Gastric ulcer (also known as stomach ulcer) is an open wound that forms on the inner wall of the stomach. 
If the location (or area) of the ulcer is in the intestine just after the stomach is spoken of duodenal ulcer.
Duodenal ulcers and stomach ulcers are also known as peptic ulcers.


Anatomy of the stomach

The stomach is an organ of the digestive system located in the abdomen just below the ribs on the left side.
The ingested food descends into the esophagus and is pushed through a sphincter (valve) into the stomach, where it mixes with the powerful gastric juice containing enzymes and hydrochloric acid.
The stomach is a muscular sac that can break down food mechanically and chemically.

Once the food has the consistency of mashed potatoes, it is pushed through a sphincter in the first part of the small intestine (duodenum).
The inner wall of the stomach (gastric or mucosal epithelium) has the shape of a comb.
Ulcers occur on this inner wall.


How does digestion occur?

Food descends down the esophagus in the stomach. The stomach produces acidic substances that are not essential, but help to digest the food.
The food is mixed in the stomach, then passes into the duodenum (the first part of the small intestine).
In the duodenum and small intestine, food is digested by enzymes (proteins).
Enzymes are produced by the pancreas and the cells lining the intestine. Enzymes break down (digest) foods that are absorbed into the body.


Classification of gastric ulcers

There are two variations of ulcer: hemorrhagic ulcer and perforated ulcer.

Hemorrhagic ulcer
This is a serious complication of ulcer and can be deadly in the elderly or in patients with other diseases.
Bleeding from stomach ulcer is more common in people treated with blood thinners (anticoagulants), such as warfarin, aspirin, and clopidogrel (Plavix).
These patients should take anti-ulcer medications to avoid this complication.

Perforated Ulcer
A severe, untreated ulcer can spread through the wall of the stomach, allowing gastric juices and food to flow out into the abdominal cavity. This medical emergency is known as a perforated ulcer.
It usually occurs in the antral area (pyloric antrum).
Treatment usually involves immediate surgery.

Causes of stomach ulcer

Normally, the inner wall of the stomach and small intestine is protected against irritating acids produced in the stomach.
If this tissue stops working properly and gets injured, the consequence is an ulcer or an inflammation (gastritis).
Most ulcers occur on the first layer of the inner wall. A hole that traverses the entire stomach or duodenum is called a perforation. A piercing is a medical emergency.
The most frequent cause in adults and children is a stomach infection with bacteria called Helicobacter pylori (H. pylori).
Most people with peptic ulcers have these bacteria that live in their gastrointestinal tract.
However, many people with these bacteria do not develop an ulcer.

Risk factors for peptic ulcers:

  • Drinking alcohol in excess;
  • Regular intake of aspirin, ibuprofen, naproxen or other anti-inflammatory drugs(NSAIDs). Intake of aspirin or anti-inflammatories from time to time is harmless to most people;
  • Smoking cigarettes or chewing tobacco;
  • Being seriously ill, for example, those who live attached to a respirator;
  • Undergo radiotherapy treatments;
  • Stress.

Smoking does not only cause ulcers but also increases the risk of complications such as bleeding, perforation, and stomach clogging. Cigarette smoke is the leading cause of failure of ulcer treatment.

Contrary to popular belief, alcohol, coffee, coke, spicy foods and caffeine are not causes of ulcer formation.


Symptoms of gastric ulcer

Gastric ulcer may be asymptomatic (not always cause symptoms), and according to location, there are strong differences.
A gastric ulcer causes pain in the stomach as soon as the person begins to eat because the production of hydrochloric acid that irritates the wall of the stomach begins.
If the ulcer is in the lower part of the stomach, the pain disappears when the stomach is full, but returns only empty.
In the case of duodenal ulcer, pain occurs only when the valve is closed between the stomach and the duodenum (pylorus), then when the stomach is empty, or when the duodenum empties, ie 2 hours and 3 hours after eating.
Since when the food is ingested the pain passes quickly, gastric ulcer is called “hunger pain” because the patient feels the desire to eat to feel better.
In some cases the pain is nocturnal.

Acute phase symptoms are:

Signs of worsening

  • Vomiting with blood
  • Digested blood can darken stools
  • The person feels tired and loses weight


When do symptoms appear?

  • Can wake from sleep,
  • It increases a lot after eating,
  • It can last a few minutes or several hours,
  • It makes the sensation of hunger unusually strong,
  • It can be relieved by taking antacids.

Ulcers can cause severe disturbances and severe belly pain  . One of the problems is bleeding.

Symptoms of bleeding include:

  • Black stools that correspond to digested blood (mane);
  • Vomit that looks like coffee grounds or blood
  • Weakness
  • Severe abdominal pain
  • Fever


Ulcer examination and instrumental diagnosis

gastroscopy is a test that can confirm a stomach ulcer. In this examination, a doctor looks inside the stomach by inserting a thin, flexible endoscope through the esophagus.
It is possible to see the inflammation or ulcer.

In case of ulcer the test is done for the bacterium Helicobacter pylori .
If Helicobacter pylori is found it is likely that this caused the ulcer.
Briefly, a stool sample may be collected with the breath test , a blood test or tissue sample during an endoscopy of the stomach.

Biopsy of the stomach or duodenum
A piece of tissue is usually removed in and around the ulcer during endoscopy.
The sample is then sent to the laboratory for examination under a microscope.
This occurs in the case of cancer (which usually does not cause an ulcer).


What are the treatments for a benign ulcer in the stomach?

Pharmacological treatment

Drugs antacids
Usually the doctor prescribes a course of 4-8 weeks antacids that reduce the amount of acid produced in the stomach.
The most commonly used drug is a proton pump inhibitor (PPI). IBPs are a class of drugs that act on the cells of the inner wall of the stomach, reducing acid production.

These include: Esomeprazole, Lansoprazole, Omeprazole (can be taken during pregnancy ), Pantoprazole and Rabeprazole are found under various trade names.
Sometimes another class of medications called histamine H2 receptor antagonists is used. These medicines act differently on the cells inside the stomach wall, reducing acid production.
They include: Famotidine, Ranitidine and Cimetidine. Since the amount of acid is reduced considerably, the ulcer usually heals.

If the ulcer is caused by Helicobacter pylori.
Most stomach ulcers are caused by Helicobacter pylori infection. Therefore, a major part of the treatment is to remove the infection.
If the infection is not resolved, the ulcer will most likely return after stopping taking antacid medications.
Two antibiotics are needed to remove Helicobacter pylori bacteria.
In addition, you need an antacid medication to reduce gastric acid in the stomach.
This is necessary to allow antibiotics to work well.
You need to follow this combination therapy (sometimes called ‘triple therapy’) for a week.
One cycle of combination therapy excludes Helicobacter pylori in up to 90% of cases.
If Helicobacter pylori is removed, the possibility of a recurrence of ulcer in the stomach is very difficult.
However, in a small number of cases, a recurrence occurs in the future.

If the ulcer was caused by a non-steroidal anti-inflammatory drug.
If possible, you should stop taking the anti-inflammatory drug.
This allows the ulcer to heal.
Antacid medication is also usually prescribed for several weeks. This blocks the production of gastric acid in the stomach and cures the ulcer.
However, in many cases anti-inflammatory medication is needed to relieve symptoms of osteoarthritis or other diseases, while aspirin is needed to protect against the formation of blood clots.
In these situations, one option is to take an antacid every day, indefinitely. This reduces the amount of acid produced by the stomach and reduces the chance of forming an ulcer again.


Surgery for an ulcer

In the past, surgery was needed to treat an ulcer in the stomach.
This occurred before discovering that Helicobacter pylori was the cause of most stomach ulcers and before the discovery of antacids.
The operation is usually done only if it is extremely necessary, a complication of an ulcer in the stomach, such as severe bleeding or perforation.

After treatment
Repeating endoscopy is usually recommended a few weeks after the end of treatment. This mainly occurs to check if the ulcer is cured and also make sure that the ulcer was not caused by stomach cancer. If the ulcer was caused by Helicobacter pylori examinations are recommended to see if the bacteria has disappeared. This is done at least four weeks after the end of treatment.
In most cases, if the test is ‘negative’ it means that the infection is resolved. If the bacteria is still present, the doctor may advise a new antibiotic therapy.


What to eat? Diet for ulcer

Some people with ulcers do not seem to have problems with any food, but the symptoms can worsen based on what you eat.
It may help to keep a food journal to determine which foods trigger the pain.
If you do not want to, simply simply avoid foods that are the most common causes, including:

  • Coffee, tea, soda and carbonated drinks,
  • Alcoholic beverages or cocktails,
  • Milk, increases the production of gastric acids,
  • Greasy food,
  • Fried food,
  • Spicy foods,
  • Citrus, (orange, lemon, etc.), but it is necessary to eat other fruits,
  • Tomato-based foods, but it’s important to include lots of greens in food.

Among the natural remedies against heartburn from ulcer is baking soda. We recommend that you take a teaspoon of this substance dissolved in water after meals.
It is a short-term remedy, but some patients also use it to digest better.

To heal faster, it is recommended to take an infusion of ginger and eat foods rich in zinc, such as cereals ( oats and barley) or vegetables (peas).


Why does not the ulcer heal?

With proper treatment, the time for ulcer healing is short, about a week or two, but a peptic ulcer that does not heal with the treatment is called a refractory ulcer.
There are many reasons why the ulcer can not heal.

These reasons may be:

  • The patient does not take medication according to instructions,
  • Some types of Helicobacter pylori are resistant to antibiotics,
  • Cigarette smoke,
  • Regular consumption of painkillers that increase the risk of ulcers.

The causes are:

  • Extreme overproduction of gastric juice, occurs for example in Zollinger-Ellison syndrome.
  • An infection other than Helicobacter pylori
  • Stomach cancer
  • Other diseases that can cause sores like ulcer in the stomach or small intestine, such as Crohn’s disease .

Treatment for refractory ulcers usually involves the elimination of factors that can interfere with healing along with the use of different antibiotics.

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