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What Is a Peptic Ulcer and What Causes It to Bleed?
A peptic ulcer is an open sore in the lining of the stomach, small intestine and/or esophagus. Until fairly recently, peptic ulcers were believed to be caused by excessive stomach acid due to stress, personality type, or too much spicy food, caffeine, coffee, cola sodas and alcohol. Now, peptic ulcers are believed to be primarily caused by either an infection of the stomach by the bacteria Helicobacter pylori (H. pylori) or the use of nonsteroidal anti-inflammatory drugs or NSAIDs, such as aspirin, ibuprofen and naproxen.
The gastrointestinal tract is coated with mucus that protects tissue from damage from digestive juices. Both H. pylori and NSAIDs cause the mucus lining to break down, allowing the digestive juices to irritate the walls of these organs and cause peptic ulcers. Peptic ulcers are more commonly found in the duodenum — the first part of the small intestine — and less frequently in the stomach. Cigarette smoking is also a contributing cause to the development of peptic ulcers.
Peptic ulcer bleeding is the most common complication of peptic ulcers and can be potentially fatal if left untreated. According to the New England Journal of Medicine, approximately 400,000 hospital admissions are made per year for acute upper gastrointestinal bleeding due to peptic ulcers, many of which can be attributed to NSAID medication use. Over two-thirds of these admissions are for people over age 60 (and one quarter are over age 80) and the mortality rate is 5 to 10 percent.
Peptic ulcers bleed because the irritation becomes so severe that the blood vessels in the walls of the gastrointestinal tract actually rupture. The internal bleeding can occur slowly or hemorrhage quickly at a critical rate. The type of internal bleeding — whether it is a slow trickle or hemorrhaging excessively — also determines which signs and symptoms are present during a peptic ulcer bleed.
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What Are the Signs and Symptoms of Peptic Ulcer Bleeding?
Slow bleeding from a peptic ulcer generally does not present with any overt symptoms until the blood loss is enough to cause anemia. Signs of anemia include fatigue, weakness, lack of energy, and skin pallor. These symptoms, coupled with the other symptoms of a peptic ulcer — a gnawing or burning abdominal pain, nausea, vomiting and pain that occurs after one to three hours after eating, in the middle of the night or while lying down — might indicate bleeding from a peptic ulcer and should be checked by a physician.
Excessive bleeding from a hemorrhaging peptic ulcer has more pronounced symptoms and requires immediate emergency attention. The most obvious signs of heavy internal bleeding are:
- Vomit containing bright red blood or clumps of partially digested reddish-brown blood resembling “coffee grounds"
- Sticky, tarry black stool or noticeably bloody stool
- Light-headedness and/or fainting upon standing
Individuals exhibiting these signs need immediate intravenous replacement of lost body fluids and may require blood transfusions if the blood loss is severe or persistent. A physician will also perform an esophagogastroduodenoscopy, also known as an EGD or upper endoscopy, by inserting a specially-lit camera down the esophagus to view the stomach and opening of the upper intestine to see where the peptic ulcers are and the extent of the bleeding.
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The first course of treatment for peptic ulcer bleeding is the use of supportive therapies such as intravenous replacement of body fluids and/or blood transfusions. However, if bleeding from the peptic ulcer continues or becomes a recurrent bleed, the morbidity and mortality rates become considerably higher, necessitating more aggressive therapies such as endoscopic therapy and proton pump inhibitors (PPIs).
Endoscopic therapy generally occurs during the EGD or soon afterward. Endoscopic therapy for bleeding peptic ulcers consists of:
- Injection therapy using diluted solutions of epinephrine to act as a tamponade by compressing the blood vessels and stopping the bleeding
- Thermal therapy, such as multipolar electrocoagulation and heater probe
- Mechanical therapy, such as endoscopic clips
Any one of these therapies can be used alone or in combination to successfully stop a peptic ulcer bleed, except for injection therapy with epinephrine, which should be used in conjunction with another therapy to be most effective. Overall, any of these methods are more successful in stopping a rebleed than no endoscopic involvement at all and a combination of therapies helps to further decrease the rates of recurrent bleeding, surgical intervention and mortality.
The use of proton pump inhibitors has also proven to considerably lessen the risk of recurrent bleeding, surgical intervention and death. Proton pump inhibitors are medications that decrease acid production by blocking the enzyme located in the stomach wall that is responsible for producing acid. Reducing acid in the stomach helps prevent new ulcers from forming while allowing any existing peptic ulcers in the gastrointestinal tract to heal. A physician will administer a proton pump inhibitor bolus dose — a rapid injection to decrease the response time of a drug — before beginning a continuous drip of the PPI for approximately 72 hours.
Surgical intervention used to be the treatment of choice in stopping peptic ulcer bleeds, but with the use of the therapies outlined above, surgical rates are now estimated at between 5 and 7 percent and surgery is only used if endoscopic therapy fails or is not accessible.
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The American College of Gastroenterology website, http://www.acg.gi.org/patients/gihealth/peptic.asp
Medscape.com website, "Management of Acute Peptic Ulcer Bleeding", http://www.medscape.org/viewarticle/579654
Medicinenet.com website, http://www.medicinenet.com/peptic_ulcer/article.htm