Gastric Ulcers: Causes, Symptoms, Diagnosis, and Treatment

Gastric ulcers, also known as stomach ulcers, are a type of peptic ulcer disease (PUD) characterized by open sores that develop on the inner lining of the stomach. These ulcers occur due to an imbalance between protective factors in the gastric mucosa and aggressive factors such as stomach acid and pepsin. Gastric ulcers are a significant global health concern, affecting millions of individuals and contributing to considerable morbidity.

This comprehensive overview delves into the causes, risk factors, clinical manifestations, diagnostic approaches, treatment modalities, and preventive strategies for gastric ulcers, providing a detailed understanding of this condition.

Pathophysiology and Causes

Gastric ulcers develop when the stomach’s protective mechanisms are overwhelmed by damaging factors, leading to erosion of the gastric mucosa. The prevalence rate is 10% which makes it much more common than is widely acknowledged (Selim et al., 2023; Gong et al., 2024)The primary protective mechanisms include:

• Mucus production: Forms a protective barrier over the gastric lining.
• Bicarbonate secretion: Neutralizes stomach acid at the mucosal surface.
• Adequate blood flow: Maintains tissue health and promotes repair.
• Prostaglandins: Enhance mucus and bicarbonate production while reducing acid secretion.

When these protective factors are compromised or aggressive factors are amplified, the risk of ulceration increases.

Key Causes and Risk Factors (Wang et al., 2019; Yasumura et al., 2024):

1. Helicobacter pylori infection:
   • This spiral-shaped bacterium colonizes the gastric mucosa, causing chronic inflammation. It disrupts the mucosal barrier, increasing vulnerability to acid-induced damage.
2. Non-steroidal anti-inflammatory drugs (NSAIDs):
   • Medications like aspirin, ibuprofen, and naproxen inhibit cyclooxygenase (COX) enzymes, reducing prostaglandin production. This impairs mucosal defence and increases susceptibility to ulcers.
3. Excessive acid secretion:
   • Conditions like Zollinger-Ellison syndrome, which involves gastrin-secreting tumours, can lead to hyperacidity and ulceration.
4. Smoking and alcohol consumption:
   • Both impair mucosal healing and exacerbate damage to the gastric lining.
5. Stress:
   • Severe physiological stress from trauma, burns, or major surgery (“stress ulcers”) can impair mucosal defences.
6. Dietary factors:
   • Spicy foods and caffeine may exacerbate symptoms but are not primary causes.
7. Genetics:
   • A family history of peptic ulcers increases susceptibility.

Clinical Manifestations

Gastric ulcers present with a range of symptoms, which can vary depending on the ulcer’s severity and location:

1. Epigastric pain:
   • A burning or gnawing pain in the upper abdomen, often worsened by eating.
2. Nausea and vomiting:
   • These symptoms may result from irritation of the stomach lining or gastric outlet obstruction in severe cases.
3. Loss of appetite and weight loss:
   • Chronic pain or fear of eating due to discomfort can lead to reduced food intake.
4. Bloating and belching:
   • Common complaints due to impaired gastric motility.
5. Hematemesis and melena:
   • Vomiting blood (hematemesis) or passing black, tarry stools (melena) are signs of bleeding ulcers and warrant immediate medical attention.
6. Anaemia:
   • Chronic blood loss from an ulcer can result in iron-deficiency anaemia.

Diagnosis

Accurate diagnosis of gastric ulcers involves a combination of clinical evaluation, laboratory tests, and imaging studies:

1. Medical history and physical examination:
   • A detailed history helps identify risk factors such as NSAID use or H. pylori infection. Physical examination may reveal epigastric tenderness.
2. Endoscopy:
   • Esophagogastroduodenoscopy (EGD) is the gold standard for diagnosing gastric ulcers. It allows direct visualization of the ulcer and enables biopsy for histopathological examination, ruling out malignancy.
3. H. pylori testing:
   • Non-invasive tests: Urea breath test, stool antigen test, and serology.
   • Invasive tests: Biopsy-based urease testing and histology during endoscopy.
4. Laboratory tests:
   • Complete blood count (CBC) to assess for anaemia.
   • Serum gastrin levels in suspected Zollinger-Ellison syndrome.
5. Imaging studies:
   • Upper gastrointestinal series with barium contrast may be used when endoscopy is unavailable, though it is less sensitive.

Complications

Untreated or poorly managed gastric ulcers can lead to serious complications:

1. Gastrointestinal bleeding:
   • The most common complication, ranging from mild to life-threatening haemorrhage.
2. Perforation:
   • An ulcer can erode through the stomach wall, causing peritonitis, a medical emergency.
3. Gastric outlet obstruction:
   • Chronic inflammation and scarring can narrow the gastric outlet, leading to persistent vomiting and weight loss.
4. Malignancy:
   • Although rare, chronic ulcers may undergo malignant transformation, particularly in the presence of H. pylori infection.

Treatment

The management of gastric ulcers focuses on relieving symptoms, promoting healing, and preventing recurrence. Treatment typically involves a combination of pharmacological and non-pharmacological approaches:

1. Pharmacological treatment:
   • Proton pump inhibitors (PPIs):
     • Drugs like omeprazole, lansoprazole, and esomeprazole reduce gastric acid secretion, promoting ulcer healing.
   • H2 receptor antagonists:
     • Examples include ranitidine and famotidine, which also lower acid production.
   • Antibiotics:
     • For H. pylori infection, a combination of antibiotics (e.g., clarithromycin, amoxicillin, metronidazole) and a PPI is used in a regimen called triple therapy or quadruple therapy.
   • Antacids and sucralfate:
     • These provide symptomatic relief and protect the ulcerated mucosa.
   • Misoprostol:
     • A prostaglandin analogue used to prevent NSAID-induced ulcers.
2. Lifestyle modifications:
   • Avoiding NSAIDs, smoking, and alcohol.
   • Maintaining a balanced diet and reducing stress.
   • Different natural therapeutics are currently being investigated such as cumin. The essential oil has some protective roles in rat gastric ulcer models which are generating excitement.
3. Surgical intervention:
   • Reserved for complications or refractory ulcers.
   • Options include vagotomy (cutting the vagus nerve to reduce acid secretion) and partial gastrectomy.

Prevention

Preventing gastric ulcers involves addressing modifiable risk factors and adopting healthy lifestyle practices:

1. Eradicate H. pylori infection:
   • Early detection and treatment of H. pylori can prevent ulcer formation.
2. Cautious use of NSAIDs:
   • Use the lowest effective dose for the shortest duration.
   • Consider co-prescription of PPIs or misoprostol in high-risk individuals.
3. Healthy lifestyle:
   • Avoid smoking and excessive alcohol consumption.
   • Manage stress through relaxation techniques or therapy.
4. Regular medical check-ups:
   • Particularly for individuals with a history of ulcers or significant risk factors.

Prognosis

With appropriate treatment, most gastric ulcers heal within a few weeks, and recurrence can be minimized through preventive measures. However, complications can arise if ulcers are neglected or inadequately treated. Early intervention and adherence to medical advice are crucial for favourable outcomes.

Gastric ulcers are a common yet potentially serious condition with a multifactorial aetiology. Advances in diagnostic tools and therapeutic interventions have significantly improved the management and prognosis of this disease. Public awareness, early detection, and preventive strategies remain key to reducing the global burden of gastric ulcers. By addressing risk factors and adhering to evidence-based treatment protocols, patients can achieve long-term relief and improved quality of life.

References

Gong, H., Zhao, N., Zhu, C., Luo, L., & Liu, S. (2024). Treatment of gastric ulcer, traditional Chinese medicine may be a better choice. Journal of Ethnopharmacology, 324, 117793 (Article).

Selim, H. M., Negm, W. A., Hawwal, M. F., Hussein, I. A., Elekhnawy, E., Ulber, R., & Zayed, A. (2023). Fucoidan mitigates gastric ulcer injury through managing inflammation, oxidative stress, and NLRP3-mediated pyroptosis. International Immunopharmacology, 120, 110335 (Article).

Wang, Y., Sun, Y. W., Wang, Y. M., Ju, Y., & Meng, D. L. (2019). Virtual screening of active compounds from Artemisia argyi and potential targets against gastric ulcer based on Network pharmacology. Bioorganic Chemistry, 88, 102924 (Article).

Yasumura, K., Tochio, T., & Ohana, M. (2024). Refractory gastric ulcer in the antrum. The American Journal of Gastroenterology, 119(4), 608 (Article) .