Ulcers,
Stomach Ulcer, Duodenal Ulcer, Peptic Ulcer, Bleeding Ulcer
Introduction: Although
people talk about "stomach ulcers", most peptic ulcers are actually
duodenal ulcers as they are located in the first part of the duodenum. When food
leaves the stomach it is saturated with hydrochloric acid and it is forced around
a C-shape
curve of the duodenum. It is at the beginning of this C-shape
wall of the duodenum that there is the highest risk of developing a duodenal ulcer.
Peptic ulcers can develop when the normal defense mechanisms of the mucosa lining
are undermined.
This can be from the chronic use of anti-inflammatory
medication for arthritis (NSAIDs). But it can also be from a bacterium
called H.pylori. This bacterium has developed a remarkable
ability to survive in the acidy milieu of the stomach and duodenum as it produces
several enzymes, which enable it to neutralize the acid in its immediate micro
surrounding. It also produces mucolytic enzymes, which are capable of breaking
down the superficial layer of the gastric and duodenal wall so that acid can now
do the rest and erode the wall of the mucosa. A peptic ulcer (or simply ulcer)
is a defect of the mucosal layer. The term "peptic ulcer" comes
from a time when physicians thought that ulcers would come from a combination
of acid and the enzyme pepsin, which would in combination lead to the ulceration
of the esophagus, stomach wall or duodenal wall. As pointed out above, we now
know that defense mechanisms also play a tremendous role as does a high secretion
of ACTH and cortisol in the case of stress ulcers, which leads to a further weakening
of these defense mechanisms. NSAIDs lead to a weakening of the repair mechanisms
in the mucosal wall and increase the acidity on a cellular level, which means
that the medication is "ulcerogenic"(can cause ulcers). Ulcers
come in different forms. With NSAIDs it is often a multitude of erosions.
These can be seen by gastroduodenoscopy. They are often located in the stomach,
are very shallow and measure a few mm in diameter. Then there is a chronic
duodenal ulcer, which may measure from 0.5 to 2 cm in diameter,
and where the bacterium H.pylori may play a role as a chronic propagator. It is
clear that any defect of the mucosa, which is full of blood vessels, can lead
to bleeding ulcers.
Ulcer
symptoms: There is a wide variety of symptom presentation
with ulcers. It can be that a person only has a mild stomach ache in the mid upper
abdomen (called the "epigastric area"). To some it feels like a hunger
pain, to others like a burning or gnawing pain. This pain might disappear
with food or milk, only to awaken the person in the middle of the night again.
It can go on like this for several weeks. Usually by that time the person sees
a physician and complaints that there is something wrong. Only about 50% of patients
present with these typical complaints, the other ones have atypical symptoms.
With a gastric ulcer the symptoms are such that
eating something does not relieve the pain, but aggravates it. If the ulcer is
at the outlet of the stomach (the pyloric area), the swelling in the area can
obstruct the outflow of food and the symptoms are nausea, bloating and vomiting.
Duodenal
ulcer A duodenal ulcer is causing a more prominent
abdominal pain and tends to be more chronic. It happens first in the mid morning,
but gets better with food. Only 2 or 3 hours after food intake the pain is back.
It may get better with antacids, but this is short lasting. The typical awakening
with pain in the middle of the night as mentioned above, is characteristic for
duodenal ulcer.
Gastric
ulcer and gastric erosions In case of multiple
gastric erosions or a deep duodenal or gastric ulcer
where a blood vessel got eroded, there can be profuse bleeding with
the patient throwing up coffee ground type clotted blood (bleeding
ulcer). There also may be diarrhea with melena type, black
stool, which is from digested blood. If the ulcer perforates, which is nowadays
less common, there will be acute abdominal symptoms with a rigid abdomen as well
as possible symptom of shock. These last scenarios are life threatening situations,
which need quick attention to this patient in a hospital setting with the help
of a surgeon.
Diagnosis:
The history gives the physician a good indication of what diagnosis to expect.
However, this assumed diagnosis needs to be confirmed. The physician may
order a barium swallow, which may or may not show the ulcer. As there are so many
projections, it could easily be that there is one corner, which was overlooked
by this x-ray method. The most efficient way to diagnose an ulcer is by endoscopic
procedure, called by many names: Gastroscopy (looking into the stomach),
gastroduodenoscopy (= looking into stomach and duodenum), panendoscopy ( "pan-"
means "all" to express that the physician is looking at all of the upper
gastrointestinal tract including the esophagus, stomach and duodenum). Diagnosis
by endoscopy is now the established way to diagnose ulcers. The reason for this
is that with endoscopy the gastroenterologist can do more than just look. This
method is superior to X-ray images, because the specialist can take samples through
channels in the fiberoptic instrument. Bleeders can be cauterized under vision.
Multiple biopsies can be taken during the same procedure in case an ulcer
looks suspicious of cancer. Minor surgery can be done such as removal of polyps
or banding or sclerosing esophageal veins that bleed. The endoscopist can also
take pictures of the findings, which can be useful as a teaching tool to give
to the patient or for the physician to document a certain finding on a specific
date as a baseline for future comparison. Like with any procedure there is a complication
rate, in this case about 0.2 % of all procedures, and a mortality rate of 0.03
%. In the elderly patient friable tissue may be a cause for complications and
in an end stage liver cirrhosis patient there can be a rupture of some dilated
esophageal varices when the endoscopic instrument passes into the stomach. This
can cause profuse bleeding, which is extremely difficult to control.
H.Pylori
tests To test for the possibility of H.pylori
infection of the mucosa, two reliable tests are available. The one
test is the rapid urease test, which can test samples
taken by endoscopy with a special indicator paper. The other test is the urea
breath test utilizing carbon-13 or carbon-14 labeled urea. This
is administered as a capsule by mouth and breath samples are taken 20 to 30 minutes
after ingestion, which determines how much of the urea was digested by H.pylori,
as the amount of liberated labeled carbon dioxide is proportional to this process.
Sensitivity and specificity of this sophisticated test is more than 90%, which
means that it is remarkably reliable.
Treatment: The
treatment is tailored according to the underlying problem. If there are recurrent
peptic ulcers in the lower esophagus, the stomach or the duodenum, then there
is a high probability that H.pylori is present and appropriate testing should
be made. In the case of a positive test, the patient should receive a triple
therapy regimen, which consists of a proton pump inhibitor combined with two antibiotics
(see Ref. 1 for one such regimen). The one year relapse rate used to be more than
60% for gastric and duodenal ulcer patients after cessation of traditional anti
ulcer therapy. After triple therapy for H.pylori the recurrence rate is less than
10% after one year, clearly supportive of the idea that H.pylori plays a role
in the more chronic ulcer cases. Most of the ulcers, however, are not due to H.pylori.
They may simply be due to the fact that the balance of ulcerogenic factors versus
body defense mechanisms was tilted in the ulcerogenic direction. Reduction of
alcohol intake, quitting to smoke (or at least cutting down to a minimum) and
adding an H2-blocker will often help restore the balance within a few days. Another
useful agent in this scenario are the cytoprotective drugs. One such medication,
which has been around for some time, is sucralfate (brand names: Sulcrate, Carafate)
which binds to the surface of the mucous membrane and protects against noxious
substances(see Ref. 2). Another such cytoprotective medication is misoprostol(
brand name: Cytotec). The H2-blockers are now widely available over the counter
in pharmacies. Some common H2-blockers are: the first one to be developed
was cimetidine (brand name: Apo-, Gen-, Nu-,Novo-, Nu- and PMS-Cimetidine, Peptol,
Tagamet). Then ranitidine (Zantac, Alti-, Apo-, Gen-Ranitidine, Novo-Ranidine,
Nu-Ranit) came on the market. Since then famotidine (brand name: Pepcid, Ulcidine,
Maalox H2 Acid Controller and generic preparations) has been added as well as
nizatidine (brand name: Axid, Apo-Nizatidine). No doubt, there will be more added
in this lucrative market. However, the problem is not that one of these H2- blockers
would be better than another, the challenge is to find out why the patient does
not respond to one or two courses of therapy. The proton pump inhibitors
(PPI) are the strongest anti-acid medications. There is an FDA approved
non-drug method available, IceWave
patches from Lifewave, which could be used in chronic cases in conjunction
with the other methods described to control pain. These pain patches are mentioned
in the book "Breakthrough" by Suzanne Somers (Ref. 34) where newer insights
of antiaging medicine are also reviewed. Although the patches are placed over
acupuncture points, there are no needles involved. Nanotechnology, a newer technology,
was used in the manufacturing of these patches and infrared (heat) waves from
body heat are utilized to stimulate an acupuncture point, which modifies pain
perception and reduces pain to half or less. Medically this would be considered
an excellent pain reliever. For more info on the patches see the IceWave patches
from Lifewave link above (click "products"). In the US a 5 pack of the
IceWave spray is available that can be directly sprayed onto the skin in the area
where the pain is located.
Ulcer
Look-Alikes It is up to the physician to rethink the "differential
diagnosis". Is it really a peptic ulcer? Or is this patient one of those
more chronic cases with H.pylori and perhaps this should be tested again? If not,
why is the patient still having symptoms? There could be an underlying Zollinger-Ellison
syndrome, a rare condition where benign tumors in the pancreas
produce gastrin, which in turn is a powerful stimulus for acid production in the
stomach. In rare cases of very chronic H.pylori infection, a gastric lymphoma
(MALT
lymphoma) can develop in the gastric erosions or ulcers.
The gastroenterologist will have to carefully follow this condition with serial
endoscopies and biopsies while the patient is being treated with combination therapy.
Some of these cases get cured with anti H.pylori therapy, but others progress
despite therapy and have to then be referred to an oncologist for chemotherapy
or radical surgery. When gastric outlet problems have developed from chronically
scarred ulcers in the pylorus area (gastric outlet), a general surgeon with experience
in stomach surgery should be consulted. There are some procedures, called Billroth
I and II, which were originally developed for intractable ulcers when H2-blockers
were not yet available. Sometimes a patient needs one of these procedures done
or else a selective vagotomy. The gastroenterologist and surgeon can advise you
further. Life style changes, although still important, are not as crucial as in
the past since the introduction of H2-blockers and the proton pump inhibitors. |
