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 ulcersand
to rely on old-time treatments. The message: Even if you've suffered
from ulcers for years, you can be cured.
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.
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
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.