Advancements in treatment of ulcers… exploring the myths
“Ulcers always occur in the stomach.”
An ulcer is a defect in a body surface. An injury damages the surface tissue, leaving a raw, inflamed depression or “ulcer.” Peptic ulcer disease refers to ulcers that occur in the upper portion of the gastrointestinal (GI) tract. The majority of ulcers occur in the duodenum, which is the first division of the small intestine. Although less common, they also occur in the stomach and in the esophagus.
“Ulcers can be diagnosed by x-ray.”
The medical history provides clues to ulcer disease from the characteristic symptoms. Persons suffering from an ulcer usually have gnawing or burning pain in the upper abdomen, often worse on an empty stomach and relieved by eating food or taking an antacid. Nausea, vomiting, loss of appetite, and weight loss may occur. Examining the abdomen through touch is unreliable although tenderness may be present when symptoms are acute, or if a complication such as rupture or obstruction has occurred. The most ominous symptom of an ulcer is vomiting blood or passing blood per rectum, which suggests the ulcer is bleeding. Such bleeding can become massive and life threatening. Slow unnoticeable bleeding may occur, resulting in anemia. Occasionally, bleeding with an absence of pain may be the only symptom of an ulcer. The bleeding may be the result of a history of NSAID use for arthritis or other painful condition.
Twenty years ago, an x-ray exam called an upper gastrointestinal series (UGI) was frequently done to diagnose ulcers. For this study, the patient swallowed a white chalky liquid containing barium, which will outline the esophagus, stomach, and duodenum on x-ray. However, this test lacks accuracy. Now the most reliable test for an ulcer is an EGD, esophagogastroduodenoscopy. For this procedure, done under light sedation, the physician inserts a lighted scope into the upper gastrointestinal organs. This scope gives the advantage of direct visualization of an ulcer, as well as the ability to obtain samples of tissue for analysis, a biopsy. This procedure is also used for treatment in the case of an ulcer that is bleeding. The presence of infection with H. pylori can be detected from biopsy as well as a blood test, breath test, and stool sample.
“Ulcers are caused by stress.”
Physicians once considered peptic ulcer disease as a psychosomatic illness caused by stress. Although emotional stress may aggravate the symptoms of an ulcer, we know now that peptic ulcers are usually the result of an infection by a bacteria, Helicobacter pylori (H. pylori for short), or due to irritation from drugs like the NSAIDs (nonsteroidal anti-inflammatory drugs). Peptic ulcer disease affects four million people in the United States, with 500,000 new cases yearly. Most affected persons are between 25 and 64 years old although it can rarely occur in teen-agers and children.
“Once an ulcer, always an ulcer”
ULCER CAUSING MEDICATIONS - the NSAIDs:
nonsteroidal anti- inflammatory drugs
Generic - Brand names
aspirin – Bayer, Ecotrin
diclofenac – Voltaren, Cataflam
ibuprofen- Motrin, Advil
naproxen- Aleve, Anaprox
MEDICATIONS USED TO TREAT
ULCERS - the acid blocking drugs
Generic - Brand names
The cure rate for ulcers is at least 80%. Treatment with an antibiotic to eradicate H. pylori infection, along with an H2 blocker or a PPI, quickly controls symptoms and will lead to resolution of the ulcer. An ulcer patient should discontinue any aggravating medications, such as aspirin; the patient should also quit smoking, and avoid alcohol use. No specific diet regimen is recommended but any foods known to aggravate symptoms should be avoided. Frequent small meals may be better tolerated until the condition is controlled.
About 25% of persons with ulcers experience serious complications such as bleeding, rupture, or intestinal blockage. These patients are usually older than 60 years and often are taking a NSAID. These complications often require surgery.
Ulcers can be prevented. H. pylori infection is common but only a minority of affected people develops ulcers. Mode of transmission is believed to be through food or water contaminated by persons already infected. Therefore, good hygiene by hand washing with soap and water after voiding and before food preparation and eating is important. Currently there is no vaccine for H. pylori infection. Avoidance of tobacco and alcohol are also protective measures.
NSAID use may trigger ulcer development in those infected with H. pylori as well as anyone who takes it often or regularly. Use should be limited to the lowest dose and shortest duration necessary. Occasionally physicians will prescribe an H2 blocker or PPI along with an NSAID. In cases where NSAID use is essential, the drug misoprostol (Cytotec) may be given concurrently. This drug protects the gastric surface from acid, thereby preventing ulcers; however, it can cause miscarriage if a pregnant woman takes it. Therefore, its use must be closely supervised.
Many people take aspirin to prevent a heart attack or stroke. If they are diagnosed and treated for an ulcer, they should talk with their physician and fully understand the risks and benefits of resuming or remaining off aspirin indefinitely. For mild, occasional pain such as a headache or backache, or fever, acetaminophen (“Tylenol”) is the safest choice for most people.
“Ulcers are treated by restriction of diet.”
In the past, physicians recommended a bland diet and frequent doses of antacids containing aluminum or magnesium hydroxide or calcium carbonate (“Tums”) for ulcer treatment. If this treatment failed to relieve symptoms, surgery was effective but created unpleasant side effects, chiefly diarrhea. Fortunately, treatment changed with the development of the H2 (histamine 2) blocking drugs, which effectively slow the production of acid in the stomach, thus stopping the painful burning of an ulcer. These drugs, such as ranitidine and cimetidine, revolutionized ulcer treatment and surgery soon became almost obsolete. These drugs were followed by the PPI drugs, (proton pump inhibitors), even more potent acid blockers. One of these, omeprazole, is now available over the counter.
The discovery that ulcers are caused by infection opened up a new avenue for treatment. If infection with H. pylori is confirmed, a ten to fourteen day course of antibiotics is prescribed. Several different regimens are advocated using different combinations of antibiotics including amoxicillin, tetracycline, clarithromycin, and metronidazole. An acid blocking drug is also taken with the antibiotic.
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"Advancements in treatment of ulcers… exploring the myths"
Dr. Aletha Oglesby practices family medicine at the Utica Park Clinic in Tulsa, Oklahoma. She has an interest in international health issues and has traveled overseas on numerous humanitarian medical trips....