Ask Your Family Doctor

Developed by the College of Family Physicians of Canada

What is an ulcer?

Ulcers are sores on the lining of your digestive tract (see picture below). Most ulcers are located in the duodenum. The duodenum is the first part of the intestine and starts just after your stomach. These ulcers are called duodenal ulcers. Ulcers located in the stomach are called gastric ulcers. Ulcers in the esophagus are called esophageal ulcers. Two other disorders are much like ulcers. These are an inflamed lower esophagus (esophagitis) and an inflamed stomach lining (gastritis).

Signs of ulcers

	Feel better when you eat or drink and then worse an hour or two after eating (duodenal ulcer) or feel worse when you eat or drink (gastric ulcer).
	Stomach pain that may wake you up at night
	Feel full fast
	Heavy feeling, bloating, burning or dull pain anywhere in your stomach
	Times when you feel bad and then times when you feel good in between
	Vomiting
	Weight loss

What causes ulcers?

A type of bacteria called Helicobacter pylori (H. pylori) is thought to be a cause of many ulcers. Acid and other juices made by the stomach can lead to ulcers by burning the lining of your digestive tract. This can happen if your body makes too much acid or if the lining of your digestive tract is damaged in some way. Esophageal ulcers or esophagitis occur when stomach acid makes its way up into the lower esophagus.

What things can damage the lining of my digestive tract?

Even though most people use anti-inflammatory drugs without problems, these drugs can sometimes damage the stomach lining and cause ulcers. Anti-inflammatory drugs include ASA (Aspirin), ibuprofen (some examples are Advil, Medipren, Motrin IB), and a number of prescription drugs for arthritis and related problems. Acetaminophen doesn't damage the stomach lining.

Smoking also seems to delay or prevent ulcer healing. For some people, physical stress (such as being sick for a long time) may help cause ulcers. The role that emotional stress plays is not certain.

How can my doctor tell if I have an ulcer?

Your doctor may start you on some medicine before doing tests. This is because ulcers, gastritis and esophagitis usually feel better within a week or so after starting treatment. You may not need tests if you're getting better.

If you don't get better, a doctor might want to do an endoscopy or barium x-ray to study your digestive tract. During an endoscopy, your doctor looks into your stomach through a thin tube. He or she may take a sample of the stomach lining (a biopsy) to test for H. pylori. Blood and breath tests can also be used to test for H. pylori. For a barium x-ray, you'll drink a chalky liquid, called barium. The barium will highlight your ulcer on an x-ray. You may need blood tests to look for low blood (anemia) or an H. pylori infection.

How can ulcers be treated?

One way to treat ulcers is to get rid of the H. pylori bacteria. Treatment may also be aimed at lowering the amount of acid that your stomach makes, to neutralize the acid that is made and to protect the injured area so it can have time to heal. It's also very important to stop doing things, such as smoking or drinking, that damage the lining of your digestive tract.

Triple therapy/Antibiotics. A common treatment to eliminate H. pylori is to take two antibiotics and bismuth (an example is Pepto-Bismol or PPI), called triple therapy. Many combinations are effective.

H2 blockers. Medicine called H2 blockers reduce the amount of acid that your stomach makes. These medicines include cimetidine (an example is Tagamet), ranitidine (an example is Zantac), famotidine (an example is Pepcid) and nizatidine (an example is Axid). They usually help people start to feel better within three days. Usually the full dose can be given before bed. These drugs are not as costly as some other treatments. Some H2 blockers are available without a prescription. The nonprescription form is usually a lower dose than the prescription form.

Proton Pump Inhibitors (PPI's). These medicines include omeprazole (an example is Losec), lansoprazole (and example is Prevacid) and pantaprazole (an example is Pantoloc) and they work to stops the stomach from making any acid.

Antacids. Antacids neutralize acid that the stomach makes. They may take a little longer than H2 blockers and PPI's to work. Some antacids can cause constipation or diarrhea. They may help relieve symptoms but are not great for curing ulcers.

Sucralfate. A medicine called sucralfate (an example is Sulcrate) coats your ulcer to protect it from the acid so it has time to heal.

Cytoprotective Agents. These drugs like misoprostol (An example is Cytotec) help maintain the lining of the stomach.

Tips on healing your ulcer

	Don't smoke.
	Avoid anti-inflammatory drugs like ASA (an example is Aspirin) and ibuprofen (some examples are Advil, Medipren, Motrin IB)
	Avoid caffeine, alcohol and milk (or have them only in small amounts and on a full stomach).
	Avoid spicy foods when you're having pain, or any other food that adds to the pain.

How long will I have to take medicine?

Treatment of H. pylori usually takes about two to three weeks. Usually you won't need to take medicine for longer than eight weeks. Most ulcers heal within this time. If your symptoms come back after you stop taking medicine, your doctor may suggest that you take a low dose of medicine even when you're not having symptoms to keep the ulcer from coming back

Does what I eat affect my ulcer?

It may. But this isn't true for everyone. Certain foods and drinks may be more likely to make your pain worse. These include regular and decaffeinated coffee, tea, cocoa, chocolate, meat extracts, alcohol, black pepper, chili powder, mustard seed, and nutmeg. You may want to avoid these things to see if this helps you feel better.

Keep your diet balanced. Don't avoid foods unless they have bothered you more than once. If you drink alcohol or caffeine drinks, drink them only when you are eating and in small amounts. Eating small, frequent meals when you're having pain may help you feel better.

Are ulcers affected by pregnancy?

Ulcer symptoms often go away during pregnancy. During pregnancy, the body makes less stomach acid. If you have pain from an ulcer during pregnancy, your doctor may suggest that you take antacids, sucralfate or H2 blockers. Misoprostol should never be used during pregnancy.

Even though ulcers may improve during pregnancy, symptoms of heartburn may be common in the last few months as your growing baby presses on your stomach. Eating smaller meals more often and trying not to eat just before going to sleep often helps. Avoid drinking liquids at the same time as you eat.

Are ulcers serious?

Not usually. Ulcers don't cause cancer, but some cancers can form ulcers as they grow. This is more common with cancer of the stomach than with cancer of the esophagus or duodenum.

Ulcers sometimes can lead to other problems. These problems include bleeding, perforation (when the ulcer eats all the way through the wall of your digestive tract) or obstruction (when your digestive tract gets blocked and food can't leave your stomach).

The signs listed box below warn of these problems. Get help right away if you notice any of them.

Warning signs that your ulcer is getting worse

	You vomit blood.
	You vomit food eaten hours or days before.z
	You feel cold or clammy.
	You feel unusually weak or dizzy.
	You have blood in your stools (blood may make your stools look black or like tar
	You have ongoing nausea or repeated vomiting.
	You have sudden, severe pain.
	You keep losing weight.
	Your pain doesn't go away when you take your medicine.
	Your pain reaches your back.
	You have no appetite.
	You have difficulty swallowing.
	You have new symptoms and you are over 45 years old.

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Revised 2007 The College of Family Physicians of Canada

This information provides a general overview on this topic and may not apply to everyone. To find out if this information applies to you and to get more information on this subject, talk to your family doctor. This health education material has been favorably reviewed by the Patient Education Review Committee of the College of Family Physicians of Canada: Dr Cathy MacLean, Halifax, NS (Scientific Editor) Dr C. Richard Fischer, Pickering, ON Dr Patrice Laplante, Fleurimont, QC Dr Richard Moffatt, Red Deer, AB Dr David Nunn, Kentville, NS Dr Cornelius Woelk, Winkler, MB The College of Family Physicians of Canada, one of the nation's largest medical groups, is committed to promoting and maintaining high standards for family physicians - the doctors who provide ongoing, comprehensive care for people of all ages. This patient education information was developed by The College of Family Physicians of Canada in cooperation with the American Academy of Family Physicians.

Support for this program has been provided by an educational grant to the Research and Education Foundation by Scotiabank.