Peptic Ulcer

How is an ulcer diagnosed? 

Upper gastrointestinal endoscopy is the best diagnostic test, but ulcers can also be detected by barium contrast X-rays. They can also be detected by the urease breath test in which C-labelled urea is taken orally and the resultant C02 released by the urease enzyme is measured on the breath.

Why treat H. pylori?

Chronic infection with H. pylori weakens the natural defenses of the lining of the stomach against the ulcerating action of acid. Medications that neutralize stomach acid (antacids), and medications that decrease the secretion of acid in the stomach (H2-blockers and proton pump inhibitors or PPIs) have been used effectively for many years to treat ulcers. H2-blockers, include ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet), and nizatidine (Axid).

PPIs include omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), and esomeprazole (Nexium). Antacids, H2-blockers and PPIs, however, do not eradicate H. pylori from the stomach, and ulcers frequently return promptly after these medications are discontinued. Hence, antacids, H2-blockers or PPIs have to be taken daily for many years to prevent the return of the ulcers and the complications of ulcers such as bleeding, perforation, and obstruction of the stomach. Eradication of H. pylori prevents the return of ulcers and ulcer complications even after the medications are stopped. Eradication of H. pylori is also important in the treatment of the rare condition known as MALT lymphoma of the stomach.

Pharmaceutical anti-ulcer drugs reduce the acid in the stomach, allowing a temporary healing, but they also can also cause a number of negative side effects. They deprive the body of acid, which is necessary for digestion, for protection against unfriendly bugs, for good bone health, and for turning on the rest of your digestive enzymes. These drugs may block good prostaglandin production, which can cause inflammation and cellular damage in your body. They can damage your gastrointestinal lining. Many of these anti-ulcer medications (H2-receptor blockers) allow the growth of all kinds of viruses, bacteria, and fungi such as candida albicans, which would normally have been killed in the stomach. There is also a high rate of relapse with pharmaceuticals, 80% after one year and 100% after two years.

Patients with ulcers generally function quite comfortably. Some ulcers probably heal even without medications. Therefore, the major problems resulting from ulcers are related to ulcer complications, including ulcer bleeding, ulcer perforation, and gastric obstruction.

Patients with ulcer bleeding may report black tarry stools (melena), weakness, a sense of passing out upon standing (orthostatic syncope), and vomiting blood (hematemesis). Initial treatment involves rapid replacement of lost body fluids intravenously. Patients with persistent or severe bleeding may require blood transfusions. An upper endoscopy is performed to establish the site of bleeding and to stop active ulcer bleeding with the aid of heated instruments.

Ulcer perforation leads to the leakage of gastric contents into the abdominal (peritoneal) cavity, resulting in acute peritonitis (infection of the abdominal cavity). These patients report a sudden onset of extreme abdominal pain, which is worsened by any type of motion. Abdominal muscles become rigid and board-like. Urgent surgery is usually required.

Patients with gastric obstruction often report increasing abdominal pain, vomiting of undigested or partially digested food, diminished appetite, and weight loss. The obstruction usually occurs at or near the pyloric canal. The pyloric canal is a naturally narrow part of the stomach joining the upper part of the small intestine called the duodenum.

Upper endoscopy is useful in establishing the diagnosis and excluding gastric cancer as the cause of the obstruction. In some patients, gastric obstruction can be relieved with tube suction of the stomach contents for 72 hours, along with intravenous anti-ulcer medications, such as cimetidine (Tagamet) and ranitidine (Zantac). Patients with persistent obstruction require surgery.