Eradication of the organism dramatically reduces
the recurrence rate in peptic ulcer (from over 80% per year to less than 10%
for duodenal ulcer, and from 48% to 7% for gastric ulcer).

PROVEN PEPTIC ULCER:

Treatment is as for dyspepsia/GORD.

H.Pylori eradication needs to be undertaken (see above) should the patient test positive.

If the ulcer persists after 6 months, having tried the eradication plus the
medication for GORD regime, then surgery may have to be considered.

BLEEDING ULCERS:

Blood loss from ulcers often occurs unnoticed. It is most likely that the only
overt sign will be black, tarry stools. However, the blood loss may be too
gradual to notice.

Symptoms of increasing tiredness, shortness of breath and looking pale might
suggest anaemia; a blood test is necessary to exclude bleeding from the ulcer.
Also, should the test confirm anaemia, a test on the stool may be necessary
(Faecal occult blood) to detect blood loss from the gut.    

Bleeding ulcers may present as a medical emergency:

• Acute onset of severe abdominal pain, often just below the solar plexus
• Pain may radiate through to the back
• There may be vomiting of frank red blood or ?coffee grounds'
• There may be black, tarry stools (melaena) *
  

*Note that if you are taking iron tablets, your stools may be almost
black, but they should not be tarry.

NSAID-RELATED ULCERS

There are over 2,000 deaths a year from NSAIDs, and about 12,000 hospital
admissions. (McQuay) Many of these are due to GI tract adverse effects from
these drugs.

The Committee on Safety of Medicines (CSM) states that all NSAIDs
are contra-indicated in patients with peptic ulceration. Discontinue
the NSAID where possible.

HEALING ULCERS

• 1. IN PATIENTS WHO HAVE STOPPED NSAIDs: Standard treatment is an
  8-week course of H2-antagonists such as Cimetidine, which is effective and safe for most patients. The other H2 antagonists, nizatidine and ranitidine, are also licensed for use in this indication and may be useful for patients unable to take cimetidine because of interaction with concurrent medication or previously encountered side effects. If there has been a GI bleed, it may be more appropriate to use a PPI. If the patient is H pylori positive the need for eradication therapy is unclear.
• 
  2. IN PATIENTS WHO ARE CONTINUING NSAIDs: healing and prophylaxis
  is necessary: Omeprazole (is currently the only proton pump inhibitor
  licensed for both healing and prophylaxis of NSAID-associated ulcers.)
  Misoprostol is also licensed but has a higher incidence of side effects than omeprazole.