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Friday, January 16, 2009

Peptic Ulcer

What is an ulcer and how is peptic ulcer different?

The definition of an ulcer is a break in the lining, which is more than three millimetres in size. Peptic ulcer is situated in the stomach or the early part of the intestine, which is known as duodenum. Quite often it is called gastric ulcer or duodenal ulcer.

What is the cause of peptic ulcers?

There is constant balance going on in the lining of the stomach and duodenum whereby it is getting destroyed and regenerated. Anything that tips the balance towards more destruction would lead to an ulcer. The commonest cause being an infection by an organism known as H. pylori and there are other causes like excess intake of aspirin and other painkillers, smoking, alcohol, stress and so on.

How does this bacteria cause the problem? How does it get inside the body?

The H. pylori bacterium was discovered in 1984 to be the cause of the peptic ulcer or duodenal ulcer. They enter the body via food or contaminated water. Once they enter a part of the stomach called antrum, they produce antral gastritis or inflammation in the stomach. This inflammation results in excessive acid production in the stomach; this acid then goes to the duodenum and attacks the duodenal lining, which then gets ulcerated. This is the mechanism by which, Helicobacter pylori causes duodenal or gastric ulcer disease, which is predominantly known as peptic ulcer.

What is the difference in behaviour of this ulcer in children and adults?

There is no difference between the ulcer behaviour in children or adults. In children, the infection comes early and that is why they develop symptoms like burning sensation and pain in the empty stomach. The only difference in children and adults is that in adults if the ulcer occurs repeatedly, they may get the narrowing or constriction of duodenum causing duodenal stenosis or these ulcers can bleed massively which is not very common in children, though it can happen in children also.

Is stress a cause of peptic ulcer?

Yes, stress of various kinds like stress of surgery, day-to-day stress due to certain drugs or diseases, can tip the balance of injury versus regeneration. So if regeneration is not taking place in proper time then the ulcer can form and lead to problems.

What are the symptoms of peptic ulcer?

The commonest symptom is pain in the upper part of the abdomen. This pain comes for about two to three hours after meals depending upon the location of the ulcer. People often wakeup at night due to the pain, which can be relieved by taking glucose or biscuits.

Which food products should be avoided in peptic ulcer?

Food products like caffeine and nicotine can delay the natural healing. Everybody at some point of his or her life gets a mild injury in the stomach but not everyone develops an ulcer. The ulcer would only develop if there is a repeated stress, infection or repetitive use of any drug, which tips the balance. It is also a biochemical phenomenon where certain chemicals being produced are inhibited by drugs and the body.

These symptoms are very often similar to other gastric problems; how would a person know that the problem is peptic ulcer specifically?

The symptoms of peptic ulcer can mimic other diseases like oesophageal reflux disease. Gastric cancer can also produce similar symptoms and some sort of gastritis also produces similar symptoms. But there are other symptoms like a burning pain on empty stomach, which increases at night and bleeding may occur sometimes. If the patient gets black coloured stools or vomits two to three hours after meals, then these are the symptoms, which tell that there is a high chance of getting peptic ulcer disease. But final diagnosis can only be done by endoscopy.
Is endoscopy the 100 per cent proof of getting the correct diagnosis?

Yes, endoscopy is the 100 per cent proof of getting the correct diagnosis in peptic ulcer disease. At the same time, one can take the biopsies and confirm the H. pylori infection and differentiate whether one has any other type of gastritis, cancer or lymphoma.

Ten years back my ulcer started bleeding suddenly and I was admitted to the hospital. The bleeding was so profuse that my haemoglobin, which used to be 13, came down to 6.8 in a couple of hours. I was infused with blood and it was diagnosed as ulcer and I was given the treatment for 45 days. A few years later I bled again and had to be hospitalised where my bleeding was controlled within 24 hours. I was given the treatment for H. pylori for 45 days again. But I still feel the pain in my chest. Specially while travelling on a scooter on a bumpy road. Do I have to go for treatment and endoscopy again? Is it an extreme case?

No it’s not an extreme case. In the present era, complications of ulcers bleeding and perforation are seen more often than they were seen earlier, because most early ulcers are being treated very well by medications. Bleeding is a life-threatening situation, where the caller was rightly endoscoped. Quite often doctor’s give the injection around the ulcer endoscpically and stop the bleeding. There is a standard protocol, which we follow and after a certain criteria is reached, we declare that the medical treatment has failed therefore a surgical option is required. But in the patient's case, the medical treatment has worked very well. If he is continuing to have symptoms, he could see a gastroenterologist.

I am 22 years old. I am suffering from peptic disease. There is a continuous pain in the food pipe. I do not smoke or drink. What should I do?

Your symptoms are of gastro-oesophageal reflux disease. Generally, there is a one-way traffic from the food pipe to the stomach and the contents of the stomach are not allowed to go into the food pipe. But when the acid from the stomach goes into the food pipe, it produces pain and burning sensation in the chest. This is aggravated by heavy meals or food items like chocolate, coffee, or excess of smoking. Sometimes this problem gets aggravated if the person is overweight. The cause of reflux disease is weakness of the muscle at the end of the food pipe or hiatus hernia, which allows free passage into the oesophagus. These symptoms can be controlled by diet manipulation. You should have small frequent meals, avoid coffee and chocolates, do not lie down for two to three hours after the meals. If your symptoms disappear with these adjustments, its very good. But if this lifestyle modification is not adequate, then you need a medical treatment to suppress the acid in the stomach like proton pump inhibitor or H2-receptor blockers. In case the disease is severe, you need an operation.

I am suffering from severe peptic disease for the past one year. I have tried various medicines like Nxpro, Mucaine gel and many other gels. But no ulcer was found in the endoscopic examination. However, there was a positive test for H. pylori. But despite continued medication, I have severe pain in the food pipe. I have a lot of discomfort. I do not smoke or drink, I don't eat chocolates or drink coffee and neither am I overweight. I work in a call centre so I have a night scheduled job. Please help me.

Firstly, the bacteria should be eradicated. Secondly, she has the symptoms of gastro-oesophageal reflux disease rather than those of ulcer. For that, the gastroenterologist would need to go into the details of her history. If that is the case, then some modifications in the medication would be required.

Her symptoms can be labelled as non-ulcer dyspepsia. She has dyspeptic symptoms but there is no documented ulcer on endoscopy. In this situation, lifestyle modification helps a lot.

What is the treatment of peptic ulcer? Does medication help? At what stage is surgery required?

Firstly, we need to find out an established cause. There could be an infection or the patient would be taking aspirin or other medications, intake of alcohol, smoking, etc. The cause has to be removed, because one cannot continue smoking and expect medicines to work. The medicines have undergone a revolutionary change. The present day medications are excellent and very few patients have to go for an operation. Failed medical treatment requires surgery. Surgery is required only when there is perforation of the ulcer or uncontrolled bleeding. If the ulcer has narrowed the passage from where the food moves forward, then we have to make an alternate passage.

Can drinking alcohol and smoking be continued after treatment?

The incidence of ulcer coming back after restarting smoking or drinking is quite high, so one should avoid it completely.

I am suffering from oesophageal reflux from the last 20 years. I am taking symptomatic treatment, which is responding well. Please suggest some remedies and precautions because I am diabetic. I am non-smoker and non-alcoholic.

Since he is suffering from reflux disease and the medications are helping him, the general plan is to have a lifestyle modification. One should take small frequent meals and not lie down, do not have spicy food and do not have colas and chocolates. The medications should be taken in the full dose six to twelve weeks. The medications can be reduced after six to twelve weeks of complete healing. The medicines should be brought to a minimum level when symptoms are not there. If it is completely asymptomatic on a low dose of medication for six months, he can be taken off the medication. But if his requirement of medication is continuous for 20 years, I would suggest evaluation for laparoscopic surgery by which the reflux disease can be reduced.

I am 21-year-old student. I have been living in the hostel for the past three years; therefore, my eating timings are not regular especially for lunch. Whenever I wakeup in the morning I get burning sensation in the solar plexus area. I showed it to a doctor, who said that this probably is the beginning stage of an ulcer. He told me to take Rabeprazole sodium. What is the efficacy of the medicine? Do I need diet restriction or do I have to take medication all my life? How can stop this from becoming a chronic problem?

Your symptoms are suggestive of peptic ulcer disease. Rabeprazole sodium is a good medication to improve peptic ulcer. But to completely eradicate the ulcer, it is better to treat the H. pylori infection. Once the infection is eradicated completely, the chances of ulcer becoming chronic are less than one to two per cent. You should avoid NSAID’s (Non-steroidal anti-inflammatory drugs) like aspirin, ibuprofen. You need to take small frequent meals. Don’t keep your stomach empty for a long time, this will help you to improve your symptoms. To completely eradicate the ulcer it is better to undergo endoscopy to confirm whether you have H. pylori infection. Then get it treated completely.

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