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PEPTIC ULCER DISEASE
SOME THINGS YOU SHOULD KNOW...
What is an Ulcer?
An ulcer is a sore or break in the lining of the
digestive tract. Most ulcers are found in the duodenum, the portion
of the small intestine just beyond the stomach. Ulcers may also
form in the stomach, and these are called gastric ulcers. The
terms duodenal ulcer and gastric ulcer refer to the location of
the ulcer. Peptic ulcer indicates the ulcer is due to the damaging
effects of acid and peptic, or digestive juices. In the past it
was felt that peptic ulcer disease was a chronic, recurrent disease
of unknown cause. An ulcer could be healed, but nothing could
be done to alter the underlying tendency to develop ulcers.
What Causes an Ulcer?
The stomach produces hydrochloric acid and enzymes
to help digest the food you eat. Normally, the stomach and duodenum
are protected from damage by these substances. In the stomach,
a layer of mucous covers the lining to protect it from the acid.
In the duodenum, fluid from the pancreas neutralizes the acid
before any damage occurs. An ulcer forms either because of too
much acid or some weakness in these normal protective mechanisms,
Many people with gastric ulcer produce normal or less than normal
amounts of acid. For this reason, we know that acid is not the
only factor involved in the formation of ulcers.
Helicobacter Pylori
Many patients develop ulcer disease as a result of
infection of the stomach lining with a bacteria called Helicobacter
pylori. This infection weakens the lining and may allow an ulcer
to form. These ulcers may heal with the usual antiulcer drugs,
but often recur when treatment is stopped. Antibiotics and Pepto-Bismol
may cure the infection and allow the ulcer to heal. In addition
to helping the ulcer heal, eradication of this infection may eliminate
the tendency to develop recurrent ulcers.
NSAIDs
Aspirin, ibuprofen, and many antiarthritis drugs
(Non Steroidal Anti Inflammatory Drugs or NSAIDs) weaken the lining
of the stomach and can cause ulcers. These drugs slow the production
of prostaglandins. These are chemicals which help protect the
stomach lining from damage by acid. Cytotec is a synthetic prostaglandin
which can prevent ulcers from occurring as a result of taking NSAIDs. The most common side effects of Cytotec are nausea and
diarrhea. PPIs (proton pump inhibitors--see below) are also useful in prevention
of ulcers in patients taking NSAIDs. A new class of drugs for arthritis
has been developed, called Cox-2 inhibitors. These drugs , Celebrex and
Vioxx, are significantly safer in terms of their effect on the stomach. Both
drugs have a lower risk of ulcers than the NSAIDs. Unfortunately, some patients
still develop stomach irritation and ulcers while on these drugs.
Gastrointestinal bleeding can also occur. When ulcers occur in patients on
these drugs, the drug should be stopped in order to aid in healing the ulcer. If
necessary for pain control, another drug should be substituted, preferably
acetominophen or other medications that will not irritate the stomach. If the
NSAID must be continued, continuous use of a PPI is often necessary.
What are the Symptoms of an Ulcer?
Ulcer pain is often described as a burning or gnawing
sensation. It is usually located in the upper abdomen or lower
chest. Typical duodenal ulcer pain occurs 30-60 minutes after
a meal and is relieved by eating again. Pain is usually worse
when the stomach is empty, and often awakens the patient from
sleep. Gastric ulcer pain generally worsens immediately with eating.
Nausea, vomiting, belching, loss of appetite, bloating, indigestion,
and heartburn are other symptoms which can occur with an active
ulcer. At times, an ulcer may cause no pain at all and is only
found when the patient presents with bleeding or other complication.
This occurs most often in older patients, especially if they are
taking NSAIDs.
Complications of Ulcer Disease
Black stools or vomiting blood indicate that the
ulcer is bleeding. Severe abdominal pain may be the result of
a perforated ulcer. Either of these complications is an emergency,
requiring immediate medical care. Scarring from recurrent ulcers
may narrow the lower end of the stomach or duodenum. If this causes
a blockage, surgery could be required. Many cases can be treated
by stretching open the narrowed area with a balloon at the time
of gastroscopy.
How is an Ulcer diagnosed?
The two tests used to identify ulcers are the upper
GI series and gastroscopy. The upper GI series is an x-ray done
after drinking barium to outline the stomach and duodenum. Gastroscopy
is looking inside the stomach with a lighted fiberoptic instrument.
Gastroscopy is the more accurate test. Between 10 and 25% of ulcers
are not seen on an upper GI series. Gastroscopy also allows diagnosis
of Helicobacter Pylori and other conditions which cannot be diagnosed
by x-ray.
If an ulcer is suspected, medication is often tried
before any testing is done. Patients who respond promptly may
not require any testing. If a person has weight loss, bleeding,
difficulty swallowing, or does not respond to treatment, then
gastroscopy should be performed.
Gastric ulcers pose a special concern. Small, early
stomach cancers can sometimes resemble an ulcer. For this reason,
most gastric ulcers should be biopsied. After 6-8 weeks of treatment,
gastroscopy is repeated to be certain the ulcer has healed. When
an ulcer does not heal, it raises the suspicion of cancer, even
if biopsies are negative. Surgery may be recommended for a non
healing gastric ulcer.
What Can I Do For My Ulcer?
Antacids are the first medication which is usually
prescribed by the physician or tried by the patient. If antacids
are not effective then stronger medication may be necessary. If
symptoms improve with antacids, it usually indicates they are
related to acid.
Most of the drugs for treatment of ulcers reduce
acid production in the stomach. These include Tagamet, Zantac,
Axid, and Pepcid. These are all H2 (histamine) blockers and work
by the same mechanism. They decrease, but may not completely eliminate
acid production, so antacids may still be necessary while taking
these drugs. Prilosec, Prevacid, Aciphex, and Protonix are more powerful drugs which
are capable of completely turning off acid production.
Carafate works by creating a protective coating over
the ulcer to protect it from acid and digestive juices, thus allowing
it to heal. It also helps to strengthen the defenses of the stomach
lining. Carafate may be more effective than H2 blockers in patients
who smoke.
Smoking
Smoking increases acid production and also weakens
the defenses of the stomach lining, probably by altering the circulation
in the lining. This delays ulcer healing and increases the risk
of recurrent ulcers. Smoking at bedtime is particularly harmful.
This is another excellent reason to stop smoking.
Diet
Most ulcer patients do not need to be on a special
diet. Diet was the only treatment available many years ago. Modern
medications are so effective that diet no longer plays a significant
role in ulcer treatment. Certain foods may cause pain or other
symptoms when you have an ulcer. Avoiding such foods is only necessary
for your comfort. These foods will probably not keep the ulcer
from healing. Coffee and alcohol may cause symptoms and delay
ulcer healing, and make recurrence more likely.
Is Stress Important?
Emotional stress rarely causes ulcers. Stress causes
increased acid production, and can also cause bowel spasms. These
can cause symptoms which might suggest an ulcer or other digestive
disorder. Testing is often necessary to identify the cause of
these symptoms.
Updated 2/20/2001
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