Ulcer nausea in morning: Bloating, Heartburn, Nausea, Pain, & More

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Peptic Ulcer Disease: Symptoms and Complications

Peptic ulcers are open wounds found either in the stomach (gastric ulcers) or the upper part of the small intestine, otherwise known as the duodenum (duodenal ulcers). Peptic ulcers can cause a variety of symptoms, such as pain, discomfort, or gas, though many people do not experience any symptoms at all.

Peptic ulcers can get worse, may bleed, and can cause a perforation (hole) or obstruction (blockage) in the digestive system—all serious emergencies. This is why you should consult your doctor if you notice any related symptoms.

Anna Bizon / Getty Images

Frequent Symptoms

Pain is the most common symptom of a peptic ulcer. It is typically located in the upper part of the abdomen, anywhere from your breastbone to your navel, but you may also feel it in your back. Your pain may be dull, burning, or gnawing; it is less commonly intense or stabbing. Often, the pain is worse at night or in the morning, but it can vary. The duration of pain can last from a few minutes to a few hours.

Many people with peptic ulcers particularly complain of pain on an empty stomach. You may experience relief immediately after eating only to have pain return or worsen within an hour. This brief reprieve does not cause people with ulcers to overeat, however, as frequent nausea and discomfort can squash appetite or the desire to eat. Some people feel that certain foods (like fatty choices) exacerbate the symptoms, while other foods either alleviate or do not affect them.

While pain is the most common symptom, be aware that more than half of the people with peptic ulcers have no symptoms at all.

Other common symptoms of peptic ulcers include:

Discomfort, bloating
Indigestion, heartburn
Chronic nausea or a sense of discomfort with eating
Frequent burping
Loss of appetite

Signs can include unexplained anemia or iron deficiency.

Rare Symptoms

These symptoms are rare, but are more severe and could point to a complication:

Vomiting (with or without blood)
Blood in the stool; black and tarry stool
Fatigue or weakness, which can result from malnutrition or anemia due to small amounts of bleeding from the ulcer
Unexplained weight loss

Symptoms of peptic ulcers can occur as a result of other conditions, including gastroesophageal reflux disease (GERD), chronic dyspepsia, gallbladder disease, liver disease, or a gastrointestinal infection. It’s important to see your doctor to determine what’s at the root of your pain.

Complications

There are a number of complications that can occur if you have a chronic or worsening peptic ulcer. These include:

Bleeding: Bleeding is the most common complication of peptic ulcer disease. Slow and subtle bleeding can often go unnoticed and may be detected only once you have developed anemia due to this constant small loss of blood. Black or tarry stools are a sign of this bleeding. But the ulcer can erode a blood vessel and cause a sudden and even massive loss of blood, becoming life-threatening.
Malnutrition: You can become deficient in vitamins and minerals due to low food intake. Immune deficiencies, bone weakness, and skin fragility can all result from malnutrition, but may not be noticeable at first. However, malnutrition is not common in today’s world as a complication of peptic ulcers.
Perforation: An ulcer can eventually wear away at the lining of the stomach or small intestine, causing a perforation (hole), which can leak gastrointestinal fluid into the body. This can cause severe abdominal pain and shock. This is an emergency that requires urgent medical treatment, which is often surgery.
Obstruction: An ulcer can become inflamed, blocking the passageway of digested food and causing severe dysfunction of the small intestine. Like perforation, this is a medical emergency.
Fistula: A perforated ulcer can establish a connection (fistula) with an adjacent abdominal organ or structure, including the colon, biliary tree, pancreas, or a major blood vessel. This results in exchanges of material and fluids, which can result in vomiting these materials or hemorrhages. This is a medical emergency that requires surgical correction.

People are prone to peptic ulcers due to infection by the Helicobacter pylori bacterium, but there are some habits that can contribute to their development, such as taking non-steroidal anti-inflammatory medications (NSAIDs) or smoking. These habits interfere with your natural production of the mucus that coats your digestive system to protect it from acidity, abrasion, and bleeding.

Despite common misconceptions, one lifestyle factor that does not cause ulcers is stress. Doctors used to attribute ulcers to stress until Helicobacter pylori was discovered.

When to See a Doctor/Go to the Hospital

You may feel relief with an antacid, but you should not ignore symptoms of a peptic ulcer. If you have persistent symptoms for longer than a week, it is best to see your doctor. He or she will determine whether you need prescription medications and whether you have complications, such as bleeding or anemia.

Make an appointment with your doctor if you have:

Pain that radiates to the back
Pain that doesn’t go away when you take medication
Unintended weight loss
Weakness, fatigue
Vomiting
Difficulty swallowing

Call or see a doctor immediately if you have these serious symptoms:

Vomiting blood
Black or tar-like stool
Sudden, severe pain in the abdominal area
Fever
Chills, shaking
Dizziness
Loss of consciousness

Frequently Asked Questions

What are the symptoms of a bleeding ulcer?

Symptoms may include vomiting blood that looks like coffee grounds and bowel movements that look black and tarry. You may also have anemia from bleeding, which can cause you to feel weak or faint. Seek emergency care for symptoms of a bleeding ulcer.

How long do ulcer symptoms last?

Pain may last for minutes or hours at a time. Symptoms will keep coming back until you get treatment for the ulcer. With treatment, the ulcer may take about eight weeks to heal, but the pain usually goes away after several days.

A Word From Verywell

Peptic ulcers do not simply go away on their own. Be sure to see your doctor when you notice the symptoms. While such an ulcer can take time to heal, the discovery of H. pylori as a cause makes it curable rather than something you must simply learn to live with.

Peptic Ulcer Disease | Michigan Medicine

Topic Overview

What is a peptic ulcer?

A peptic ulcer is a sore in the inner lining of the stomach or upper small intestine.

Ulcers form when the intestine or stomach’s protective layer is broken down. When this happens, digestive juices—which contain hydrochloric acid and an enzyme called pepsin—can damage the intestine or stomach tissue.

Treatment cures most ulcers. And symptoms usually go away quickly.

Peptic ulcers that form in the stomach are called gastric ulcers. Those that form in the upper small intestine are called duodenal (say “doo-uh-DEE-nul” or “doo-AW-duh-nul”) ulcers.

What causes peptic ulcers?

The two most common causes of peptic ulcers are:

H. pylori and NSAIDs break down the stomach or intestine’s protective mucus layer.

What are the symptoms?

Symptoms include:

A burning, aching, or gnawing pain between the belly button (navel) and the breastbone. Some people also have back pain. The pain can last from a few minutes to a few hours and may come and go for weeks.
Pain that usually goes away for a while after you take an antacid or acid reducer.
Loss of appetite and weight loss.
Bloating or nausea after eating.
Vomiting.
Vomiting blood or material that looks like coffee grounds.
Passing black stools that look like tar, or stools that contain dark red blood.

Different people have different symptoms, and some people have no symptoms at all.

How are peptic ulcers diagnosed?

Your doctor will ask you questions about your symptoms and your general health, and he or she will do a physical exam.

If your symptoms aren’t severe and you are younger than 55, your doctor may do some simple tests (using your blood, breath, or stool) to look for signs of H. pylori infection.

The only way for you and your doctor to know for sure if you have an ulcer is to do a more complicated test, called an endoscopy, to look for an ulcer and to test for H. pylori infection. An endoscopy allows the doctor to look inside your esophagus, stomach, and small intestine. An endoscopy is usually done by a gastroenterologist, a doctor who specializes in digestive diseases.

How are they treated?

To treat peptic ulcers, most people need to take medicines that reduce the amount of acid in the stomach. If you have an H. pylori infection, you will also need to take antibiotics.

You can help speed the healing of your ulcer and prevent it from coming back if you quit smoking and limit alcohol. Continued use of medicines such as aspirin, ibuprofen, or naproxen may increase the chance of your ulcer coming back.

Ignoring symptoms of an ulcer is not a good idea. This condition needs to be treated. While symptoms can go away for a short time, you may still have an ulcer. Left untreated, an ulcer can cause life-threatening problems. Even with treatment, some ulcers may come back and may need more treatment.

Cause

The two most common causes of peptic ulcers are:

Infection with

Helicobacter pylori

(

H. pylori

) bacteria. Although many people are infected with H. pylori bacteria, only a few get ulcers.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
. When used for weeks or months, NSAIDs can damage the lining of the digestive tract, causing an ulcer or making an existing ulcer worse. NSAIDs include aspirin, ibuprofen, and naproxen.

A rare cause of peptic ulcers is Zollinger-Ellison syndrome. In this condition, the stomach makes too much acid, damaging the stomach lining.

Symptoms

Common symptoms

Common ulcer symptoms include:

A burning, aching pain—or a pain that feels like hunger—between the navel and the breastbone. The pain sometimes extends to the back.
Belly pain that can last from a few minutes to a few hours and that usually goes away for a while after you take an antacid or acid reducer.
Weeks of pain that comes and goes and may alternate with pain-free periods.
Loss of appetite and weight loss.
Bloating or nausea after eating.

Less common symptoms

Less common but more serious symptoms of ulcers include:

Vomiting after meals.
Vomiting blood and/or material that looks like coffee grounds.
Black stools that look like tar, or stools that contain dark red blood.

Ulcers and pains

Symptoms of ulcers in the upper small intestine (duodenal ulcers) and in the stomach (gastric ulcers) are similar, except for when pain occurs.

Pain from a duodenal ulcer may occur several hours after you eat (when the stomach is empty) and may improve after you eat. Pain also may wake you in the middle of the night.
Pain from a gastric ulcer may occur shortly after you eat (when food is still in your stomach).

Silent ulcers

Some ulcers don’t cause symptoms. These are known as silent ulcers. Silent ulcers are more common in:

Symptoms in children

In children, symptoms vary with age:

Toddlers and young children may complain of general stomach pain.
Teenagers may have symptoms more like those of adults.

The symptoms of an ulcer often can be confused with other abdominal conditions, such as dyspepsia or gastroesophageal reflux disease (GERD).

What Happens

Many people who have peptic ulcers may not see a doctor when their symptoms begin. Their symptoms, such as belly pain, may come and go. Even without treatment, some ulcers will heal by themselves.

And even with treatment, ulcers sometimes come back. Certain factors such as cigarette smoking and continued use of nonsteroidal anti-inflammatory drugs (NSAIDs) increase the risk of ulcers coming back.

Sometimes ulcers can cause complications, such as bleeding, perforation, penetration, or obstruction. That’s why it’s important to treat an ulcer, even if you have one that isn’t causing any symptoms.

Most peptic ulcers without complications heal, regardless of the cause. But an ulcer is likely to come back if you have an H. pylori infection that is not successfully treated. Recurring ulcers caused by reinfection with H. pylori are not common in the United States, except in areas that are overcrowded or have poor sanitation.

Ulcers in the stomach (gastric ulcers) often heal more slowly than ulcers in the upper small intestine (duodenal ulcers).

What Increases Your Risk

Risk factors you can control

The following things can increase your chance of getting a peptic ulcer and may slow the healing of an ulcer you already have:

Taking nonsteroidal anti-inflammatory drugs (NSAIDs). These include aspirin, ibuprofen (such as Advil), and naproxen (such as Aleve).
Smoking.
Drinking too much alcohol. This is more than 2 drinks a day for men and more than 1 drink a day for women.

In the past, spicy foods, caffeine, and moderate amounts of alcohol were thought to increase ulcer risk. This is no longer believed to be true.

Risk factors you cannot control

Some things that you cannot control may increase your risk of getting an ulcer. These include:

A Helicobacter pylori ( H. pylori) infection, the most common cause of ulcers.
Physical stress caused by a serious illness or injury (such as a major trauma, surgery, or the need to be on a ventilator to assist breathing).
Hypersecretory condition, in which your stomach produces too much acid.
A personal or family history of ulcers.

When should you call your doctor?

If you have been diagnosed with a peptic ulcer, call 911 or other emergency services immediately if you have:

Symptoms that could indicate a heart attack or shock.
Sudden severe, continuous belly pain or vomiting.

Call your doctor or seek medical attention right away if you have:

Frequent feelings of dizziness or lightheadedness, especially when moving from lying down to a seated or standing position.
Blood in your vomit or something that looks like coffee grounds (partially digested blood) in your vomit.
Stools that are black or that look like tar, or stools that contain dark red or maroon blood.

Call your doctor if you have been diagnosed with a peptic ulcer and:

Your symptoms continue or become worse after 10 to 14 days of treatment.
You begin to lose weight without trying.
You are vomiting.
You have new belly pain or belly pain that does not go away.

Watchful waiting

If you have been diagnosed with a peptic ulcer and medical treatment is not helping, call your doctor. Waiting until your symptoms get worse can be serious.

If you don’t know if you have a peptic ulcer and you don’t have any of the emergency symptoms listed above, you may try taking an antacid or nonprescription acid reducer and other home treatment, such as making changes to your diet.

If your symptoms don’t get better after 10 to 14 days, call your doctor.
If your symptoms go away after you take antacids or acid reducers and try home treatment, but then the symptoms come back, call your doctor.

Who to see

To evaluate your symptoms, see your:

If further testing or treatment is needed, you may need to see someone who specializes in the treatment of diseases of the digestive tract (gastroenterologist).

If surgery is needed, your doctor may refer you to a general surgeon. But surgery is rarely needed to treat ulcers.

Exams and Tests

Although not all peptic ulcers are caused by bacteria, it’s getting more common to do a test for Helicobacter pylori whenever someone has ulcer symptoms. This includes testing your blood, breath, stool, or a sample of tissue from your digestive tract (biopsy).

An endoscopy may be done so that a doctor can:

Look at the inside of your stomach and your upper small intestine to check for an ulcer.
Collect a tissue sample (biopsy) that can be tested for H. pylori or cancer.

If you are older than 55, you may need an endoscopy because of a higher risk for stomach cancer. This is especially true if you have:

Ulcer symptoms for the first time.
Ulcer symptoms that return before or after treatment is completed.
A family history of stomach cancer.
Other symptoms that may point to a more serious problem, such as stomach cancer. These include:
- Blood in the stool.
- Weight loss of more than 10% of body weight.
- Difficulty swallowing (dysphagia).
- Jaundice.
- Abdominal mass.

Other tests that may be done include:

Fecal occult blood test (FOBT). This test may be done to detect blood in the stool, which may be caused by a peptic ulcer or another serious problem, such as colon cancer. By itself, an FOBT cannot diagnose peptic ulcer disease, but it may show if an ulcer is bleeding.
Complete blood count (CBC). This blood test may be done to look for anemia, which may be caused by a bleeding ulcer.
Upper GI series. This X-ray exam of the esophagus and stomach may be used to diagnose peptic ulcer disease, although this test is being used less frequently.

Treatment Overview

Left untreated, many ulcers eventually heal. But ulcers often recur if the cause of the ulcer is not eliminated or treated. If ulcers keep coming back, you have an increased risk of developing a serious complication, such as bleeding or a hole in the wall of your stomach or intestine.

Most of the time, treatment means taking medicines—such as h3 blockers and proton pump inhibitors (PPIs)—and making lifestyle changes, including:

Not taking nonsteroidal anti-inflammatory drugs (NSAIDs), if possible. These include aspirin, ibuprofen (such as Advil), and naproxen (such as Aleve).
Quitting smoking.
Not drinking too much alcohol (no more than 2 drinks a day for men and 1 drink a day for women).

H. pylori infection

If your ulcer is caused by Helicobacter pylori ( H. pylori) bacteria, treatment usually involves a combination of medicines, including antibiotics.

If treatment isn’t working, you may need more tests to look for bacteria. If you still have an H. pylori infection, your doctor will likely try a different combination of medicines. He or she may also suggest that you see a gastroenterologist. This specialist will do an endoscopy to look at your ulcer and to take a tissue sample (biopsy).

Treatment if ulcers get worse

If you have serious complications from a peptic ulcer, such as bleeding or obstruction, you may need an endoscopy, even if you have already had one.

If your stomach or intestine has a perforation or your ulcer continues to bleed despite treatment, you may need surgery. But surgery is rarely used to treat an ulcer.

Prevention

You can greatly reduce the chance that you will get a peptic ulcer if you:

Don’t smoke. Smokers are much more likely than nonsmokers to get ulcers. For ways to quit smoking, see the topic Quitting Smoking.
Avoid NSAIDs. Avoid taking aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs (NSAIDs) for longer than a few days at a time. If you are taking one of these medicines daily, for example taking aspirin for heart problems, ask your doctor about taking medicine to help protect your stomach and intestines from ulcers.
Drink alcohol only in moderation. Limit alcohol to 2 drinks a day for men and 1 drink a day for women.

Home Treatment

Many people who have mild ulcer symptoms first try home treatment for a short time without seeing a doctor.

But see your doctor if your symptoms don’t get better after 10 to 14 days of home treatment, or if you have other symptoms such as weight loss, nausea after eating, or consistent pain. This is even more important if you are middle-aged or older, because the risk for cancer or other illnesses that cause symptoms similar to peptic ulcer disease increases with age.

Try these home treatment steps to stop symptoms and help an ulcer heal:

Stop smoking.
Try nonprescription medicines that reduce stomach acid. Make sure you tell your doctor about any medicines you are taking.
Make changes to your diet, such as eating smaller, more frequent meals. (These changes may improve your symptoms, but they won’t help your ulcer heal.)
Drink alcohol only in moderation, or not at all. Limit alcohol to 2 drinks a day for men and 1 drink a day for women. Drinking too much alcohol may make an ulcer heal more slowly and may make your symptoms worse.

Medications

Medicines are used to:

Treat peptic ulcers by reducing the amount of acid produced by the stomach.
Kill Helicobacter pylori ( H. pylori) bacteria if they are infecting the stomach lining.
Protect the lining of the stomach and upper small intestine from injury caused by nonsteroidal anti-inflammatory drugs (NSAIDs). These include aspirin, ibuprofen (such as Advil), and naproxen (such as Aleve).

Medicine choices

Medicines to reduce stomach acid

Medicines that reduce the amount of acid produced by the stomach are used to treat all forms of peptic ulcer disease.

Antacids (such as Tums)
Acid reducers
- h3 blockers (such as Pepcid). Some h3 blockers are available without a prescription.
- Proton pump inhibitors (PPIs) (such as Prilosec). Some PPIs are available without a prescription.

Be careful when you take over-the-counter antacid medicines. Many of these medicines have aspirin in them. Read the label to make sure that you are not taking more than the recommended dose. Too much aspirin can be harmful.

Medicines to kill H. pylori bacteria

Doctors prescribe combination drug therapy to cure infection with H. pylori bacteria. This usually includes at least two antibiotics, a proton pump inhibitor, and sometimes a bismuth compound.

Medicines to protect the stomach

Medicines used to protect the stomach from damage caused by frequent use of aspirin or other NSAIDs include:

Acid reducers. These include:
- h3 blockers (such as Tagamet).
- Proton pump inhibitors (PPIs) (such as Prilosec).
Prostaglandin analogs (such as Cytotec).

You can get some h3 blockers and PPIs without a prescription (over the counter or OTC). If you are using OTC acid reducers (such as Prilosec or Pepcid) to help with your symptoms for more than 10 to 14 days at a time, or if your symptoms are very bad, be sure to see your doctor.

Surgery

Surgery is rare, but it is needed sometimes to treat:

Ulcers that don’t heal (intractable peptic ulcers).
Life-threatening complications of an ulcer, such as severe bleeding, perforation, or obstruction.

If surgery is suggested, you may want to:

Seek a second opinion and ask whether all medicine treatment options have been tried.
Compare the cost of long-term medicine treatment to the one-time cost of surgery.
Remember that no surgery can completely prevent ulcers from returning.
Find a surgeon who has a lot of experience with surgery for ulcers.

Surgery choices

When surgery is done, it usually involves one or more of the following:

Cutting one or more of the nerves to the stomach (vagotomy).
Widening the opening of the bottom of the stomach (pyloroplasty).
Removing part of the stomach (partial gastrectomy).

References

Other Works Consulted
Yang YX, et al. (2006). Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA, 296(24): 2947–2953.

Credits

Current as of:
April 15, 2020

Author: Healthwise Staff
Medical Review:
E. Gregory Thompson MD – Internal Medicine
Adam Husney MD – Family Medicine

Peptic Ulcer Disease – Causes, Symptoms, Treatment, Diagnosis

A peptic ulcer is an erosion or sore in the lining of the stomach or intestine that occurs when the protective mucus layer wears away in certain areas, allowing damage to occur from the natural acids of the stomach.

Around 10% of people will have peptic ulcer disease (PUD) at some point in their life. The majority of peptic ulcers are caused by bacteria called Helicobacter pylori (H. pylori) or by taking ASA (acetylsalicylic acid) or nonsteroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen*, ketoprofen, naproxen).

Gastric ulcers are sores in the lining of the stomach.

Duodenal ulcers are those in the first part of the small intestine, called the duodenum. This is an area where food is digested after passing through the stomach.

Causes

Although stress and spicy foods might make the symptoms of peptic ulcer worse, they aren’t the cause of the condition as was once thought.

A bacterium called H. pylori causes the majority of ulcers. The bacteria can spread into the mucus lining that usually protects the stomach and small intestine from digestive acids, damaging it in the process. By 60 years of age, up to 50% of people are infected with this bacteria, but only 10% to 20% of these people will actually develop stomach problems.

The other major cause of PUD is the use of ASA (acetylsalicylic acid) and other NSAIDs such as ibuprofen or naproxen. NSAIDs can penetrate the lining of the stomach and release substances that damage cells. NSAIDs also block natural chemicals called prostaglandins that can help to protect and repair those cells. People more at risk of ulcers caused by NSAIDs include those who:

are seniors
have a history of a peptic ulcer
have a family history of peptic ulcer disease
are also taking glucocorticoids (e.g., prednisone, dexamethasone)
are taking high doses of NSAIDs or ASA
have several medical conditions
are taking more than one NSAID or ASA

Excessive alcohol use can put people at higher risk for PUD, but it isn’t a true cause.

Symptoms and Complications

The most common symptom of peptic ulcers (both duodenal and gastric) is a gnawing or burning pain in the abdomen between the breastbone and the navel, sometimes passed off as “heartburn. “ An ulcer can also feel like a dull ache or strong hunger pangs. Yet some people, especially the elderly, may not feel any pain at all from an ulcer. Ulcer pain can come or go and can be aggravated by eating or an empty stomach. Ulcers can also cause belching and bloating.

The most common complication of stomach and duodenal ulcers is bleeding. Although the blood loss is usually too slow to be noticed, it might be enough to make you tired, pale, and weak.

If bleeding from the peptic ulcer is heavier, blood may show up in the stool or vomit. Stools that have blood in them may look tarry, black, or red. If you notice any of these signs, see a doctor right away. If a bleeding ulcer is severe, it can be fatal if left untreated. Keep in mind also that, since NSAIDs are such strong painkillers, they can mask the pain of bleeding ulcers.

Very rarely, ulcers can make a hole, called a perforation, in the stomach or intestine. This can cause sudden and severe pain. Sometimes an ulcer can create a blockage out of the stomach or in the duodenum. This may cause bloating, feeling full after eating, vomiting, and weight loss.

If an ulcer causes scarring, spasm, or inflammation, it is considered a gastric outlet obstruction and may lead to weight loss and dehydration. It may cause loss of appetite with fullness after eating, or it may cause large-volume vomiting up to 6 hours after a meal.

Making the Diagnosis

If you have the typical symptoms of PUD, your doctor will perform a physical exam and may order one or more of the following tests:

A breath test (drinking a fluid and exhaling into a tube), blood test, or stool test may be used to check for H. pylori infection. If you have H. pylori, treatment may be given to cure the infection without the need for more invasive tests.

A series of GI (gastrointestinal) X-rays may be done. These are X-rays of your stomach, duodenum, and esophagus (the swallowing tube). To make the ulcer easier for the doctor to see, you’ll first need to swallow a chalky liquid called barium.

Endoscopy is another test used to detect ulcers. After numbing the throat, the doctor carefully guides a thin tube with a tiny camera on its end into the mouth and down the throat to get close-up pictures of the esophagus, stomach, and duodenum.

If ulcers are detected by these tests, then appropriate treatment will be prescribed.

Finally, all people older than 50 years who, for the first time, show symptoms suggestive of a stomach acid-related disorder, and anyone of any age with “alarm” features such as vomiting, bleeding, anemia, an abdominal mass, unexplained weight loss, or trouble swallowing should have an endoscopy to identify the cause quickly and to rule out cancer.

Treatment and Prevention

Medical treatment focuses on eliminating the H. pylori bacteria in people where it has been detected. The majority of peptic ulcers caused by H. pylori can be cured with a combination of antibiotics and acid-reducing medications called proton pump inhibitors (PPIs; e.g., omeprazole, lansoprazole, esomeprazole, pantoprazole, rabeprazole) plus two antibiotics (clarithromycin plus amoxicillin or metronidazole), all taken twice a day for 2 weeks.

Other combinations of acid-reducing medications and antibiotics may also be used, including ones that use a total of four medications. For some people, several courses of treatment may be needed to get rid of H. pylori. Once the treatment for H. pylori is complete, the acid-suppressing medication should be continued for a total of 4 to 6 weeks.

When an ulcer is not associated with H. pylori or is caused by NSAIDs, treatment with a PPI is prescribed for 2 to 4 weeks. Some people may need to continue treatment for longer periods of time. Another type of acid reducer, h3-antagonists (e. g., ranitidine, nizatidine), may also be used.

If the peptic ulcer was caused by NSAIDs, such as ASA, your doctor will most often recommend that you stop taking them if possible. Some people are more susceptible to peptic ulcers caused by NSAIDs, including those who:

are seniors
have a history of a peptic ulcer
are also taking glucocorticoids (e.g., prednisone, dexamethasone)
are taking high doses of NSAIDs or ASA
have several medical conditions
are taking more than one NSAID or ASA

If you’re taking a NSAID and have one of these risk factors, your doctor may prescribe a protective medication to take along with it. Acid-suppressing medications (e.g., PPIs) or misoprostol may be used for this. Misoprostol encourages the stomach to produce its protective mucus coating and improves blood flow.

It’s important for people with PUD to quit smoking. Smoking can delay healing and can cause ulcers to return.

Very rarely, surgical treatment may be needed for PUD and its complications.

All material copyright MediResource Inc. 1996 – 2021. Terms and conditions of use. The contents herein are for informational purposes only. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Source: www.medbroadcast.com/condition/getcondition/Peptic-Ulcer-Disease

A Case Report and Literature Review

Medical and surgical disorders in pregnancy can be can be quite challenging for the obstetrician gynaecologist even in resource rich countries. Reaching an accurate diagnosis and admininstering appropriate management can be difficult in the presence of an on-going pregnancy. The importance of involving specialist from other disciplines (multidisciplinary care) cannot be overemphasized. We present an interesting case of perforated duodenal ulcer in a pregnant patient, review the literature ,discuss the differential diagnosis and evaluate the management principles for this rare condition.

1. Introduction

Peptic ulcer disease (PUD) is uncommon in pregnancy and pureperium. Pregnancy creates several difficulties in the diagnosis and management of peptic ulcers. Firstly the symptoms of PUD (nausea, vomiting epigastric discomfort) are also quite common in pregnancy, secondly diagnostic tests for PUD in the general population (upper gastrointestinal series X-rays and esophagogastroduodenoscopy EGD) are only performed with great hesitancy in pregnancy, and thirdly some drugs used in the general population for PUD (e.g., misoprostol) are contraindicated in pregnancy. Nevertheless prompt diagnosis and timely management of PUD in pregnancy are essential as complications can result in quite significant morbidity or even mortality for the patient. We present an interesting case of perforated duodenal ulcer in the puerperium.

2. Case

A 27-year-old primiparous patient presented to our unit when she was 38-week pregnant with the complaint of recurrent episodes of vomiting, general malaise, back pain, and vague lower abdominal discomfort. Pregnancy had been uneventful until then. She had attended antenatal clinic when she was 10-week pregnant for a booking appointment. She had no significant medical history and was on no medication. Booking blood tests as well as ultrasound scans (both booking and at 20 weeks) were normal. This admission at 38 weeks was her first admission to hospital in the pregnancy. On physical examination at admission she looked rather unwell. Her temperature was 36°C. Blood pressure and pulse were normal. Her abdomen was soft and not tender. Uterine fundal height was consistent with gestational age. Cardiotocography (CTG) demonstrated a reassuring fetal heart pattern. A presumptive diagnosis of urinary tract infection was made. Blood sample was obtained for FBC (full blood count), serum urea and electrolytes (U&E), Liver function tests (LFT), and C-reactive protein (CRP). A mid-stream urine sample was sent for culture and sensitivity, and she was started on antiemetics and antibiotics. The blood tests showed a serum potassium of 3. 4 mmol/l (3.5–5.5 mmol/l) and a raised CRP of 25 mg/L (1–10 mg/L). In spite of regular antiemetics, the patient’s vomiting became worse, occurring more frequently and becoming increasingly bile stained. The abdominal pain also became more localized to the upper abdomen. Uterine contractions ensued the same day, and she had ventouse delivery early hours of next morning on account of persistent decelerations of fetal heart rate on the CTG (cardiotocography) at full cervical dilatation. after delivery, the patient’s upper abdominal pain and vomiting continued. She also developed quite significant tenderness in the epigastrium. General surgeons were asked to see the patient. Blood tests were repeated; an abdominopelvic ultrasound scan and a chest X-ray were requested. The ultrasound scan showed a collection of fluid in the right upper quadrant of the abdomen (measuring about 8.5 × 3 cm). The fluid appeared to surround the liver and gall bladder. Liver, gall bladder, and kidneys looked normal. Uterus and ovaries looked normal. Chest X-ray was normal. Other than an increase in CRP to 131 mg/L, all the blood tests (FBC, U&E, LFT) remained normal. Based on the worsening clinical condition and these investigations, a diagnostic laparoscopy was performed. Laparoscopy revealed copious amount of pus and extensive adhesions around the stomach. Laparotomy (with a midline incision) was performed. This revealed an anterior perforation of the 2nd part of the duodenum. The perforation was repaired. An omental patch (Graham’s patch) support was created. A Nasogastric tube was left in after the operation, and the patient was kept nil by mouth for 24 hours. The patient made an uneventful postoperative recovery and was discharged home on the 7th postoperative day. She was discharged on omeprazole for a month, and clarithromycin/metronidazole for a week.

3. Discussion and Review

Multiple epidemiologic studies support a decreased incidence of PUD (Peptic ulcer disease) in pregnancy and pueperium [1].

Several theories explain the apparent decrease in incidence of PUD during pregnancy. In 1945, Horwich explained the rarity of peptic ulcer in pregnancy by correlating hypochlorhydria with increased secretion of anterior pituitary-like hormones in the urine [2]. It has also been suggested that female gestational hormones (particularly progesterone) decrease the rate of ulcer formation by increasing gastric mucus synthesis. An increase in plasma hitasmine in pregnancy (caused by placental histaminase synthesis) increases metabolism of maternal histamine, thereby reducing gastric acid secretion during pregnancy [3]. Avoidance of ulcerogenic factors such as cigarette smoking, alcohol, and NSAIDS (Nonsteroidal anti-inflammatory drugs) all probably contribute to the reduced incidence of PUD in pregnancy.

In spite of all these reasons PUD occurs in pregnancy and pueperium. The diagnosis is often made late in pregnancy with quite devastating consequences. In their literature review in 1962, Paul et al. describe 14 cases of perforated duodenal ulcer in pregnancy in which all 14 women lost their lives [4].

The symptoms of PUD are mimicked by other common gastrointestinal problems in pregnancy (e.g., Gastroesophageal reflux disease, Nausea and vomiting of pregnancy, Hyperemesis gravidarum, and Cholecystitis). Cardinal symptoms of PUD are Pain, nausea, and vomiting. The pain is often epigastric and worse at night. In the presence of a gravid uterus (and especially when labour ensues) it can be quite difficult for patients to localize pain. In our patient, pain was initially localized to the lower abdomen! Unlike Reflux disease the pain is not exacerbated by recumbency or associated with regurgitation. Although nausea and vomiting occurs in 50%–80% of normal pregnancies, it is uncommon for these symptoms to persist beyond 20-week gestation. Nausea and vomiting of pregnancy is classically most intense in the morning whilst PUD symptoms are worse nocturnally and postprandially during the day. PUD symptoms also get worse with increasing gestation and are therefore usually most severe in the 3rd trimester. Occasionally PUD may present with hematemesis. Uncomplicated PUD produces minimal physical signs. When complicated physical signs are often present, abdominal tenderness (or even guarding), rebound tenderness, and fecal occult blood may be present.

Management should always be multidisciplinary involving obstetricians, gastroenterologists, and surgeons.

Baseline investigations should include Full blood count, serum urea and electrolytes, liver function tests, and serum amylase. Abdominal ultrasound evaluation is useful to exclude cholelithiases and gall stone pancreatitis. Although abdominal X-rays are generally contraindicated in pregnancy, they must be performed when there is suspicion of gastrointestinal perforation to assess the presence of pneumoperitoneum. The maternal and fetal benefits of prompt diagnosis and treatment far outweigh any fetal risks of teratogenicity or childhood cancer. Several studies suggest that when indicated (e.g., in patients with gastrointestinal haemorrhage or gastric outlet obstruction) esophagogastroduodenoscopy (EGD) is safe both for fetus and mother [5]. When gastrointestinal perforation is suspected, EGD is contraindicated. This is because endoscopic intubation can convert a contained perforation into a free intraperitoneal perforation thereby promoting intraperitoneal spillage of contaminated intestinal contents.

For patients who have mild symptoms of PUD, lifestyle changes (avoidance of fatty foods, caffeine, cigarette smoking, alcohol, and NSAIDS) or medications such as antacids or Histamine receptor antagonists, for example, ranitidine can be used. Surgery becomes mandatory when perforation is suspected. Early surgery improves maternal and fetal prognosis. Fluid resuscitation and correction of electrolyte imbalance should be instituted before surgery. Surgery for duodenal perforation usually involves a Graham patch closure (primary closure with omental patch support). For patients who are preterm at the time of diagnosis, laparotomy may result in premature labour, and hence intramuscular steroid administration for fetal lung maturation must be considered.

Postoperative antibiotics should be continued for at least a week. Medical treatment for PUD must be started and continued until patient is seen at the follow-up clinic. Our patient was started on omeprazole a PPI (Proton pump inhibitor). These agents are highly effective in treatment of duodenal ulcers and can be used once patient has delivered. Their safety in pregnancy is however currently unproven because of scant clinical data. Clear follow-up instructions must be given before discharge.

4. Conclusion

Complications of peptic ulcer disease do occur in pregnancy (albeit very rarely). Often times when they occur, diagnosis is made very late with resulting severe morbidity. In the case above, we have sought to highlight the main features to look for in diagnosing complicated PUD in pregnancy. We also outline the management of perforated duodenal ulcer in pregnancy. We hope that this increases the awareness of health practitioners of this rare complication of duodenal ulcer in pregnancy.

Copyright

Copyright © 2011 Papa Essilfie et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Why Does My Stomach Hurt When I Wake up? Behind Your Morning Discomfort

Should you be concerned about stomach pain? Nearly everyone experiences a stomachache from time to time and the underlying cause could be just about anything. From indigestion and gas to constipation, many different health issues can afflict the stomach, causing you to feel some kind of pain or discomfort in the abdomen area. But if your stomach hurts almost every time you wake up, you deserve answers – not guesses.

Why does your stomach hurt when you wake up in the morning? It could be related to a wide variety of things, whether it’s due to a serious health condition, if its mood related, or simply you’re simply passing gas. Keep reading to find out what could be causing your stomach pain in the morning and consider consulting a physician if the pain or discomfort persists.

Sometimes stomach pain can be serious, while other times, it isn’t.

Some conditions that cause stomach pain, upon diagnosis, require medical care. Per Oxford Academic, 1 in 10 patients suffering from abdominal pain are experiencing a symptom that stems from an acute disease, such as appendicitis (1.9 percent), diverticulitis (3.0 percent), biliary or pancreatic (4.0 percent), or neoplastic (1.0 percent) diseases. However, unless you’re experiencing other acute symptoms, your morning stomach pain is most likely harmless, due to gas, overeating, or constipation.

Stomach pain can also be caused by stress, depression or anxiety. Per U Chicago Medicine, high levels of cortisol – the stress hormone – can cause gastrointestinal discomfort while dealing with stress.

“When a person is stressed, the adrenal glands make and release the hormone cortisol into the bloodstream,” according to U Chicago Medicine. “This causes the fight-or-flight response and can also trigger abdominal discomfort, stomach cramps, constipation, diarrhea, nausea, and other symptoms.