Peptic Ulcer



What is Peptic Ulcer?

A Peptic Ulcer means that there is an invasion of the lining of the stomach or duodenum by the powerful hydrochloric acid and pepsin produced by the glands of the stomach wall. It is ironical that the organ producing these juices should in turn be subject to destruction by the product it manufactures.



It is estimated that ten per cent of people have a peptic ulcer during their lifetime. It is most common among young and middle-aged adults, and men are affected four times as often as women. Diagnoses based on endoscopic and X-ray examination indicate that there is a 9:1 preponderance of duodenal over gastric ulcers although other reports claim that at autopsy there is an equal incidence. The exact cause is not known. Why some succumb to the action of the gastric juices while others do not is remarkable. About 15 per cent of patients with gastric ulcers either have, or did have, a duodenal ulcer as well, indicating that there must be some common etiology.

There is increasing evidence of an inherited factor as gastric ulcers occur three times more commonly in relatives of patients who also have a gastric ulcer. Recently it has been shown that a large proportion of ulcer patients belong to blood group 0. The role of stress is still equivocal. A peptic ulcer is anecdotally considered to be the hallmark of success in the striving businessman. However, in many surveys, the results of this are still left in question. Social status has often been claimed to play a part, and certainly in the overall picture, gastric ulcers tend to occur more often in those of poorer social and economic status.



Ulcers appear to be more common in patients who are on certain forms of medication. Patients on regular and high intakes of Salicylates (simple aspirin and compounds) are more likely to develop them. Indeed, this is a common cause of gastric hemorrhaging, and is not without its dangers in children, to whom aspirin compounds should not be given (there are other less dangerous analgesics on the market). The anti-arthritis drugs, called the Nonsteroidal Anti-inflammatory Drugs (NSAI Ds for short) which are widely used by arthritics, are well-known possible causes. Patients taking Corticosteroids are also at high risk. Although the overuse of alcohol, tobacco and condiments has often been cited as a possible cause, this has not been proved to the satisfaction of all researchers.

The sensible approach for the person with an ulcer is attacking all possible causes and rectifying as many as possible, whether they be substantiated or not. While every suggested cause will certainly not apply to everyone, there may be applications in individual cases well worth taking note of and following.



Diagnosis of peptic ulcer is usually made after examination, suggested by the history. Sometimes the first sign of an ulcer is a massive hemorrhage, with blood suddenly pouring from the mouth as well as abdominal discomfort and general weakness and shock. Investigation for an ulcer is primarily dependent on X-ray and endoscopic examination. The barium-meal radiograph will pick up a large number, but a negative result does not mean that an ulcer is not present.

The development and use of the pliable fiber-optic endoscope has revolutionized diagnosis of all conditions of the stomach, duodenum, lower esophagus, and in fact nearly all of the intestinal system. This soft, narrow, extremely maneuverable device can give the operator a direct view into all parts of the stomach and duodenum. No area is invisible, for the leading head can be turned and twisted so as to enable a view of every part.



This makes diagnosis very accurate. It may also rapidly pick up bleeding points, and it can assess progress of treatment when a series of examinations is carried out at later dates. Today, a combination of X-ray and endoscopy form the two chief methods of accurate diagnosis.

Peptic Ulcer Symptoms



Peptic ulcers, whether gastric or duodenal, produce similar symptoms, pain is the chief one. Typically it comes on during the morning and becomes worse toward evening. It is usually localized in the epigastrium, the area just below the far end of the breastbone. The pain may awaken the patient around 2 am and may be eased, or aggravated by food. Alkaline preparations usually bring quick relief in ten to fifteen minutes. Symptoms may disappear only to recur later on, but remissions have been known to last for days, weeks, months and even years. The symptoms run a very fickle course and may occasionally include vomiting. This may be highly acid in nature, and may bring considerable relief. Sometimes water brash occurs; this is an accumulation of saliva at the lower end of the esophagus, which may be regurgitated into the mouth.

The chief complications that may follow on from an ulcer are perforation of the wall of the stomach or duodenum, erosion of a major blood vessel, giving rise to sudden and profuse hemorrhage or, later, scarring near the pylorus (the far end of the stomach), so narrowing the stomach outlet into the duodenum. In some cases, cancer may develop in a chronic gastric ulcer.

Peptic Ulcer produces another type of surgical emergency. This however is more common with duodenal ulcers. A blood vessel in the wall becomes eroded and may bleed violently, producing massive blood loss. This may be vomited up (haematemesis), or passed through the bowel (melaena). When vomited, it may come as bright red blood, or if it has been in the stomach for a period of time, may have the appearance of coffee grounds.

By the time the blood has passed through the bowel it is often altered and may appear black, and be tarry in consistency. Often the blood loss produces severe shock and, especially if this occurs a second time in older patients, it may be fatal.



Peptic Ulcer Treatment

Immediate admission to hospital as a surgical emergency is essential. Here, immediate assessment of the patient and blood transfusion are the most likely factors that will preserve life. After this, an assessment as to the needs for surgical intervention should be made and appropriate action taken.

In recent years there have been many changes in treating peptic ulcers as new information is discovered, new medication developed, and an entirely new system worked out. Long-term “cure” is now believed possible. The present suggested routine, now advised by most doctors, will probably change again as results of current treatment regimens are assessed over the next several years.

Kill the Germ. By serendipity, a Perth doctor discovered an organism in the stomach of patients suffering from peptic ulcers. It was the sheer chance observation of a stomach “culture” having been left in the incubator for longer than usual due to a holiday weekend. By taking a potent brew of the “germ” the doctor developed a severe ulcer himself, which led him to believe it had caused the ulcer, and not necessarily excess acid, which had been the belief until this time.



Although scoffed at by colleagues at the time, he worked on his theory and found a combination of chemicals (including antibiotics) that quickly and permanently destroyed the germ. These are an antibiotic (a synthetic penicillin, often amoxicillin or tetracycline), metronidazole (Flagyl), and a bismuth product called De-Nol. Taken for several days or weeks, the germ was permanently killed.

Today, in many centers (and certainly in America), this is now considered the standard form of treating peptic ulcers. The germ, it seems, in the presence of acid, produces another chemical with the capacity to destroy the cells of the stomach or duodenal wall. It is commonly referred to as “triple therapy,” and may be given in conjunction with the acid-suppressant medication.

Doctors had believed excess acid was the chief cause of ulcers. A large range of powerful acid-suppressant forms of medication have been produced and more are continually being developed, while others are in the developmental pipeline. The two main groups are the “Histamine H2-Receptor Antagonists” and, more recently, the so called Proton-Pump Inhibitors. The first group includes Cimetidine (Tagamet), the first to be developed, Ranitidine (Zantac) and Famotidine (Pepcidine). These medications prevent acid glands in the stomach wall from producing acid. The second group includes Omeprazole (Losec), the first in its class, and Lansoprazole (Zoton).

These are believed to stop acid from being pumped from the glands into the stomach. Undoubtedly, other related medications will appear in time, which may or may not be superior. These medications quickly suppress acid in the stomach. In the past, ulcers tended to heal rapidly. However, it was soon found that although pain relief often occurred within 12 hours or more from commencement of treatment, when stopped, symptoms invariably returned. This simply meant the condition had been relieved, but not cured.



So the method of choice currently seems to be to prescribe the acid-checking medication, as well as to administer triple therapy. Pain vanishes very quickly, especially with the pump inhibitors, often within hours. Acid is kept at a low level, while the triple therapy kills the germ. After a few weeks, all medication can be stopped and, according to latest evidence, with the germ killed, symptoms do not recur, and this may be a lifetime result. Re-infections of course are probable, for the germ is widely dispersed in nature.

With this totally new concept of treatment there is now little need for other forms of medication. Some may find use of the old-time antacids helpful as a temporary measure if there is any residual discomfort. Most of the other medications which claimed to help ulcers heal are now not required. There are no dietetic limitations, except smoking is not recommended, and commonsense should prevail regarding alcoholic intake. Otherwise, the patient may eat whatever foods are desired.

However, although most cases will be cured, some recalcitrant ones may persist. These may be suspect cancers, so other measures may be required. If an ulcer has not healed with intensive medical therapy within four weeks, then surgery may be indicated. This is probably even more important in gastric ulcers, for it is claimed that about ten percent of these prove to be cancerous. Also, there is little hope of a cure if a long-standing peptic ulcer has been present in the duodenum for five years.

Surgical operations that produce satisfactory results are now available. The nature of these has been an unending argument for some years, as each new variation claims to have some value over its predecessor. Surgery is not without its own set of complications in certain patients.

Many patients find the task of ceasing smoking a major one. Efficient methods are now readily available in all capital cities. With development of the stick-on nicotine impregnated skin patch, many patients are able to quickly give up smoking. A commitment is necessary, for success is more likely in highly motivated patients with the desire to “quit.” Medical supervision and support help, and attending an understanding doctor willing to spend time to offer psychological counseling and support is recommended. Most courses last ten to fourteen weeks. Other community and hospital-based services are also available involving other methods.