Today, we will take a look at PEPTIC ULCERS.
WHAT IS A PEPTIC ULCER?
A peptic ulcer is a sore on the inside lining of the stomach, duodenum (the first part of the small intestine), or the esophagus (gullet). When you think about it, it’s just as when you have a sore on your leg or foot or other parts of your body; it is usually really an ulcer.
We’ll get to the causes and aggravating factors in a while. Just allow me to mention that an ulcer is designated by its location. An ulcer in the stomach is a GASTRIC ulcer, one in the early part of the small intestine is a DUODENAL ulcer (most common) and one in the gullet is an ESOPHAGEAL ulcer.
HOW DOES IT HAPPEN?
When there is a breakdown of the inside lining of these areas, the mucous layer, gastric acid and pepsin produced by special cells in the stomach to digest our food, attack these areas and a sore forms. Don’t think that because they are inside our bodies that these acids are mild stuff. They are strong, and they have to be, because they have to kill a lot of harmful stuff that enter our mouths.
WHAT ARE THE SIGNS AND SYMPTOMS?
The most common is pain. It’s mostly a burning pain but different persons will describe it differently. It is caused by the ulcer itself, but also when it is attacked by gastric (hydrochloric) acid. It is mostly in the epigastrium, that is the area between your navel and the end of your chest bone. The pain may last for minutes to hours, and is worse on an ‘empty stomach,’ if the ulcer is in the small intestine. It tends to flare up at night, typically at 1:00 or 2:00 in the morning. It is temporarily relived by taking in certain things that buffer acid, or by acid-reducing drugs. And it may last days to weeks. A lot of people have gotten relief by drinking milk at night, but some research says that the calcium in milk stimulates acid production and makes matters worse. All I can tell you is the science, folks, you can do what you wish with it. By the way, an ulcer in the stomach feels worse after eating.
OTHER SYMPTOMS, SIGNS
Less commonly, there is hematemesis, or vomiting blood. It can be red blood, but most often, because it has been altered by stomach acid, it comes up as a coffee-grounded color. Blood can also come out at the other end, in what we call melena stools – black, tarry, hard – to – flush stools. If the transit through the system is fast, then it will come out as bright red. Of course, it will often make you anemic. There can be nausea and vomiting, weight loss, and chest pain.
WHAT IS THE CAUSE?
Peptic ulcers are actually caused by bacteria; cock-screw shaped ones called Helicobacter pylori (or just H.pylori). They live and multiply in the mucous layer of the affected area and initiate the process whereby acid and pepsin do their work. They are found in food and water and can be passed from person to person by close contact such as kissing (saliva). Have an ulcer? Starve yourself from some “sugar” for a while, in the interest of your partner.
Another factor lies in drugs we call NSAID’S which include Ibuprofen (Motrin, Advil, Naproxen (Aleve), Aspirin and others. They inhibit a substance we call cyclo-oxygenase, which is a step toward production of prostaglandins, which in turn protect the mucous layer of the gastrointestinal tract. Many of you will remember me asking you if you’ve ever had problems with your “stomach” such as ulcers or gastritis, so that I don’t give you medication to worsen or reactivate it.
Smoking is a causative factor, as is alcohol. Is there nothing bad that alcohol is not involved in? Stress can aggravate an ulcer, so you want to be mindful of this.
HOW IS A PEPTIC ULCER DIAGNOSED?
Usually a doctor will order a Barium meal, or a Barium swallow. This is a special X-Ray, where you are given something to drink which, as it goes down and down, X-Rays will show how it coats your system and if there is an ulcer, it may show up. But not always, which is why endoscopy is sometimes done, before or after, in fact. This is the tube with the camera which goes down your gullet, into your stomach and early duodenum. Any thing there is seen directly, and a piece can be taken from a suspicious or definite area to test for H.pylori.
Speaking of H.pyloric, a blood test can be done to test for antibodies to it. The problem is that the antibodies may persist for a year or more after it is gone, so in order for us not to keep treating you based on a positive result when nothing may be there, we can have you do a Breath Test, believe it or not, to evaluate the effectiveness of treatment. There is also a stool Antigen Test to monitor the effectiveness of treatment.
WHAT ARE THE COMPLICATIONS OF A PEPTIC ULCER?
As we alluded to before, hemorrhage or bleeding can occur. This can never be good.
The ulcer may penetrate to the other layers of the area involved.
Obstruction of food and liquid through the channel from the stomach to the intestine can occur because of scarring from a long – standing ulcer. This causes frequent vomiting and a feeling of fullness long after eating, and means surgery might be the best option.
Perforation, meaning that the ulcer just bores a hole right through its structure, also meaning surgery, because we’re talking serious bleeding and other complications.
Can you tell by now that you don’t mess with an ulcer?
WHEN SHOULD YOU CHECK THE DOC?
If you keep going to the Pharmacy week after week, to get your antacid, but only get temporary relief, time for a visit to the office. Of course, you have enough sense to know that any sight of blood, fresh or otherwise, means the same thing.
HOW IS AN ULCER TREATED?
The treatment has to involve a two-pronged attack.
• We have to kill the bacteria,
• We have to reduce acid.
We kill bacteria with antibiotics, and to kill H.pyloric, we have different strategies and antibiotics. We may use three for two weeks, four for one or two weeks, and so on, with what are called H2 blockers, such as Zantac, or Proton Pump Inhibitors such as Losec, Nexium, Prevacid, and so on. These are acid – reducers, not eliminators, because we need some acid. We may also use substances containing Bismuth in the strategy with antibiotics and those acid-reducers I just mentioned.
They seem to inhibit H.plori’s activity. Pepto-Bismol is one.
ULCERS FAIL TO HEAL
• Because patients don’t use their medication AS PRESCRIBED.
• H.pylori becomes resistant to antibiotics.
• People continue to use Advil, and Aleve and others.
• People continue to smoke and drink.
Rare causes include
• Zollinger – Ellison Syndrome, which causes ulcers throughout the digestive system, heart problems, etc…
• Infection with bacteria other than H.pylori
• Chron’s disease or other digestive tract disease.
SURGERY: WHEN NECESSARY?
When the complications occur, and when there is relentless pain and when medicine seems to fail. There is what is called truncal vagatomy, where the vagus nerve, playing a role in acid production, is cut. There is selective vagatomy, where portions of the nerve going to particular parts of the stomach are cut, and then there is highly selective vagatomy where the nerve fibers going to the actual acid- producing cells are cut.
HOW TO HELP YOURSELF
Abstain —–From alcohol and tobacco, from foods that increase pain, from NSAID’S (Advil, etc…) and control reflux of acid from your stomach into your esophagus. We’ve talked about this and many of you have got the handout.
See you next week.
Dr. Emanuel, based in the Commonwealth of Dominica, has been an educator of medical professionals, in training and the public, for over 20 years.