It is likely that there is some abrasion, or break, in the lining membrane (or mucosa) of the stomach and/or duodenum, and that it is gradually eroded and deepened by the acidic gastric juice. The bacterium HELICOBACTER PYLORI (H.pylori) is present in the stomach of people with peptic ulcers; 15 per cent of people infected with the bacterium develop an ulcer, and the ulcers heal if H. pylori is eradicated. Thus, this organism obviously has an important role in creating ulcers. Smoking seems to accentuate, if not cause, duodenal ulceration, and the drinking of alcohol is probably harmful. The apparent association with a given blood group, and the fact that relatives of a patient with a peptic ulcer are more likely to develop such an ulcer, suggest that there is some genetic factor involved.

Episodes of pain in the middle or upper right part of the abdomen. The pain tends to occur 2–3 hours after a meal, most commonly at night, and is relieved by some food such as a glass of milk; untreated it may last up to an hour. Vomiting is unusual, but there is often tenderness and stiffness (‘guarding’) of the abdominal muscles. Occasionally, there may be an acute episode of bleeding or perforation, or obstruction of the gastric outlet, with little previous history. Confirmation of the diagnosis is made by radiological examination (‘barium meal’), the ulcer appearing as a niche on the film, or by looking at the ulcer directly with an endoscope (see FIBREOPTIC ENDOSCOPY). Chief complications are perforation of the ulcer, leading to the vomiting of blood (see HAEMATEMESIS), or less severe bleeding from the ulcer, the blood passing down the gut, resulting in dark, tarry stools (see MELAENA).

of a perforation requires the initial management of any complications, such as shock, haemorrhage or gastric outlet obstruction, usually involving surgery and blood replacement. Medical treatment of a chronic ulcer should include regular meals, and the avoidance of fatty foods, strong tea or coffee and alcohol. Patients should also stop smoking and try to reduce the stress in their lives. ANTACIDS may provide symptomatic relief. However, the mainstay of treatment involves four- to six-week courses with drugs such as CIMETIDINE and RANITIDINE. These are H2 RECEPTOR ANTAGONISTS which heal peptic ulcers by reducing gastric-acid output. Of those relapsing after stopping this treatment, 60–95 per cent have infection with H. pylori. A combination of BISMUTH chelate, AMOXICILLIN and METRONIDAZOLE – ‘triple regime’ – usually eliminates the infection: most physicians advise the triple regime as first-choice treatment because it is more likely to eradicate Helicobacter and this, in turn, enhances healing of the ulcer or prevents recurrence. Surgery may be necessary if medical measures fail, but its use is much rarer than before effective medical treatments were developed.