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Heartburn

Updated 22 August 2018

Treating peptic ulcers

The first step in a treatment plan for peptic ulcers is to reduce risk factors such as using non-steroidal anti-inflammatory medication.

Peptic ulcers tend to respond well to treatment, but often recur. The goal of treatment is to relieve pain and prevent complications.

The first step in such a treatment plan aims to reduce risk factors (e.g. use of non-steroidal anti-inflammatory medication). Medication can be taken as a second step (antibiotics and/or acid suppressors), and surgery may be necessary in severe cases.

Home treatment
Steps include the following:

  • Take paracetamol instead of aspirin, ibuprofen, naproxen or other non-steroidal anti-inflammatories (NSAIDs) to relieve pain.
  • Stop smoking.
  • Try eating smaller, more frequent meals. If this doesn’t help, return to your regular eating pattern.
  • Avoid alcohol, caffeine and spicy foods if these seem to bring on symptoms.
  • If a particular food doesn’t cause any problems, there’s no need to eliminate it from your diet.
  • If you need an antacid to neutralise stomach acid, speak to your doctor first, especially if you’re on a low-salt diet (many antacids have a high sodium content).
  • Keep emotional stress under control by using relaxation techniques such as muscle-relaxation exercises, positive mental imagery, meditation, yoga, Pilates and breathing exercises.
  • Change your lifestyle to help you cope with stress: exercise, eat balanced meals and get enough sleep and rest.
  • Get professional assistance to help you change stressful life circumstances and to develop positive coping mechanisms.

Medication

Antacids

This kind of medication neutralises the acid present in the stomach. They’re very useful for an occasional episode of symptoms. But, taken on a regular/daily basis, they have more side effects than the newer H2 blockers and proton pump inhibitors (PPIs) described below.

H2 blockers
Studies have shown that a protein in the stomach called histamine stimulates the secretion of gastric acid. Histamine antagonists (H2 blockers such as ranitidine and cimetidine) can block this action of histamine on gastric cells, and thereby reduce the amount of acid produced. This kind of medication is quite effective in healing peptic ulcers.

H2 blockers have few side effects and are well tolerated even when used continuously for a long time. However, ulcers often return when people stop taking this medication and if the causative factors aren’t addressed.

Proton pump inhibitors (PPIs)
These drugs are the most potent suppressors of gastric acid secretion. There are five main drugs available: omeprazole, lansoprazole, pantoprazole, esomeprazole and rabeprazole. The most frequent side effects are nausea, headaches, diarrhoea, flatulence and constipation.

Antibiotics for H. pylori infection
H. pylori bacteria can infect the stomach lining, but this may or may not cause a peptic ulcer. Although H. pylori can be difficult to eradicate completely, treatment with several antibiotics, sometimes in combination with other medications such as H2 blockers or PPIs, can be effective.

Commonly used antibiotics are amoxycillin clarithromycin and metromedazole. If the bacteria are eliminated completely, this can prevent ulcers from recurring.

It’s important to note that treatment with antibiotics does have a risk of causing allergic reactions, diarrhoea and sometimes inflammation of the colon. It can take 2-3 weeks for infection with H. pylori to clear and may require two to three antibiotics in combination. Some people find that this regime is difficult to adhere to.

For gastric ulcers, a follow-up gastroscopy is needed 6-8 weeks after treatment started to ensure that the ulcer has healed. Further biopsies are needed if healing doesn’t occur as fast as expected.

Sucralfate
Ulcers can also be treated and prevented with sucralfate, which binds to duodenal and gastric ulcers and erosions, coating them and protecting the mucosal lining from stomach acid.

The medication also inhibits the action of pepsin, the chief digestive enzyme in the stomach, and adsorbs bile salts – all of which can damage the lining of the stomach and duodenum.

Take note: The internationally recommended treatment for peptic ulcers is the concomitant use of a PPI and 10-14 days of treatment with amoxycillin, clarythromycin and metronidazole. An allergic response to one of these medications may change the treatment.

Surgery
In the past, surgery was done for peptic ulcers, but this has been replaced with adequate medical therapy.

However, surgery may be necessary if serious complications develop. In the case of a bleeding ulcer, your medical practitioner will repair the source of the bleeding. If the ulcer has perforated the stomach or duodenal wall, an emergency operation is required to close the perforation.

Peptic ulcer surgery is performed only in emergencies because of the associated risk of complications. These include:

  • Recurrence of the ulcer(s)
  • The formation of fistulae (connections between the small intestine and colon)
  • Vomiting of bile
  • Diarrhoea
  • Haematological complications (anaemia)
  • Dumping syndrome (see below)

Dumping syndrome occurs when the stomach empties rapidly ("dumps") into the small intestine. This may lead to reactive hypoglycaemia (low blood sugar). Symptoms include colic-like abdominal pain, diarrhoea, vomiting and/or sweating an hour after eating. Dumping syndrome may be lessened by a regimen of small meals at frequent intervals.

When to call your doctor
Contact your doctor if:

  • You have an ulcer and develop sudden, severe abdominal pain that your usual home treatment doesn’t relieve.
  • You suspect that you may have an ulcer and your symptoms don’t improve within 2 weeks of home treatment.
  • You’ve been diagnosed with a stomach ulcer and suddenly get symptoms of anaemia, such as pallor, dizziness, weakness and fatigue. Your ulcer may be bleeding and may need medical attention.
  • You have stomach ulcer symptoms and you have severe back pain. Your ulcer may be perforating the wall of the stomach and you may need urgent surgery.
  • You have stomach ulcer symptoms and vomit blood, which gastric acid may have changed to look like ground coffee. You may have internal bleeding. It’s important to call a health professional urgently.
  • You have an ulcer and become cold and clammy, feel faint or actually faint. These are symptoms of shock, usually due to massive blood loss. You’ll require immediate medical attention.
  • You feel the kind of pain associated with a peptic ulcer and shortness of breath or other symptoms that might be related to heart problems. See a doctor urgently.

Note that 2 - 3% of stomach ulcers lead to stomach cancer. Report all continuing or recurrent symptoms to your doctor.

Read more:
The causes of peptic ulcers
The complications of peptic ulcers
Preventing peptic ulcers

Reviewed by Dr Estelle Wilken, senior specialist in Internal Medicine and Gastroenterology at Tygerberg Hospital. December 2017.