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Digestive Disorders


Getting the Right Cure for Ulcers

A recent survey on ulcers by the Centers for Disease Control and Prevention (CDC) found that 60% of people still blame stress for ulcers, while only 25% are aware that the true culprit is a bacterium. That ulcers are caused by a bacterium called Helicobacter pylori clearly has been a hard pill for doctors and patients to swallow. Yet it is one of the major medical discoveries of recent times, with an impact on some 25 million Americans who will have peptic ulcer disease at some point in their lives. Research now shows that 9 out of 10 ulcers are caused by infection with H. pylori.

In theory, the cure is simple: antibiotics, combined with acid-suppressing medications. But putting the cure into practice has proven more complex, since most people remain unaware of the association between ulcers and infection. And as recently as 1995, only 5% of patients were being appropriately treated.

In response, the CDC recently launched a campaign to boost awareness of the link between ulcers and infection with H. pylori. The targets of the campaign are people age 60 and older, who are among the most likely to have chronic ulcers—and to rely on old-time treatments. The message: Even if you've suffered from ulcers for years, you can be cured.

Ulcer development

The stomach contains powerful acids that aid in digestion and possibly protect the body from ingested contaminants. But H. pylori, a corkscrew-shaped bacterium, can survive in this hostile environment. While it's not clear how we "catch" the bacterium, once it reaches the gut, it nestles into the stomach lining. There, it can quietly reside for years. But if the microbe bores through the layer of mucus that protects the stomach cavity from the acid that bathes it, an ulcer is in the making.

Ulcers, small crater-like sores, may develop in the lining of the stomach or the duodenum, the first section of the intestine. They cause a gnawing or burning pain in the upper abdomen (an area called the epigastrium). The pain is especially prominent when the stomach is empty, such as between meals and in the early morning. The pain may last from minutes to hours, and may be relieved by antacids. Nausea, vomiting, appetite loss, and bleeding (which may cause dark, tarry stools) can also develop.

Ulcers can be dangerous if left untreated. If the ulcer erodes into the stomach arteries, it can cause life-threatening bleeding. It can also perforate the stomach wall and spread infection. Each year, 40,000 people undergo emergency surgery from ulcer-induced bleeding. Ulcers also contribute to 6,500 deaths a year and raise the risk of gastric cancer.

Treating ulcers

For decades, ulcers were blamed on a high-stress lifestyle, coupled with a taste for spicy food, alcohol, and cigarettes. The remedy: a bland diet and a bland life. While stress and spicy food may make an existing ulcer feel worse, they do not cause the problem. With the discovery of powerful acid-suppressing medications called H-2 blockers (such as the over-the-counter Axid, Pepcid AC, Tagamet HB, and Zantac 75), stress took a back seat. By blocking the effects of histamine, these medications reduce production of stomach acid. This can successfully subdue an ulcer, and has led to a huge drop in ulcer surgeries.

Though not a cure, H-2 blockers, and the newer proton-pump inhibitors (such as Prilosec), still have an important place in ulcer treatment. (These drugs are also useful for alleviating heartburn.) Diagnosing and treating H. pylori is complex. Because it's not easy to tell if epigastric pain is caused by H. pylori, primary care doctors and many gastroenterologists treat about half of first-time ulcer sufferers with acid-cutting medication. Also, most people who harbor the germ have no symptoms. So chances are that a search for the bacterium, with a blood test or a breath test that measures one of its byproducts, will be positive. For reasons that are unclear, only 20% of H. pylori carriers actually develop ulcers.

The only way to determine for sure that someone has an ulcer is to perform an endoscopy. During this costly and somewhat uncomfortable procedure, a lighted, flexible scope is guided from the mouth and esophagus into the stomach and duodenum. The physician can see any ulcers, as well as biopsy them to test for infection or other problems. A barium swallow may also detect ulcers. In this procedure, a barium sulfate compound (visible on x-rays) is swallowed.

Doctors are loath to put patients through these tests needlessly. So, in an otherwise healthy person who has a first bout of pain suggestive of an ulcer, a four-week course of acid-suppressing medication may be worthwhile. At the very least, it will prevent the ulcer from worsening. If the symptoms resolve, the ulcer may be healed. If symptoms persist, worsen, or recur after treatment has stopped, further evaluation is in order. At this point, your doctor may order an endoscopy or barium swallow, or simply prescribe antibiotics. However, newer tests that can detect the bacterium with a breath test are making diagnosis of H. pylori infection quicker and less invasive.

Going for a cure

Many chronic ulcer patients once resigned themselves to a lifetime of acid-blocking medication. It is in this group that the discovery of H. pylori has had its greatest impact. Now, people with chronic, recurring ulcers can be cured. The treatment isn't simple, though it's certainly worthwhile. It requires 14 days of antibiotics, usually taken several times a day, along with an acid-suppressing medication to abet healing. If the antibiotics are taken as prescribed (which means finishing your prescription even if symptoms clear up)H. pylori can be eradicated-and ulcers cured-in 70% to 90% of cases.


From The Johns Hopkins Medical Letter: Health After 50, March 1998.


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Digestive Disorders

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