Peptic ulcer disease is a common problem of the stomach and duodenum (first part of the small intestine). It is estimated that at least 10% of the American population has a duodenal ulcer, the most common type of peptic ulcer, at any one time. One of the complications of a peptic ulcer is that it may bleed. As a result there can be slow blood loss which may lead to anemia, or there may be massive blood loss with severe complications in the short term.
Reason for Bleeding of a Peptic Ulcer
A peptic ulcer is an open sore that forms in the lining of the stomach or duodenum of the small intestine. Duodenal ulcers are more common. Although it is an open sore, peptic ulcers do not always bleed. However, if the peptic ulcer is repeatedly irritated then this can cause further damage and result in a bleeding peptic ulcer.
Read more on what is a peptic ulcer.
Normally the stomach has a mucus barrier which prevents the stomach acid from making contact with the stomach wall. Similarly the duodenum can quickly respond to stomach juices and neutralize it. These mechanisms ensure that the stomach and duodenum are not irritated or damaged by the powerful digestive secretions.
However, there are cases where these mechanisms are not sufficient or suitable to counteract injury. This leads to an ulcer. If the cause is not removed then the continued irritation and damage may erode the ulcer to the point that it bleeds. The degree of bleeding depends on the extent of damage to the blood vessels in the gut wall.
Causes for Bleeding Ulcer
The causes of a bleeding ulcer is the same as the causes of a non-bleeding peptic ulcer. The two main causes are H.pylori infection and the excessive use of certain medication.
H.pylori (Helicobacter pylori) is a species of bacteria that is able to withstand the stomach acid. It produces urease which can neutralize the acid immediately around it and allow the bacteria to burrow towards the stomach wall. Here the bacteria triggers inflammation of the stomach wall. It can survive for years within the stomach.
Excessive use of drugs, particularly NSAIDs, are another major cause of peptic ulcers. These drugs are widely available and often overused. These drugs disrupt the mucus barrier which normally protects the stomach wall from the corrosive gastric acid.
While NSAIDs like aspirin are by far the main drug cause of peptic ulcers, other drugs may also be responsible. In addition, NSAIDS like aspirin impair coagulation (clotting of the blood) and continued use in bleeding ulcers can worsen the extend of the bleed.
Certain risk factors increase the risk of developing peptic ulcers. It is important to note that contrary to popular belief, these risk factors do not cause peptic ulcers.
- Spicy foods may exacerbate the inflammation in peptic ulcers and worsen symptoms in addition to increasing stomach acid secretion.
- Tobacco smoking is a problem particularly in people with H.pylori infection as it increases acid secretion which causes further damage.
- Alcohol consumption also increases the risk of peptic ulcers, particularly with excessive and frequent use of alcohol. It compromises the mucus barrier and increases stomach acid.
- Stress is another major risk factor. This refers to severe illnesses that causes physiological stress to the body but can also refer to psychological stress which is common.
Since these factors can increase the risk of peptic ulcers, worsen it and aggravate symptoms, it may also have the same effect on bleeding ulcers.
Signs and Symptoms
The signs and symptoms of peptic ulcers with or without bleeding include:
- Pain in the stomach (upper left abdominal pain) or duodenum (upper middle abdominal pain) which varies from a dull ache and gnawing pain to a burning and even sharp pain.
- Nausea and sometimes vomiting. The nausea tends to be worse when a person is hungry or a short while after eating.
- Early satiety where a person feels full after a few bites of food. This may also be accompanied by bloating and excessive belching.
Other symptoms include heartburn or chest discomfort, changes in appetite, unintentional weight loss and disturbed sleep. The latter is a result of stomach acid secretion increasing in the early hours of the morning and exacerbating symptoms like pain. It is important to note that sometimes there is little to no symptoms of gastritis or even ulcers.
Symptoms of a bleeding ulcer specifically include:
- Vomiting of blood (hematemesis) is an indication of a bleeding ulcer. When this does occur, the vomitus has dark coffee grounds which is degraded and coagulated blood. Sometimes the blood is fresh and bright red which is known as hematochezia.
- Dark tarry stools are another sign of a bleeding ulcer. These stools are known as melena and is more likely to occur with massive or sustained blood loss. At other times the blood in the stool may only be detectable with diagnostic tests.
Anemia is a complication of a bleeding ulcer. Symptoms may include fatigue, shortness of breath and paleness. If there is massive blood loss then the symptoms can be severe and even lead to shock in rare cases.
Read more on signs of stomach bleeding ulcer.
Treatment of a Bleeding Peptic Ulcer
The initial treatment for a bleeding peptic ulcer is the same as a non-bleeding ulcer provided that the bleed is minor. Firstly the cause of the ulcers need to be removed. NSAIDs and other drugs that may be causing the peptic ulcers need to be discontinued or change to alternate medication that are less likely to affect the gut lining. Secondly peptic ulcer treatment needs to be initiated as soon as possible.
- Antibiotics to eradicate H.pylori bacteria.
- Antacids to neutralize stomach acid.
- Acid-suppressing medication to reduce stomach acid production.
- Ulcer-protecting drugs to assist ulcers to heal.
These measures should assist with the healing of the ulcer and the bleed may therefore cease. However, if there is a continuous minor bleed or massive blood loss from an ulcer then more invasive procedures are necessary. Endoscopic therapy (endotherapy) where the site of the bleed is sealed is the first option. For acute bleeds, hemoclips may also be used during or after endotherapy to stop the bleed.