WHAT is a stomach ulcer?
A stomach ulcer, also known as a gastric ulcer or peptic ulcer, as the second part of the name suggests, is a “wound, an open sore,” in the mucosa (inner wall) that penetrates the muscle layer of the stomach or of the duodenum (the first part of the small intestine attached to the stomach). The main symptom is typically burning, gnawing or hunger pains in the epigastric (stomach pit) area, often relieved by food or antacids.
What causes a stomach ulcer?
There was a time when stomach acid hypersecretion (due to stress, spicy food, alcohol, tobacco, etc.) was universally accepted in the medical community as the cause of gastric ulcer disease. A brilliant Australian physician, Dr. Barry James Marshall, who was ridiculed by his colleagues in the scientific world for postulating that peptic ulcer disease was caused by a bacterial infection (Helicobacter pylori organism), ingested the organism himself and developed acute peptic ulcer disease, proving to the medical community in 1984-85 that his postulate was correct. Multicenter studies following his treatise proved that he was right. Marshall has radically revolutionized the understanding of the disease, its diagnosis, and most importantly, its treatment.
How did this change the treatment?
Before Marshall’s discovery, gastrectomy (cutting part or whole of the stomach out) was very common as a treatment for peptic ulcer disease. Today, with appropriate triple antibiotic therapy, peptic ulcer disease is effectively managed, transforming a former surgical disease to a medical disease. Occasionally, however, surgery may still be needed for severe bleeding peptic ulcer disease but this is not as common today, with proper antibiotic treatment.
How does the H. pylori bacteria cause ulcers?
There are theories as to how this organism causes peptic ulcers. H. pylori produces urease, an enzyme that catalyzes urea to ammonia. The ammonia, which enables the bacteria to survive the acidic environment in the stomach or duodenum, also causes erosions into the mucosal lining and causes epithelial damage. Cytotoxins from the bacteria also damage the epithelium. The organism also produces mucolytic enzymes (protease and lipase) that lead to the degradation of the mucosa, making the epithelium more vulnerable to acid damages. Also, cytokines produced in response to the inflammation may damage the mucosa and lead to ulcer formation.
Do aspirin and arthritis medications cause peptic ulcers?
Yes, aspirin and NSAIDs (non-steroidal arthritis medications) are known to cause peptic ulcers and severe bleeding. The irritation is both local (on the mucosa of the stomach) and systemic (inhibiting prostaglandin production adversely affecting mucosal defenses, and thinning the blood), leading to ulcerations and hemorrhage.
Is alcohol bad for those with peptic ulcers?
Yes, most definitely. The same thing is true with cigarette smoking, chocolate, tea, coffee, spicy foods, which are also irritants for the stomach. They increase hydrochloric acid production in the stomach, which bathes and damages the stomach mucosal lining, making it more susceptible to the H. pylori bacteria. Milk, which used to be prescribed decades ago as a part of peptic ulcer therapy, is now avoided since it also causes “rebound” acid production and slows ulcer healing.
Do children develop peptic ulcers?
Yes, but it is relatively uncommon among children compared to among adults. About 15 percent to 20 percent of abdominal pains in children is due to peptic ulcer. Most primary peptic ulcer disease in children are seen in the ages between 8 and 17. The pains usually wake the child from sleep, and are sometimes aggravated by eating. About 25 percent of these pediatric patients have bleeding ulcers. Peptic Ulcer due to H. pylori infection is not very common in children. Any persistent abdominal pains in children warrants prompt medical consultation.
How is the diagnosis made?
After a good history-taking and physical examination, the physician can already make a strong presumptive diagnosis of peptic ulcer disease. Fiberoptic gastroscopy (a lighted magnifying flexible scope passed through the mouth down to the stomach used to view its inside) is today a part of the state-of-the-art investigative tool in the diagnosis of peptic ulcer disease or malignant tumor (cancer) of the stomach. Bacterial cultures may likewise be taken to check the presence of Helicobacter pylori organism. Through the scope, cytology (microscopic examination of cancer cells), cultures for bacteria and tiny biopsies may be done to make a diagnosis.
What are the possible complications of peptic ulcer disease?
Hemorrhage is the most common complication, leading to vomiting of blood or blood in the stools, coloring them black, anemia, weakness or even dizziness and syncope (passing out spells). Perforation of the wall when the ulcer “eats” the entire thickness of the stomach wall, creating a hole, allowing stomach contents to spill into the abdominal cavity causing peritonitis (severe inflammation and infection). Inflammation from peptic ulcer involving the stomach outlet into the duodenum can cause spasm and scar that blocks this outlet, causing vomiting. Stomach cancer has been reported 3 to 6 times more common in peptic ulcer due to H. pylori infection. Gastric lymphomas have also been linked to this bacteria.
Are TUMS and ROLAIDS safe for ulcer pains?
Tums, Rolaids and other over-the-counter self-proclaimed “treatment” for peptic ulcers or hyperacidity are quite popular among lay people. These will not cure hyperacidity or peptic ulcers. If the symptoms persist, it is most prudent to seek medical consultation. Remember, peptic ulcers can have life-threatening complications if not properly treated, and cancer of the stomach must be ruled out as the cause of the symptoms.
What is the treatment?
For peptic ulcers caused by the H. pylori infection, the combination of bismuth, metronidazole and tetracycline cures about 80 percent of this infection, leading to ulcer healing. Proton pump inhibitors (PPI) capsules, H2 Blocker pills, and antacids are other adjunctive modalities of the comprehensive regimen many physicians use in conjunction with the triple antibiotic therapy above.
How about surgery?
Surgery used to be very common for peptic ulcer disease. With the discovery of H. pylori infection as the major cause of peptic ulcer disease, surgery has declined precipitously. Today, surgery is relegated to the complications, like uncontrollable bleeding, perforation, gastric outlet obstruction, suspected cancerous peptic ulcer, and symptoms refractory to medical treatment. With this new triple antibiotic therapy, even the complications of peptic ulcer disease have been reduced significantly.
Philip S. Chua, MD, FACS, FPCS, Cardiac Surgeon Emeritus in Northwest Indiana and chairman of cardiac surgery from 1997 to 2010 at Cebu Doctors University Hospital, where he holds the title of Physician Emeritus in Surgery, is based in Las Vegas, Nevada. He is a Fellow of the American College of Surgeons, the Philippine College of Surgeons, and the Denton A. Cooley Cardiovascular Surgical Society. He is the chairman of the Filipino United Network – USA, a 501(c)(3) humanitarian foundation in the United States. For more data, visit philipSchua.com; Email: firstname.lastname@example.org