Peptic Ulcer Disease and NSAIDs

National Digestive Diseases Information Clearinghouse

What is a peptic ulcer? Ulcer A peptic ulcer is a sore on the inner lining of the or —the first part of the small intestine. Less commonly, a peptic ulcer may develop just above the stomach in the —the organ that connects the mouth to the stomach. Esophagus

What causes peptic ulcer Stomach

disease? Pancreas Causes of include Duodenum • long-term use of nonsteroidal anti- inflammatory drugs (NSAIDs), such as Small aspirin and ibuprofen intestine • an infection with the bacteria (H. pylori) • rarely, cancerous or noncancerous A peptic ulcer is a sore on the inner lining of the tumors in the stomach, duodenum, or stomach or duodenum. pancreas What are H. pylori? What are nonsteroidal H. pylori are spiral-shaped bacteria that anti‑inflammatory drugs? can cause peptic ulcer disease by damaging Nonsteroidal anti-inflammatory drugs the mucous coating that protects the lining reduce pain, fever, and inflammation, of the stomach and duodenum. Once or swelling. A small, daily dose of one H. pylori damage the mucous coating, common NSAID—aspirin—can even help powerful stomach acid can get through to prevent heart attacks in some people. the sensitive lining. Together, the stomach acid and H. pylori irritate the lining of the In addition to aspirin and ibuprofen, stomach or duodenum and cause a peptic another common over-the-counter NSAID ulcer. is naproxen (Aleve). Acetaminophen (Tylenol) is not an NSAID. Some NSAIDs Read more in Peptic Ulcer Disease and require a prescription. H. pylori at www.digestive.niddk.nih.gov. How do nonsteroidal Who is more likely to anti‑inflammatory drugs develop a peptic ulcer cause peptic ulcer disease? caused by nonsteroidal To understand how NSAIDs cause peptic anti‑inflammatory drugs? ulcer disease, it is important to understand People who regularly take NSAIDs— how NSAIDs work. Everyone has two including those with chronic conditions enzymes called COX-1 and COX-2. such as arthritis—are more likely to develop Enzymes are proteins in the body that a peptic ulcer than people who do not take control chemical reactions. COX-1 and them regularly. Even occasional users COX-2 produce chemicals in the body’s of NSAIDs—of any age—can develop a cells that promote pain, inflammation, peptic ulcer. The chance of developing an and fever. NSAIDs work by blocking or NSAID-induced peptic ulcer increases with reducing the amount of COX-1 and COX-2 the following: the body makes. • dose of NSAIDs However, COX-1 also produces another type of chemical that protects the stomach • frequency of NSAID use lining from stomach acid and helps control • use of multiple NSAIDs bleeding. When NSAIDs block or reduce • length of time taking NSAIDs the amount of COX-1 in the body, they also increase a person’s chance of developing a • age—peptic ulcer disease is more likely peptic ulcer. in those age 70 or older • being female • having a history of peptic ulcer disease • smoking • alcohol use • having two or more medical conditions or diseases • use of other medications, such as steroids and medications that increase bone mass

2 Peptic Ulcer Disease and NSAIDs What are the signs and symptoms of peptic ulcer Seek Immediate Care disease? A person who has any of the following symptoms should call a health care A dull or burning pain in the stomach provider right away: is the most common symptom of peptic ulcer disease. A person can feel this pain • difficulty breathing anywhere between the navel and the • dizziness or feeling faint breastbone. The pain usually • red blood in the stool or black • occurs when a person’s stomach is stools empty—such as between meals or during the night • red blood in vomit or vomit that looks like coffee grounds • lessens briefly after eating food or taking antacids • sharp, sudden, and severe stomach pain • lasts for minutes to hours These symptoms could be signs of • comes and goes for several days, peptic ulcer disease complications. weeks, or months Other, less common symptoms include • bloating • burping • changes in appetite • nausea • vomiting • weight loss

3 Peptic Ulcer Disease and NSAIDs What are the complications Medical History of peptic ulcer disease? Taking a medical history may help a health Complications of peptic ulcer disease care provider determine the cause of peptic include ulcer disease. If a patient has peptic ulcer disease symptoms, the health care provider • internal bleeding—when gastric acid or will ask about the patient’s use of over-the- a peptic ulcer breaks a blood vessel counter and prescription NSAIDs. • obstruction—when a peptic ulcer Physical Exam blocks the path of food trying to leave the stomach A physical exam may help the health care provider diagnose the cause of peptic ulcer • perforation—when a peptic ulcer disease. During a physical exam, a health grows deeper and breaks completely care provider usually through the stomach or duodenal wall • checks for abdominal bloating • peritonitis—when infection or inflammation develops in the • listens to sounds within the abdomen peritoneum, or lining of the using a stethoscope abdominal cavity • taps on the abdomen checking for tenderness or pain How is peptic ulcer disease diagnosed? Lab Tests The health care provider will look to see A health care provider diagnoses peptic if H. pylori are present using one of three ulcer disease based on simple tests: • a medical history • blood test • a physical exam • urea breath test • lab tests • stool test • upper gastrointestinal (GI) endoscopy • upper GI series • computerized tomography (CT) scan

4 Peptic Ulcer Disease and NSAIDs The breath test and stool test more Stool test. A stool test is the analysis of a accurately detect H. pylori than the blood sample of stool. The health care provider test, so some health care providers prefer will give the patient a container to take to use one of these two tests. Testing is home for catching and storing the stool. important because health care providers The patient returns the sample to the health treat H. pylori-induced peptic ulcer disease care provider or a commercial facility, and differently from peptic ulcer disease caused it is sent to a lab for analysis. Stool tests by NSAIDs. can show the presence of H. pylori. Read more in Peptic Ulcer Disease and Upper Gastrointestinal H. pylori at www.digestive.niddk.nih.gov. Endoscopy Blood test. A blood test involves drawing a Upper GI endoscopy is a procedure that sample of a patient’s blood at a health care uses an endoscope—a small, flexible provider’s office or a commercial facility camera with a light—to see the upper GI and sending the sample to a lab for analysis. tract. A health care provider performs the The blood test can show the presence of test at a hospital or an outpatient center. H. pylori. The health care provider carefully feeds the Urea breath test. For a breath test, the endoscope down the patient’s esophagus patient swallows a special liquid that and into the stomach and duodenum. The contains urea—a waste product the body small camera built into the endoscope produces as it breaks down protein. If transmits a video image to a monitor, H. pylori are present, the bacteria will allowing close examination of the GI lining. convert the urea into carbon dioxide. A A health care provider may give a patient nurse or technician will take samples of a a liquid anesthetic to gargle or may spray patient’s breath at a health care provider’s anesthetic on the back of the patient’s office or a commercial facility and send the throat before inserting the endoscope. samples to a lab to measure the level of A health care provider will place an carbon dioxide. intravenous (IV) needle in a vein in the arm to administer sedation. Sedatives help patients stay relaxed and comfortable. The test may show signs of inflammation or erosions in the stomach lining.

5 Peptic Ulcer Disease and NSAIDs The health care provider can pass tiny tools Upper Gastrointestinal Series through the endoscope to Upper GI series is an x-ray exam that • take photos of the peptic ulcer. provides a look at the shape of the upper GI tract to help diagnose peptic ulcer • obtain a biopsy of the lining of the disease. An x-ray technician performs this stomach or small intestine. A biopsy test at a hospital or an outpatient center, is a procedure that involves taking a and a radiologist—a health care provider small piece of tissue for examination who specializes in medical imaging— with a microscope by a pathologist—a interprets the images. This test does not health care provider who specializes in require anesthesia. A patient should examining tissues to diagnose diseases. not eat or drink before the procedure, as The patient will not feel the biopsy. directed by his or her health care provider. The test can show the presence of Patients should ask their health care H. pylori. provider about how to prepare for an upper • inject medications that help the blood GI series. clot. During the procedure, the patient will • stop any bleeding with an electrical stand or sit in front of an x-ray machine and probe or special medications. drink barium, a chalky liquid that coats the Read more in Upper GI Endoscopy at www. esophagus, stomach, and small intestine so digestive.niddk.nih.gov. the radiologist and health care provider can see the shape of these organs more clearly on the x rays. A patient may experience bloating and nausea for a short time after the test. For several days afterward, barium liquid in the GI tract causes white or light-colored stools. A health care provider will give the patient specific instructions about eating and drinking after the test. Read more in Upper GI Series at www. digestive.niddk.nih.gov.

6 Peptic Ulcer Disease and NSAIDs Computerized Tomography NSAID-induced Peptic Ulcer Scan Disease without H. pylori Computerized tomography scans use Present a combination of x rays and computer If NSAIDs are the cause of a patient’s technology to create images. For a CT peptic ulcer and H. pylori are not present, scan, a nurse or technician may give the health care provider prescribes the patient a solution to drink and an medication to reduce stomach acid. injection of a special dye, called contrast Medications that reduce stomach acid can medium. CT scans require the patient help relieve pain and promote healing. to lie on a table that slides into a tunnel- They include shaped device that takes the x rays. An x-ray technician performs the procedure • proton pump inhibitors (PPIs), which in an outpatient center or a hospital, and suppress acid production by halting a radiologist interprets the images. The the mechanism that pumps acid into patient does not need anesthesia. CT the stomach. While PPIs cannot scans can help diagnose a perforated kill H. pylori, they do help fight the peptic ulcer. H. pylori infection. PPIs include –– omeprazole (Prilosec, Zegerid) How is peptic ulcer disease –– lansoprazole (Prevacid) treated? –– pantoprazole (Protonix) How a health care provider treats peptic –– rabeprazole (Aciphex) ulcer disease will depend on its cause. In the case of NSAID-induced peptic –– esomeprazole (Nexium) ulcer disease, the absence or presence of –– dexlansoprazole (Dexilant) H. pylori also determines the treatment strategy. • histamine receptor blockers, which work by blocking histamine, a substance that stimulates acid production. Histamine receptor blockers include –– cimetidine (Tagamet) –– ranitidine (Zantac) –– famotidine (Pepcid) –– nizatidine (Axid)

7 Peptic Ulcer Disease and NSAIDs NSAID-induced Peptic Ulcer Bismuth subsalicylate. Medications Disease with H. pylori Present containing bismuth subsalicylate, such as Pepto Bismol, coat a peptic ulcer and H. pylori When are present, a health care protect it from stomach acid. Although provider will treat an NSAID-induced bismuth subsalicylate may kill H. pylori, peptic ulcer with PPIs or histamine receptor health care providers use it with—not in blockers and other medications, including place of—antibiotics in some treatment • antibiotics regimens. • bismuth subsalicylate Antacids. Although an antacid may • antacids make the pain from a peptic ulcer go away temporarily, it will not kill H. pylori. Antibiotics. A health care provider will Patients receiving treatment for an prescribe antibiotics to kill H. pylori. H. pylori-induced peptic ulcer should check Antibiotic regimens may differ throughout with their health care provider before the world because some strains of H. pylori taking antacids. Some of the antibiotics have become resistant to certain antibiotics that health care providers use to kill over time—meaning that an antibiotic H. pylori may not work as well if patients that once destroyed a particular strain of combine them with an antacid. bacteria is no longer effective against that strain. In addition, health care providers may use one of three standard therapies to treat Although antibiotics can cure most H. pylori-induced peptic ulcer disease: H. pylori-induced peptic ulcers, eliminating the bacteria can be difficult. People should • Triple therapy. The patient takes take all doses of their antibiotics exactly as the antibiotic clarithromycin, a PPI, their health care provider prescribes, even and either metronidazole or the when the pain from a peptic ulcer is gone. penicillinlike antibiotic amoxicillin for 7 to 14 days.

8 Peptic Ulcer Disease and NSAIDs • Quadruple therapy. The patient Patients should discuss any bothersome side takes a PPI, bismuth subsalicylate, effects with their health care provider, who and the antibiotics tetracycline and may prescribe other medications. metronidazole for 14 days. Health At least 4 weeks after a patient’s treatment care providers use quadruple therapy ends, his or her health care provider will to treat patients in one of several perform a breath or stool test again to be situations, including if the patient sure the treatment has cured the H. pylori –– cannot take amoxicillin because of a infection. Blood tests are not useful after penicillin allergy treatment because a person’s blood can test –– has undergone treatment before positive for H. pylori even after treatment with a macrolide antibiotic, such as has eliminated the bacteria. clarithromycin If the infection is still present, a peptic ulcer –– is still infected with H. pylori could return or, rarely, stomach cancer because triple therapy failed to kill could develop. Thus, some people need to the bacteria take more than one round of medications to kill the H. pylori bacteria. Quadruple • Sequential therapy. The patient therapy is one of several treatments that takes a PPI and amoxicillin for 5 days, health care providers use after an initial followed by a PPI, clarithromycin, and treatment has failed—a strategy called tinidazole for another 5 days. “rescue” or “salvage” therapy. In the Triple therapy, quadruple therapy, and second round of treatment, the health care sequential therapy may cause nausea and provider may prescribe different antibiotics other side effects, including than those that he or she prescribed in the first round. • a darkened tongue • altered taste • darkened stools • diarrhea • headaches • temporary reddening of the skin when drinking alcohol • vaginal yeast infections

9 Peptic Ulcer Disease and NSAIDs What if nonsteroidal People who need the benefits of NSAIDs can reduce the chance of a peptic ulcer anti‑inflammatory drugs returning by are still needed? • taking the NSAID with a meal People who take NSAIDs for other conditions—such as arthritis—should • using the lowest effective dose possible consult with their health care provider • quitting smoking to weigh the benefits and risks of using NSAIDs, even when NSAIDs have caused • avoiding or limiting alcohol an ulcer. People who have an ulcer and Peptic ulcer disease can return, even when have stopped taking an NSAID at their people have been careful to reduce their health care provider’s request may want risk. to resume using it once they feel better. In such cases, a health care provider can Eating, Diet, and Nutrition help a person determine how he or she can continue using an NSAID safely. Researchers have not found that eating, diet, and nutrition play a role in causing or People should tell their health care provider preventing peptic ulcer disease. about all prescription and over-the-counter medications they take. The health care In the past, people believed that drinking provider can then decide if the person may milk helped a peptic ulcer heal. Health safely use NSAIDs or if the person should care providers now know that while milk switch to a different medication. In either may make a peptic ulcer feel better briefly, case, the health care provider may prescribe it also increases stomach acid, which can a PPI or histamine receptor blocker to make a peptic ulcer worse. People should protect the lining of the person’s stomach talk with their health care provider about and duodenum. drinking milk while a peptic ulcer is healing. Stress and spicy food are not causes of peptic ulcer disease; however, they can make symptoms worse. Drinking alcohol and smoking can also worsen a peptic ulcer and prevent healing.

10 Peptic Ulcer Disease and NSAIDs Hope through Research Points to Remember The National Institute of Diabetes and • A peptic ulcer is a sore on the Digestive and Kidney Diseases’ (NIDDK’s) inner lining of the stomach or Division of Digestive Diseases and duodenum—the first part of the Nutrition conducts and supports basic small intestine. and clinical research into many digestive disorders. • Causes of peptic ulcer disease include Clinical trials are research studies involving people. Clinical trials look at safe and –– long-term use of nonsteroidal effective new ways to prevent, detect, or anti-inflammatory drugs treat disease. Researchers also use clinical (NSAIDs), such as aspirin and trials to look at other aspects of care, such ibuprofen as improving the quality of life for people –– an infection with the bacteria with chronic illnesses. To learn more about Helicobacter pylori (H. pylori) clinical trials, why they matter, and how to –– rarely, cancerous or participate, visit the NIH Clinical Research noncancerous tumors in Trials and You website at www.nih.gov/ the stomach, duodenum, or health/clinicaltrials. For information about pancreas current studies, visit www.ClinicalTrials.gov. • A dull or burning pain in the stomach is the most common For More Information symptom of peptic ulcer disease. American College of Gastroenterology A person can feel this pain 6400 Goldsboro Road, Suite 200 anywhere between the navel and Bethesda, MD 20817 the breastbone. Phone: 301–263–9000 Fax: 301–263–9025 • How a health care provider treats Email: [email protected] peptic ulcer disease will depend on Internet: www.gi.org its cause. • Stress and spicy food are not causes American Gastroenterological Association of peptic ulcer disease; however, 4930 Del Ray Avenue they can make symptoms worse. Bethesda, MD 20814 Drinking alcohol and smoking Phone: 301–654–2055 can also worsen a peptic ulcer and Fax: 301–654–5920 prevent healing. Email: [email protected] Internet: www.gastro.org

11 Peptic Ulcer Disease and NSAIDs Acknowledgments National Digestive Diseases Publications produced by the Information Clearinghouse Clearinghouse are carefully reviewed 2 Information Way by both NIDDK scientists and outside Bethesda, MD 20892–3570 experts. This publication was originally Phone: 1–800–891–5389 reviewed by Sheila Crowe, M.D., and TTY: 1–866–569–1162 David Peura, M.D., University of Virginia Fax: 703–738–4929 School of Medicine, Charlottesville, VA. Email: [email protected] Internet: www.digestive.niddk.nih.gov

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NIH Publication No. 14–4644 August 2014

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