Peptic Ulcer

Peptic ulcers refer to open sores occurring mainly in the stomach or the first part of the small intestine (duodenum), caused by erosion of the gastrointestinal mucosa due to stomach acids. Mild irritation results in gastritis, while prolonged irritation can cause ulcers or erosions. Common causes include the use of nonsteroidal anti-inflammatory drugs (NSAIDs) , smoking, alcohol, caffeine, and Helicobacter pylori infection. Triggers that exacerbate symptoms include stress, spicy or acidic foods, and irregular eating habits. Although many ulcers heal spontaneously, untreated causes may lead to serious complications such as gastrointestinal bleeding, stomach perforation, or blockage due to inflammation or scarring.

Prevention

• Improve eating habits
  • Eat meals slowly without rushing.
  • Chew food slowly and thoroughly.
  • Avoid exercising immediately after meals.
• Avoid food triggers
  • Alcoholic or caffeinated beverages.
  • High-fat or oily foods.
  • Spicy foods.
  • Highly acidic foods and fruits.

Management

• Maintain a healthy weight; obesity exacerbates reflux symptoms.
• Eat smaller, more frequent meals (5–6 times a day).
• Avoid eating within 3–4 hours before bedtime.
• Manage stress effectively to prevent indigestion.
• Elevate the head of the bed to reduce reflux symptoms.

When to See a Doctor

• Persistent or worsening symptoms
• Unexplained weight loss
• Sudden, severe abdominal pain
• Difficulty swallowing
• Jaundice (yellowing of skin or eyes)
• Vomiting blood or bloody stools

Treatment Options

1. Antacids & Antiulcerants

• Antacids neutralize gastric hydrochloric acid. Common examples include aluminium salts, magnesium salts, calcium carbonate, and sodium bicarbonate.
• Aluminium-containing antacids: may cause constipation.
• Magnesium-containing antacids: may cause diarrhea.
• Combination products (aluminium + magnesium): minimize these side effects.
• Avoid high-sodium antacids (e.g., sodium bicarbonate ) in hypertension, heart disease, kidney disease, and pregnancy.
• Complex antacids (e.g., polymigel, almagate, hydrotalcite, magaldrate ): Provide rapid and prolonged action.
• Anti-foaming agents ( simethicone, dimeticone ) or essential oils may be included to reduce gas and bloating. Alginate is sometimes added to prevent reflux and relieve symptoms.
• Local anesthetics (oxetacaine , sulcain ): Combined with antacids for immediate relief of pain or burning sensation caused by ulcers.

2. Antisecretory agents

• H2-receptor blockers (cimetidine, famotidine, ranitidine ): Quickly relieve symptoms by reducing acid secretion.
  • Cimetidine interacts significantly with many drugs (e.g., warfarin ); ranitidine and famotidine have fewer interactions.
• Proton pump inhibitors (PPIs) (omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole ): More effective than antacids and H2-blockers for healing ulcers; typically used for 4–8 weeks, depending on cause.
• Potassium-competitive acid blocker (PCAB) (vonoprazan): Reduces acid secretion by inhibiting potassium channels in gastric parietal cells. Use cautiously in patients with liver impairment.

3. Cytoprotective Agents

• Mucosal protective agents (bismuth-containing antacids, rebamipide, sucralfate, teprenone ): Promote mucus secretion, increase blood flow in gastrointestinal mucosa, and coat ulcers protecting them from acid and pepsin.
• Sucralfate: Take on an empty stomach and avoid use in patients with renal impairment; administer at least 30 minutes apart from antacids.
• Bismuth salicylate/bismuth subcitrate: Typically combined with antibiotics for H. pylori treatment.
• Synthetic prostaglandin analogues (misoprostol): Reduce gastric acid secretion; contraindicated in pregnancy; prescription-only medication.

4. Antimuscarinic Drugs

• Pirenzepine: Reduces gastric acid secretion; used for mild gastric ulcers.

5. Antibiotics for H. pylori eradication

• Clarithromycin (macrolide ): inhibits bacterial protein synthesis. Avoid with ergotamine, simvastatin, colchicine, ticagrelor, ranolazine, midazolam. Contraindicated in QT prolongation, torsades de pointes, severe hypokalemia, or severe liver/renal impairment.
• Nitroimidazoles (metronidazole,tinidazole ): Take with meals; contraindicated in blood disorders or central nervous system conditions.
• Metronidazole: Avoid alcohol (risk of disulfiram-like reaction); caution in hepatic impairment.
• Tinidazole: Avoid during first trimester pregnancy and breastfeeding.
• Amoxicillin (beta-lactam antibiotic): Avoid in patients with severe penicillin allergy.
• Levofloxacin (fluoroquinolone antibiotic ): Caution in epilepsy, tendon disorders, and renal impairment; dose adjustment necessary.
• Tetracycline group: inhibit bacterial protein synthesis; commonly used in H. pylori treatment regimens.

6. Antispasmodics

• Relieve gastrointestinal smooth muscle spasms:
• Hyoscine butylbromide (antimuscarinic): Relieves abdominal cramps and pain.
• Alverine (direct smooth muscle relaxant): May cause nausea, headache, dizziness, rash, jaundice, and hepatitis.

7. Digestive enzymes & Antiflatulents

• Often included with antacids to relieve indigestion, bloating, and associated symptoms.