Introduction

Stomach ulcer, also known as peptic ulcer, is a sore or lesion that develops on the lining of the stomach o the first part of the small intestine(duodenum). It occurs when the protective layer of the mucus that lines these organs is damaged, allowing the stomach acid to invade the underlying tissues. This erosion leads to the development of an open sore, which can cause various types of pain and discomfort.

Stomach ulcers are one of the most common and easily treatable diseases, but they can become serious medical conditions if correct treatment is not taken.

Stress and spicy foods do not cause stomach ulcers; however, these can make the symptoms get worse. The most common causes of stomach ulcers are the bacterium Helicobacter pylori (H. pylori), and the constant use of Nonsteroidal anti-inflammatory drugs (NSAIDs) present in painkillers such as ibuprofen, ibuprofen, Voltaren, and naproxen sodium.

 

Prevalence of Stomach Ulcer in Nigeria

Stomach ulcers among are the most prevalent gastrointestinal disorders in the world today, including in Nigeria. It is relatively common in the country, with a prevalence rate estimated to be around 5 – 10% of the population. The prevalence rates may vary across different regions of Nigeria due to factors such as socioeconomic status, cultural practices like smoking and alcohol consumption, dietary habits, access to good healthcare, and occurrence of risk factors such as H. pylori infection and NSAID widespread use.

H. pylori is a major risk factor for stomach ulcers and is highly prevalent in Nigeria, particularly among lower socioeconomic groups and in rural areas. The infection is commonly acquired during childhood through fecal-oral or oral-oral transmission routes, often within families or communities with poor sanitation and hygiene practices.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in Nigeria for pain relief and management of inflammatory conditions such as arthritis and musculoskeletal disorders. The prolonged or excessive use of NSAIDs, particularly in the absence of gastroprotective measures, can increase the risk of stomach ulcers and other gastrointestinal complications.

Smoking habit is relatively common in Nigeria, particularly among adult males. Tobacco smoking is a known risk factor for stomach ulcers and can aggravate existing ulcers and delay healing. While alcohol consumption patterns may vary across different regions and cultural groups in Nigeria, excessive alcohol intake contributes to gastric mucosal injury and increases the risk of gastric ulcers in the country. Also, traditional Nigerian meals are often heavily seasoned and spiced, which may irritate the stomach lining and increase ulcer symptoms in susceptible individuals. Excessive salt intake, commonly found in processed foods and traditional cooking practices, may increase the risk of stomach ulcer formation.

The difficult access to good healthcare services and infrastructure between urban and rural areas may affect the prevalence and management of stomach ulcers in Nigeria. Health literacy levels and awareness about stomach ulcers, their risk factors, and preventive measures may vary among different regions of the population, influencing healthcare-seeking behaviour and treatment outcomes.

Despite the significant burden of gastrointestinal disorders in Nigeria, including stomach ulcers, there is limited comprehensive research data available at the national level. Continued research efforts are needed to better understand the prevalence, risk factors, and outcomes of stomach ulcers in Nigeria, as well as to inform public health policies and interventions aimed at prevention and management.

In summary, stomach ulcers are a significant healthcare concern in Nigeria, with high prevalence rates, influenced by factors such as H. pylori infection, NSAID use, lifestyle factors, and healthcare access. Efforts to improve public health education, access to healthcare services, and research initiatives are essential for the effective prevention and management of stomach ulcers in Nigeria.

 

How Does Stomach Ulcer Present Itself?

How stomach ulcer presents itself among people differs. While some persons with stomach ulcers may feel certain symptoms; other people with stomach ulcers do not even have symptoms (this is called silent ulcers) until it has become more severe.

The most common stomach ulcer symptoms are a feeling like an acid burn in the stomach, or like something is eating up the stomach. Stomach acids, enzymes, and other chemicals are eating away at the wound, thereby making the pain worse, as does having an empty stomach. This pain can often be relieved by eating certain foods that buffer stomach acid or by taking an antacid. The pain may be worse between meals and at night.

Burning Pain

This is the most common symptom of a stomach ulcer. It is typically felt in the upper abdomen, between the navel and the breastbone. It usually starts as a burning sensation, which can be described as a hunger feeling/pain or a dull ache. These pains may occur shortly after eating; when the stomach is empty, especially in the midnight early part of the morning or in between meals.

Nausea and Vomiting

When a stomach ulcer occurs, some people may experience a feeling of discomfort in their stomach, and this may lead to vomiting. This can sometimes occur when the stomach is empty or after meals. Vomiting can occur as a result of the irritation of the stomach lining or in response to the pain associated with the ulcer.

Feeling of Fullness

Some people with stomach ulcers may feel full even after eating a small amount of food. This feeling can lead to loss of appetite and unintended weight loss over time.

Loss of Appetite

Due to discomfort and the pain associated with eating some people with stomach ulcers may have a loss of appetite. This can lead to inadequate nutrient intake and subsequent weight loss.

Unexplained Weight Loss

Once there is a reduction in food intake, individuals with stomach ulcers may experience unintentional weight loss over time. This is often due to decreased appetite, impaired nutrient absorption, and metabolic changes associated with chronic illness.

Black or Bloody Stool

Due to the presence of digested blood, the stools of a stomach ulcer patient may appear black, tarry, or sticky. This happens when blood from the ulcer mixes with stomach acid and digestive enzymes, causing it to undergo chemical changes. In severe cases, blood may be vomited or appear as a coffee ground-like material. This indicates active bleeding from the ulcer and requires immediate medical attention.

Other symptoms include:

• Intolerance to fatty foods
• Heartburn
• Trouble breathing
• Feeling dizzy, weak, or faint

It should be noted that these signs and symptoms may be different in severity and frequency depending on the location of the ulcer, the size of the ulcer, the overall health of the individual, his/her age, and underlying medical conditions.

 

What are the Causes and Risk Factors of Stomach Ulcers?

Stomach ulcers can be caused by several factors, but the two most common causes of stomach ulcers are the H. pylori bacterial infection, and the overuse of nonsteroidal anti-inflammatory drugs (NSAIDs) i.e. painkillers. These two cause over 90% of stomach ulcers.

Helicobacter Pylori (H. pylori) Bacteria

This bacterium is a very common bacterial infection that affects up to half of the global population. It commonly lives in the mucous layer that covers and protects tissues that line the stomach and small intestine. Often, the bacterium does not cause any problem, but sometimes it overgrows and takes over. As they continue to multiply and grow, they can cause inflammation of the stomach’s inner layer, thereby producing an ulcer.

Although it is unclear how H. pylori infection spreads, it may be transmitted from person to person by close contact, such as kissing. It may also be contracted through food and water.

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs such as aspirin, ibuprofen, and naproxen are common over-the-counter drugs used to relieve pain and reduce inflammation. The continuous or prolonged use of these medications can irritate the stomach lining, leading to the formation of ulcers. Also, NSAIDs inhibit some chemicals such as prostaglandins, which are crucial in the maintenance and repair of the stomach lining and in regulating gastric acid secretion.

It should be understood that the stomach lining is designed to recover from minor injuries, but if NSAIDs are taken too often, the stomach lining will not be able to keep up with its repairs. The more the protective lining wears away, the less it can recover.

Risk Factors

Normal lifestyle factors, like daily diet and day-to-day stress levels, do not cause ulcers, but they can make the symptoms worse. In addition to having risks related to taking NSAIDs, anything that makes the stomach more acidic can irritate the wound, and make an individual have an increased risk of stomach ulcer. These risk factors include:

• Excessive Alcohol Intake: Alcohol can directly irritate and erode the mucous lining of the stomach, increasing the amount of stomach acid that is produced. This leads to inflammation and erosion, which can contribute to ulcer formation. Chronic alcohol abuse can impair the body’s ability to heal existing ulcers and increase the risk of complications.
• Smoking: Smoking may increase the risk of stomach ulcers in people who are infected with H. pylori. It decreases the blood flow to the stomach lining, impairing its ability to repair and regenerate. Nicotine and other compounds in tobacco can stimulate the production of stomach acid, causing mucosal damage. It also delays the healing of existing ulcers and increases the recurrence risk.
• Age: Stomach ulcers are more common in older adults, possibly due to factors such as decreased mucosal repair capacity and prolonged exposure to risk factors over time.
• Family History: A family history of stomach ulcers or related conditions may increase an individual’s chance of developing ulcers, possibly due to shared genetic factors or environmental factors.
• Have Untreated Stress: While stress itself does not directly cause ulcers if it is left untreated, it can worsen symptoms and increase the risk of stomach ulcers by enhancing stomach acid secretion and impairing mucosal defense.
• Eating Spicy and Acidic Foods: While these conditions do not necessarily cause stomach ulcers, they can worsen their symptoms and increase the risk of having them.
• Certain Medical Conditions: Medical conditions such as cirrhosis or hepatitis may increase the risk of stomach ulcers due to factors such as altered blood flow to the stomach and impaired liver function. Chronic kidney disease can lead to electrolyte imbalances and metabolic disturbances that may lead to ulcer formation. Chronic obstructive pulmonary disease (COPD) or other respiratory conditions may increase the risk of stomach ulcers due to factors such as chronic hypoxia and systemic inflammation.

 

Complications of Stomach Ulcer

If left untreated, stomach ulcers can result in complications such as:

Internal Bleeding (Bleeding Ulcers)

Internal bleeding from a stomach ulcer can be mild leading to anemia, or severe which can lead to shock, requiring hospitalization or a blood transfusion.

Perforation (Hole in the stomach wall)

Stomach ulcers that cause a hole (perforation) through the wall of the stomach or small intestine are quite rare but require emergency treatment. When this happens, stomach acids and bacteria leak through the hole in the abdominal cavity, thereby putting the person at risk of having a serious infection of the abdominal cavity (peritonitis). This infection can easily spread to the bloodstream and lead to sepsis.

Obstruction

Stomach ulcers can block the passage of food through the digestive tract, causing the stomach to become full easily, vomit, and lose weight either through scarring or inflammation caused by swelling.

 

Prevention of Stomach Ulcer

Stomach ulcers can be prevented by:

Eliminating H. pylori Infection

It is not clear how H. pylori spreads, this is why most people who have the bacteria in their body are not aware of having it. But there is evidence that it could be transmitted from person to person, or through food and water. It can be diagnosed by taking a simple breath or stool test. If diagnosed with an H. pylori infection, it is essential to undergo appropriate antibiotic treatment to eliminate the bacteria. Antibiotics are typically prescribed in combination with acid-suppressing medications such as proton pump inhibitors (PPIs) or H2-receptor antagonists (H2 blockers) to enhance effectiveness and promote ulcer healing. After completing antibiotic treatment, it is important to follow up with confirmatory testing to ensure the successful elimination of the bacteria. The common prescription includes Amoxicillin 1g 12hourly for 10 days.

Also, one can protect the body from H. pylori infections by frequently washing the hands with soap and water and by eating foods that have been cooked completely.

NSAIDs Usage

An individual with a habit of managing daily aches and pains with NSAIDs such as ibuprofen, aspirin, and naproxen, should make sure he/she uses the recommended dose, and take them with food or antacids to help protect the stomach lining. And if possible, limit the use of NSAIDs to avoid the risk of developing stomach ulcers. Also, explore alternative pain relievers or treatments that are less likely to irritate the stomach, such as acetaminophen (paracetamol) for pain relief.

Lifestyle Modifications

Although risk factors such as smoking, and excessive alcohol are not the exact cause of ulcers, they can aggravate their symptoms. So, modifying such lifestyles can be beneficial in treating stomach ulcers.

Limit Alcohol Consumption: Alcohol consumption such be done in moderation, as excessive alcohol consumption can irritate the stomach lining and increase the risk of developing ulcers.

Quit Smoking: It is recommended to quit smoking to reduce the risk of stomach ulcers and promote positive health. Smoking cessation can improve the healing of existing ulcers and reduce the risk of complications.

Managing Stress: Individuals with stress should maintain a healthy work-life balance, prioritize self-care, and seek support from friends, family, or a health professional if needed. Practicing stress techniques such as relaxation exercises, meditation, yoga, or engaging in hobbies and activities that promote body relaxation.

Dietary Modifications: One should follow a balanced diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats to promote overall gastrointestinal health. Identify and avoid foods that may irritate the stomach lining or aggravate the symptoms such as spicy foods, acidic foods, caffeine, and carbonated beverages. Also, one can consider incorporating probiotic-rich foods or supplements into one’s diet to support good health and potentially reduce the risk of H. pylori infection.

Regular Medical Check-Ups

Schedule regular medical check-ups with one’s medical professionals to monitor overall health and address any medical concerns immediately. Also, discuss personal and family medical history, lifestyle factors, and any medications or supplements with medical doctors that can increase one’s risk of stomach ulcers.

 

Management of Stomach Ulcers in Healthcare

Diagnosis of Stomach Ulcer

To diagnose or detect stomach ulcers, a doctor may inquire about the individual’s family and medical history, and perform a physical exam. They may require an individual to undergo diagnostic tests, such as:

H. pylori Testing

This is required in patients with regular symptoms of stomach ulcer. The doctor may recommend tests to determine whether there is a presence of the bacterium H. pylori in the body. This is done using a blood, stool, or breath test. The breath test is the most accurate.

• For the breath test, the patient ingests a solution containing a radioactive or non-radioactive carbon or tracer, which is metabolized by H. pylori bacteria if present. Breath samples are collected at specific intervals and blown into a bag, which is then sealed. If the person is infected with H. pylori, the breath sample will contain radioactive carbon in the form of carbon dioxide.
• Blood samples are collected to detect the presence of antibodies produced by the body in response to H. pylori infection. Blood tests may also measure levels of specific antigens produced by the bacteria.
• Stool samples are collected and analyzed for the presence of H. pylori antigens or genetic material (DNA). It may be used to detect active infection or monitor treatment effectiveness.

If a patient is taking an antacid before the testing for H. pylori, the doctor must be notified. Although the type of test to use depends, it may be necessary to stop the medication for a while because antacids can lead to false-negative results.

Endoscopy

An upper endoscopy (EGD test) is a thin, flexible tube with a camera that is inserted through the mouth and into the esophagus, stomach, and duodenum. The tube goes down the throat while a patient is under sedation, and this will enable the doctor to pass long, narrow tools. The endoscope allows direct visualization of the stomach lining and duodenum, allowing the doctor to identify ulcers or other abnormalities. During endoscopy, small tissues (biopsies) may be taken from suspicious areas for further examination under a microscope to confirm the presence of ulcers and assess for H. pylori infection or other conditions.

Also, endoscopy is recommended if the patient is older, has signs of bleeding, or has experienced recent weight loss or difficulty eating and swallowing. If the endoscopy shows an ulcer in the stomach, a follow-up endoscopy should be performed after treatment to show that it has healed, even if the symptoms improve.

Upper Gastrointestinal Series (Barium X-ray)

This series of X-rays of the upper digestive system shows images of the esophagus, stomach, and small intestine. During the X-ray, patients swallow a chalky liquid containing barium, which coats the lining of the esophagus, stomach, and duodenum. The X-ray is taken while the patient is in different positions, creating images of the gastrointestinal tract and any abnormalities, such as ulcers, strictures, or tumors. While barium X-rays can detect larger ulcers or structural abnormalities, they may be less sensitive than endoscopy for identifying smaller or superficial ulcers.

Other Diagnostic Tests

• Serologic Testing: Blood samples are tested for the presence of antibodies against H. pylori. Serologic tests are less accurate than other methods and may not distinguish between active infection and past exposure.
• Endoscopic Ultrasound (EUS): Endoscopic ultrasound may be used to assess the depth of ulcer penetration into the stomach wall and evaluate nearby lymph nodes or structures. EUS is particularly useful for staging purposes in cases of suspected cancer.
• Differential Diagnosis: Other gastrointestinal conditions such as gastritis, gastroesophageal reflux disease (GERD), gastric polyps, or stomach cancer may present with symptoms similar to stomach ulcers. Differential diagnosis may be necessary to distinguish between these conditions and guide appropriate management.
• Follow-Up and Monitoring: After initiating treatment for stomach ulcers, follow-up endoscopy or other tests may be performed to assess ulcer healing and treatment effectiveness. In some cases, surveillance endoscopy may be recommended to monitor for recurrence of ulcers or assess for complications such as bleeding or malignancy.

 

Treatment of Stomach Ulcer

The stomach lining begins to heal when the cause of the ulcer goes away. If the cause of the ulcer is due to the excessive use of NSAIDs, stopping the usage might be enough for the ulcer to heal by itself. Also, if the ulcer is caused by an H. pylori infection, antibiotics may probably be enough to make it go away. Doctors may also prescribe other medications to help reduce the acid in the stomach and protect the stomach lining to promote faster healing.

Treatment of stomach ulcers is usually done using the following:

Medications

• Antibiotics: For a patient with H. pylori bacterial infection, doctors will prescribe some combination of antibiotics, and acid-suppressing medications (PPI or H2 blockers) to kill the bacteria, and prevent ulcer recurrence. Common antibiotics include a combination of two antibiotics (such as tetracycline, amoxicillin, metronidazole, and clarithromycin) with a PPI or bismuth subsalicylate for 10 to 14 days. Commonly prescribed are: Amoxicillin 1g 12hourly for 10 days and Azithromycin 500mg 12hr/g x 10 days
• Proton Pump Inhibitors (PPIs): This reduces stomach acid production by blocking the proton pump enzyme in the stomach lining. Omeprazole, lansoprazole, esomeprazole, pantoprazole, rabeprazole are examples of PPIs. They are often prescribed as first-line therapy for stomach ulcers to promote healing and provide symptom relief. Treatment duration may vary but typically ranges from 4 to 8 weeks, depending on the severity of the ulcer and patient response.
• H2-Receptor Antagonists (H2 Blockers): These blockers reduce stomach pain production by blocking histamine receptors on parietal cells in the stomach lining. Examples of these medications include ranitidine, famotidine, and cimetidine. H2 blockers are used to reduce gastric acid secretion and promote ulcer healing, especially in cases where PPIs are not available or tolerated. Treatment duration may vary but is very similar to that of PPIs.
• Antacids: Antacids neutralize stomach acid, providing immediate relief from symptoms such as heartburn and indigestion. Examples include calcium carbonate, magnesium hydroxide, and aluminum hydroxide. They are often used as secondary therapy to provide symptomatic relief while waiting for acid-suppressing medications to take effect. Antacids do not promote ulcer healing or address the underlying cause of ulcers but can help alleviate discomfort.
• Cytoprotective Agents: These are medications that help to coat and protect the lining of the stomach and the small intestine. In some cases, doctors often prescribe these medications to treat and prevent stomach ulcers related to NSAID use. Examples of cytoprotective medications include sucralfate, misoprostol, and bismuth subsalicylate.

Follow-Up and Monitoring

Follow-up endoscopy may be recommended to assess ulcer healing and treatment response, particularly in cases of complicated ulcers or H. pylori infection. Adjustments to medication dosage or regimen may be necessary based on symptom severity and patient response. Monitor complications such as bleeding, perforation, or obstruction, and intervene promptly if necessary.

Surgical Intervention (In Severe Cases or Complications)

Surgery may be indicated for complications such as perforation, severe bleeding, or obstruction that do not respond to medical management. Surgical options may include ulcer excision, vagotomy (nerve cutting to reduce acid secretion), antrectomy (removal of the lower part of the stomach), or pyloroplasty (widening of the pylorus). This treatment option is typically reserved for cases where conservative measures have failed or for patients at high risk of complications.

NOTE: By following these treatment options, doctors can effectively manage stomach ulcers, promote ulcer healing, prevent recurrence, and reduce the risk of complications associated with the condition.

 

Prognosis of Stomach Ulcer

With appropriate treatment, adherence to medications, lifestyle changes, and avoiding things that might aggravate the ulcer, most stomach ulcers heal completely within a few weeks to months and reduce the risk of recurrence. Healing typically occurs gradually, with symptoms improving over time as acid-suppressing medications reduce gastric acid secretion and promote mucosal healing. Doctors may conduct follow-up tests to make sure the ulcer has healed, and any form of infection does not exist.

However, without proper treatment and management, ulcers can recur and lead to complications such as bleeding, leading to symptoms such as hematemesis (vomiting blood) or melena (black, tarry stools). Prompt medical intervention is necessary to control bleeding and prevent complications. For ulcers that perforate through the stomach or duodenal wall, leading to peritonitis (inflammation of the abdominal cavity) and other serious complications, surgical intervention may be required. In case of scarring from chronic ulcers which may cause narrowing of the stomach (pylorus) or duodenal lumen, resulting in gastric outlet obstruction, treatment may involve endoscopic dilation or surgical intervention.

In uncomplicated cases managed promptly and effectively, the prognosis for stomach ulcers is generally favorable, with most ulcers healing completely and a low risk of recurrence. However, it is necessary to monitor for complications and ensure ongoing management to prevent recurrence and optimize long-term outcomes. This is why early diagnosis, appropriate treatment, and diligent management are key to achieving favorable outcomes and minimizing complications associated with stomach ulcers. Collaboration between patients and doctors is essential for successful management and long-term ulcer control.