by Rick Alan
Until recently, ulcers were believed to be caused by stress, anxiety, smoking and/or a diet rich in spicy foods. However, recent research has demonstrated that most ulcers are caused by a spiral-shaped bacteria known as Helicobacter pylori (H. pylori). While generally not life threatening, stomach and duodenal ulcers can be quite serious if not treated properly, resulting in more than 40,000 surgeries and as many as 6,000 deaths each year.
Anatomy of an ulcer
When we eat, food passes down the esophagus and into the stomach, where hydrochloric acid and pepsin (an enzyme) begin the digestive process. Next, food passes to the duodenum? the upper portion of the small intestine? where the digestive process continues. An ulcer is a sore or lesion that forms either in the lining of the stomach or in the lining of the duodenum.
While the entire process by which H. pylori causes ulcers is not yet fully understood, researchers do know that:
- H. pylori bacteria can live in the stomach because it produces an enzyme that neutralizes the corrosive effects of stomach acid.
- H. pylori's shape allows it to penetrate the protective mucous layers of both the stomach and the duodenum.
- H. pylori can also weaken the stomach and duodenum by attaching to cells therein, further weakening the stomach and duodenum's defense system.
- Only 5%-10% of young people have H. pylori in their digestive tracts, but 50% of people 60 or older have H. pylori.
- Not everyone who harbors the H. pylori bacteria will develop an ulcer.
An ulcer that goes untreated can cause several problems in the abdomen, including internal bleeding of the stomach walls, perforation (a hole) in the stomach or duodenum allowing food and bacteria to spill into the abdomen and cause infection, or an obstruction of the opening between the stomach and duodenum.
Discovering the causes of ulcers
The story behind the discovery of the H. pylori bacteria and its relationship to ulcers is an unusual one. In 1982, Drs. Barry Marshall and Robin Warren?two Australian researchers?detected H. pylori in the stomach lining of people suffering from gastritis. When further study demonstrated the presence of H. pylori in nearly 100% of patients with duodenal ulcers and 80% of people with stomach ulcers, Marshall and Warren proposed that H. pylori might be the cause.
When their hypothesis met with a great deal of skepticism, Marshall ingested a teaspoonful of H. pylori bacteria. Within 24 hours, he developed severe gastritis. Further research by Marshall, Warren, and others established that H. pylori does in fact cause 50% of stomach ulcers and 90% of the much more common duodenal ulcers.
Of the 10%-20% of ulcers that are not caused by H. pylori bacteria, virtually all are caused by large doses of NSAIDs?non-steroidal anti-inflammatory drugs such as ibuprofen, aspirin and naproxyn sodium. NSAIDs irritate the lining of the stomach and duodenum, and over time, can result in the development of an ulcer.
The telltale burn
The most common symptom of an ulcer is a chronic burning pain in the abdomen, usually between the breastbone and the naval. Often recurring in the middle of the night, upon waking and/or two to three hours after a meal, this pain is sometimes relieved by eating. Less common symptoms include:
- Nausea
- Vomiting (can be bloody or appear like coffee grains)
- Loss of appetite
- Loss of weight
- Bloody or black stool (caused by bleeding from the ulcer)
- Weakness (caused by bleeding from the ulcer)
Diagnosis
It's important that ulcers be properly diagnosed, because the symptoms common to ulcers can also be caused by a number of other conditions. In addition H. pylori and NSAID-caused ulcers are treated somewhat differently. There are two tools for diagnosing an ulcer:
- Upper GI series - x-rays of the esophagus, stomach, and duodenum (75%-90% accurate in diagnosing ulcers)
- Endoscopy - an examination of the esophagus, stomach and duodenum via a small, flexible, tube-like instrument inserted through the patient's throat (approximately 95% accurate)
Once an ulcer is diagnosed, a test for the presence of H. pylori is done to determine whether the ulcer is caused by bacteria or NSAIDs. These tests include a blood test, a breath test, or a tissue test.
Removing the offending agent
Treatment involves removing the underlying cause of the ulcer and healing the ulcer. Dr. Stanley Rosenberg, gastroenterologist at Boston's Beth Israel Deaconess Medical Center explains: "If NSAID use is suspected as the cause, especially if no H. pylori bacteria is detected, the patient will be directed to stop all NSAID use and to take a substitute medication, such as prescription strength Tylenol. In more severe conditions, [the patient may be prescribed] steroid-based anti-inflammatory medications, or, more recently, COX2 inhibitors a new class of anti-inflammatory drugs that are less likely to cause ulcers."
However, Dr. Rosenberg continues, if H. pylori is suspected as the cause, antibiotics are the first line of treatment. The most effective treatment is called triple therapy. It involves taking two antibiotics to eliminate the bacteria usually metronidazole and tetracycline daily for two weeks, along with an acid suppressor or a stomach lining shield. This method works effectively over 90% of the time and works to kill the bacteria, heal the ulcer and prevent recurrence. It may cause a number of side effects, including:
- Stomach upset
- Nausea
- Diarrhea
- Vomiting
- Dizziness
- Yeast infections in women
An alternative antibiotic regimen uses omeprazole, which reduces the acid, in conjunction with amoxicillin. This causes fewer side effects, but is less effective (80%).
Healing the ulcer
Dr. Rosenberg explains that one of a number of drugs can be prescribed that either reduce or temporarily eliminate stomach acid while the antibiotics kill the bacteria, in addition to soothing and healing the ulcer. These include:
Histamine H2 blockers- These drugs, including Pepcid, Zantac, and Tagamet, are given for up to six to eight weeks. They suppress the amount of acid produced in the stomach by blocking histamine a substance that causes the stomach to produce acid.
Acid pump inhibitors- Stronger than H2 blockers, these drugs, including Prilosec and Losec, stop the stomach's production of acid by shutting down the stomach's acid pump. Such drugs are generally only prescribed for more severe ulcers for only a short period of time.
Mucosal protective drugs- These drugs, including Carafate and Cytotec, coat the stomach and duodenal lining, thus protecting the lining from stomach acid damage.
Finally, many patients also take antacids to neutralize stomach acid and/or Pepto bismol, which both coats the stomach and duodenum lining and helps to fight the H. pylori bacteria.
Steering clear of ulcers
To prevent NSAID-caused ulcers, try to avoid using NSAIDs in large doses for long periods of time. Unfortunately, researchers don't yet know how to prevent the development of H. pylori bacteria in the digestive tract. Some recommended precautions are to wash hands after using the bathroom and before eating and to make sure to drink water from a clean source. The development of an H. pylori vaccine is currently being studied.