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Peptic Ulcers and Esophagitis During Pregnancy

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The term peptic ulcer refers to a sore in the inner lining of the digestive tract stomach. Most of the time, this happens in the stomach or in the duodenum, the first part of the small intestine where food enters after the stomach. In the stomach, the condition is called a gastric ulcer, whereas in the duodenum, it’s called a duodenal ulcer. There is also a condition called erosive esophagitis, which is a severe complication of the reflux of acidic stomach contents entering the esophagus. The reflux of stomach contents is called gastroesophageal reflux disease (GERD), but only after GERD causes erosion of parts of the esophageal wall is the person said to have ulcerative esophagitis. While severe GERD is the most common reason for erosive esophagitis, the latter can also occur together with peptic ulcer disease.

Gastric and duodenal ulcers are common during pregnancy, because Helicobacter pylori, a bacterial species that causes such ulcers, infects an estimated 50 percent of the human population. The chances of infection are influenced strongly by geography, ethnicity, and socioeconomic status. Highest rates of infection are in developing countries, most infections begin in childhood, and risk is highest in places with poor hygiene practices. H. pylori infects about 20-30 percent of pregnant women in European countries, Australia, and Japan, while very high rates of infection —up to 80 percent!— have been reported in Egypt and Gambia. Turkey has reported rates ranging from 50-70 percent. Symptoms do not develop in everybody who is infected with H. pylori, but pregnancy may increase a woman’s susceptibility to becoming infected in the first place. Erosive esophagitis is rare, but GERD is quite common during pregnancy, so erosive esophagitis does occur among pregnant women.

Infection with H. pylori is the most common reason why people develop peptic ulcers, and why peptic ulcers develop in pregnant women. Erosive esophagitis can occur during pregnancy, because the growing womb puts pressure on abdominal contents, making you susceptible to GERD.

Determination of whether you have stomach or intestinal disease is made based on your history, particularly, upper abdominal pain, nausea, bloating, and other symptoms. You doctor also will ask questions and examine you to investigate more specific problems such as GERD and ulcers. The doctor will ask whether the symptoms are worse after you eat, or before you eat. Whereas GERD tends to be worse after a meal, peptic ulcers can feel worse, either between or after meals. Consequently, if the pain occurs only between meals and never after meals, GERD is unlikely and the doctor will lean toward diagnosis of an ulcer.

To test your stomach for the presence of H. pylori bacteria, your doctor may order what’s called a urea breath test. In this test, you’ll be given a light meal with an agent called urea that is labeled with a special carbon atom that can be detected either by a radiation sensor (carbon-14), or through a process called mass spectrometry (carbon-13). To evaluate you for GERD, and to test for damage to the esophagus such as erosive esophagitis, you may be sent for a procedure called upper endoscopy in which a device with a camera and the ability to take a biopsy is inserted down your throat. If you have GERD, or GERD related complications, various imaging tests may be performed to determine whether you have a condition called a diaphragmatic hernia, characterized by part or all of the stomach penetrating into the chest cavity, leading to GERD.

In addition to being painful, gastric and duodenal ulcers can lead to perforations in the wall of the gastrointestinal tract. They can lead to bleeding, which can cause you to become anemic while your blood pressure drops. In the long-term, such ulcers also can lead to cancer. Additionally, there may be an association between H. pylori and a rare pregnancy complication called hyperemesis gravidarum (HG), which features extreme nausea and vomiting, much worse than the usual nausea and vomiting of pregnancy. GERD can develop, producing heartburn, sore throat, and cough, and if it continues can lead to erosive esophagitis and other severe esophageal complications, all of which can lead eventually to cancer. If you do develop erosive esophagitis, you may develop nausea and vomiting more than what is usual for pregnancy, and continuing into the later parts of pregnancy rather than being limited to early pregnancy. Erosive esophagitis can make it difficult to swallow and can suppress your appetite, leading to malnutrition. You also may develop sores in your mouth due to exposure of the mouth to stomach acid. You also may experience typical GERD symptoms, such as heartburn, sore throat, and cough.

It’s possible that H. pylori infection could increase the risk of insufficient growth in the womb, congenital malformations, and even fetal death, although more studies are needed to determine if such a risk is real. Gastric and duodenal ulcers do not affect the baby directly, but if you develop a bleeding ulcer, causing a blood loss, it can disrupt delivery of oxygen and nutrients to the placenta and the fetus, leading to insufficient growth, or fetal loss through spontaneous abortion (miscarriage). Erosive esophagitis can lead to an inability to swallow and lack of appetite that can lead, in turn, to nutritional deficiencies, disrupting fetal growth in the womb and contributing further to the risk of spontaneous abortion.

  1. pylori infection that underlies most stomach and duodenal ulcers is treated with triple therapy, meaning a combination of three medications. Sometimes four medications are used, in which case it is called quadruple therapy. The medications include a proton pump inhibitor, such as lansoprazole or omeprazole, which reduces acid production in the stomach. They also include one or two antibiotics, such as clarithromycin or metronidazole, and a bismuth-containing drug, such as bismuth biskal citrate. There has been some suspicion that clarithromycin could increase the risk of spontaneous abortion early in pregnancy, but generally the drug considered relatively safe, as is metronidazole. Most proton pump inhibitors are considered pregnancy safe, as are certain bismuth drugs. GERD and erosive esophagitis can be treated with medications called H2 blockers agents and or with proton pump inhibitors. Proton pump inhibitors, most bismuth drugs, clarithromycin, metronidazole, and most of the other antibiotics that that often are used against H. pylori, are thought to be safe during breastfeeding.

In some instances, such as when bleeding ulcers or erosive esophagitis develop, surgical procedures may become an option, or may be required. In most cases, such procedures can be performed through an endoscope, rather than through an open approach in which the abdomen or chest is cut.

David Warmflash
Dr. David Warmflash is a science communicator and physician with a research background in astrobiology and space medicine. He has completed research fellowships at NASA Johnson Space Center, the University of Pennsylvania, and Brandeis University. Since 2002, he has been collaborating with The Planetary Society on experiments helping us to understand the effects of deep space radiation on life forms, and since 2011 has worked nearly full time in medical writing and science journalism. His focus area includes the emergence of new biotechnologies and their impact on biomedicine, public health, and society.

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