When digestive juices corrode, you’ve got an ulcer

When digestive juices corrode, you’ve got an ulcer

Louise Fenner

The image sticks in the mind: A middle-aged executive grimacing over a pain in his stomach, gulping down a chalky tasting antacid and mournfully waving away pizza or chili because his doctor won’t “let” him east spicy food. The portrait of a man with an ulcer.

In truth, more than a third of ulcer sufferers are women, and they appear to be gaining on men. Children and teen-agers also develop ulcers. Antacids are still a popular treatment, but three new prescription drugs are now available. And, instead of giving up broad categories of food, ulcer sufferers need only avoid foods that bother them.

Peptic ulcers are small sores or lesions in the lining of the stomach or small intestine. The term “peptic” comes from pepsin, a digestive enzyme that acts in concert with dydrochloric acid to digest food in the stomach. The thought, sight, smell and taste of food can cause even an empty stomach to secrete acid and pepsin. Normally the lining of the stomach and small intestine can resist corrosion from these digestive juices, but sometimes resistance breaks down and an ulcer develops. Why this happens is not completely understood.

An estimated 4 million Americans suffer from peptic ulcer disease at any given time. About 12 percent of U.S. males and 4 to 8 percent of females will develop one or more ulcers during their lifetimes.

Peptic ulcer disease can be painful and debilitating, but it is usually not life-threatening unless there are complications. In 1982, 176,000 ulcer, according to the most recent survey by the National Center for Health Statistics. About 6,000 people die each year from complications of peptic ulcer. The death rate increases with age, and in many cases the ulcer combines with another disease to cause death. The Stanford Research Institute has estimated that in the United States peptic ulcer disease costs nearly $3 billion annually in medical expenses and lost earnings (including earning losses due to death).

There are two main types of peptic ulcer: Duodenal ulcer occurs in the duodenum, the first few inches of the small intestine after it exits from the stomach. More than twice as many men as women have duodenal ulcers. They usually strike people during their most productive years and are four to eight times more common than gastric ulcers. Gastric ulcer occurs in the stomach, most commonly in older patients. It rarely develops before age 40, and the peak incidence is from 55 to 65. Incidence is the same for men and women.

Who is most likely to develop an ulcer? Smokers are, and their ulcers take longer to heal. They have more ulcer recurrences, more complications, and a higher ulcer-related death rate. The same does not appear to be true for alcohol users, except those with cirrhosis of the liver.

The tendency to have ulcers can run in families. The risk of developing a duodenal or gastric ulcer is three times greater in people who have close relatives with these ailments. Persons with group O blood are at greater risk of having duodenal ulcer disease. Blacks appear to have a higher ulcer rate than whites, including deaths from complications.

Several studies have shown more gastric ulcer disease among patients who take large quantities of aspirin than those who don’t. Aspirin is known to cause lesions in the lining of the stomach. The same ulcer rate is shown for buffered aspirin as for plain aspirin, but the risk is much smaller with enteric-coated aspirin (which dissolves in the small intestine instead of the stomach). Other drugs for arthritis, the steroids and the non-steroidal anti-inflammatory drugs, also are suspected fo contributing to stomach ulcers.

Stress may help cause some people’s ulcers, but its importance has not been conclusively shown. Emotional stress in difficult to measure, and people do not react to stressful situations in the same manner. A pressured executive, for instance, may be less anxious than an assembly line worker or a 2-year-old’s mother. There is no occupation or personality type that characterizes ulcer suffers.

Some studies indicate that stressful events frequently precede the development of an ulcer, but other studies fail to implicate such events in ulcer cases. Air traffic controllers as a group experience tremendous occupational stress, but they develop no more ulcers than the general population. However, during the bombing of London in World War II there was a notable increase in the incidence of certain ulcer complications. Apparently, some people are more susceptible than others to the effects of stress on their gastrointestinal tracts.

Certain foods, beverages and spices may bring on indigestion, but there is no convincing evidence that they cause or reactivate ulcers. Food buffers stomach acid and can temporarily relieve ulcer pain. However, some foods are particularly potent stimulators of stomach acid secretion. A few of the most common offenders are certain beverages, such as carbonated drinks, beer, tea and coffee (regular, decaffeinated and acid-neutralized). To make matters worse, these buffer little acid, particularly if they travel rapidly through an empty stomach. Many ulcer sufferers drink milk because it neutralizes stomach acid, but unfortunately it has a “rebound” effect. That is, afer a certain amount of acid has been buffered, the calcium and protein in milk stimulate the production of even more acid.

Several studies have shown that a bland “peptic ulcer” diet does not produce healing or relieve ulcer symptoms any better than regular or slightly modified diets. Current advice to ulcer suffers is to eat several meals a day (to keep the stomach from being empty too long) and void food that cause stomach distress. Coffee and other acid stimulators should be used in moderation, especially on an empty stomach. Milk should not be used as an antacid. Many ulcer patients take antacids or other medications at bedtime to control excess acidity; therefor, bedtime snack, which stimulate acid secretion, are not recomemded. If symptoms occur in the middle of the night, an antacid can provide relief.

gastric ulcer patients are often advised to avoid or decrease alcohol use because alcohol in high concetrations can damage the lining of the stomach. The situation is different for duodenal ulcers because alcohol is partially absobed or diluted in the stomach before it reaches the duodenum. The question of alcohol’s impact on a duodenal ulcer remains to be answered.

“I don’t diet, but through trial and error I’ve learned what food has an effect on me.” says a 54-year-old former duodenal ulcer patient. “Some brands of beer, wine and scoth really upset my stomach, but not others.

Most foods are OK except cabbage or sometimes highly acidic things like tomato sauce and pizza. And I’ve stopped skipping breakfast. The worst thing you can do for an ulcer is leave the stomach empty.”

His ulcer experience was fairly typical. He learned he had an ulcer the way many people do. It told him.

“I was a guy who always took pride in having a castiron stomach. I had a job on a newspaper, and the greater the pressure the more I loved it. I started feeling this burning sensation in my gut, but I ignored it until I couldn’t anymore and it was affecting my job. The soreness would persist for hours. It was never severe pain, just constant soreness, and it debilitated me. I couldn’t think straight, couldn’t concentrate. I drained me. I’d try different things–antacids, ice cream. Any relief would be temporary.”

Following treatment with antacids his ulcer healed, and he is curretly on medication to prevent a recurrence. “I’ve been lucky,” he says.

Some people with an ulcer do not experience distinct symptoms and, ironically, many patients with symptoms do not have a detectable ulcer crater. Nevertheless, the most common sign of an ulcer is a steady gnawing or burning pain between the navel and the lower end of the breastbone. It usually starts when the stomach has emptied, and it can often be relieved by eating more food or by taking antacids. Pain may awaken the patient at night.

It is often difficult to distinguish between a gastric and duodenal ulcer from symptoms alone. However, with a duodenal ulcer it is not uncommon for symptoms to disappear and return repeatedly over several years, with intervening pain-free periods lasting a few months to a few years. One textbook noted that over half of duodenal ulcer patients have had symptoms for more than two years before seeking medical advice. Complications of gastric and duodenal ulcers may produce symptoms such as dark stool (a possible sign of internal bleeding), severe pain, nausea, vomiting and weight loss.

The traditional method of diagnosing an ulcer is a series of X-rays commonly known as an “upper GI (gastrointestina) series.” On an empty stomach, the patient swallows a chalky liquid containing barium, a metal that shows in X-rays. The stomach and duodenum are outlined on the film, and an ulcer crater may be seem filled with the barium.

In a newer technique called endoscopy, a long flexible tube (endoscope) made of optical fibers that transmit light is snaked down the sedated patient’s throat and into the stomach and duodenum. This allows the physician to see the ulcer directly and to collect tissue for a biopsy if necessary Endoscopy is more expensive, but it avoids exposing the patient to X-rays and offers somewhat greater accuracy in detecting ulcers. (See “A Physician’s Spyglass For Looking Inward,” FDA Consumer, December 1982-January 1983.)

The basic aim of ulcer treatment is to relieve pain and give the ulcer a chance to heal itself–either by reducing the amount of acid and irritants in the stomach or by coating and protecting the ulcerated area.

Antacids have been used for decades to neutralize hydrochloric acid in the stomach. They are still prescribed or recommended by many physicians for use alone or with other ulcer medications. (Antacids should not be taken at the same time as certain other ulcer drugs, since they can inferfere with absorption.) Studies show that antacids compare favorably with newer drugs in ulcer healing, but the periods of relief are shorter, necessitating more frequent doses. Patients often become frustrated with the dosage schedule, the tatste, and the side effects, and they neglect to follow the schedule.

The most common side effects are diarrhea from magnesium-based antacids, constipation from aluminum-based products, and acid rebound from calcium-type antacids. Some newer combination aluminum-magnesium preparations may reduce these bowel disturbances. Because of potential drug interactions, patients using antacids for prolonged periods should ask a doctor before taking other medications.

Since 1977 three new prescription drugs have been approved by the Food and Drug Administration for treatment of specific types of ulcers. Cimetidine (brand name Tagamet) entered the U.S. market in 1977 and is used to treat duodenal and gastric ulcers and to prevent recurrence of duodenal ulcers. Two other drugs–sucralfate (Carafate) and ranitidine (Zantac)–were approved in 1981 and 1983, respectively, for use in treating duodenal ulcers.

These drugs work in two very different ways. Cimetidine and ranitidine and powerful inhibitors of stomach acid and pepsin secretion, while sucralfate forms a protective coating over the ulcer to shield it from irritation as it heals. Various clinical studies do not show great differences between the three drugs in rates of duodenal ulcer healing. All three drugs have low incidences of side effects, but since some potential effects are seriuos, patients should be carefully monitored by a physician.

Several antiocholinergic drugs are also occasionally used as adjuncts to other ulcer medications. They inhibit the action of a chemical called acetylcholine, which stimulates acid-producing cells in the stomach. Because anti-cholinergics are not as effective as the new acid blockers and often have unpleasant side effects, they are rarely prescribed by themselves. Several other drugs currently under study for treatment and prevention of ulcers include colloidal bismuth, pirenzepine, tricyclic antidepressants, and prostaglandins.

Many ulcers clear up without drug therapy or with only occasional use of antacids. Studies show, however, that a strict regimen of antacids or prescription drugs usually produces somewhat faster symptomatic relief and higher healing rates than placebos (inert substances). In duodenal ulcer studies, healing took place in about 70 to 85 percent of patients taking drugs, compared with 30 to 60 percent of those given a placebo.

After healing–with or without drugs–60 to 80 percent of duodenal ulcer patients will have an ulcer again. In about two-thirds of all cases, the disease seems to subside for good after about 10 or 15 years. One drug, cimetidine, is currently approved for use in preventing duodenal ulcer recurrence. It reduces the recurrence rate to less than 20 percent, but this protection disappears as soon as the drug is stopped. The consequences of long-term use of cimetidine–that is, beyond one year–are not known.

The pattern for gastric ulcer disease is different. Symptoms of a gastric ulcer are similar to those of stomach cancer, and it is therefore imperative to make sure the ulcer has healed (an indication it is benign). This finding may be made with an endoscope, which also can be used to remove tissue for biospy. A patient with a persistent or recurrent gastric ulcer probably will have to undergo surgery to determine if the lesion is benign, as well as to relieve symptoms. In contrast, duodenal ulcers are rarely cancerous, and surgery is less often needed in recurrences.

Simple ulcers sometimes develop into more serious conditions that require hospitalization, and even surgery. The three main complications of peptic ulcers are hermorrhage, perforation and obstruction.

Internal bleeding or hemorrhage affects 10 to 20 percent of ulcer patients. As an ulcer burrows into a muscular portion of the intestinal wall, it can damage blood vessels and cause bleeding into the intestinal tract. One sign of slow internal bleeding is a dark, tarry stool. Eventually the patient may become anemic. If the ulcer damages a large blood vessel, there may be rapid hemorrhaging, vomiting of blood, faintness, and sudden collapse. Without prompt medical action, the patient may bleed to death.

Perforation–erosion by an ulcer all the way through the stomach or duodenal wall–occurs in about 5 percent of patients. It is often heralded by sudden severe pain throughout the abdomen. Perforation may allow digested food and bacteria to spill into the abdominal cavity and cause infection, and it can be fatal if untreated.

Obstruction occurs when the narrow opening between the stomach and duodenum becomes blocked by swelling or scarring. This keeps food from passing out of the stomach, and the patient may vomit or constantly regurgitate stomach secretions. It affects about 2 percent of ulcer patients and often must be corrected surgically.

Each year about 50,000 Americans undergo surgery for peptic ulcers. Some suergery is to treat complications, but most often it is done to alleviate severe, incapacitating ulcers that won’t heal or stay healed.

At one time the most commong ulcer operation consisted of cutting out two-thirds of te patient’s stomach to reduce the amouth of acid-secreting tissue. Now, there are less drastic techniques that produce fewer side effects.

One common operation involves severing the nerve that stimulates the stomach to secrete acid and empty food into the intestine (the vagus nerve). This is accompanied by a procedure that allows the stomach to empty its contents more rapidly into the intestine, or by removal of the small part of the stomach where a hormone is produced that stimulates acid secretion. These techniques drastically reduce ulcer recurrence, but some patients suffer severe digestive side effects and may need additional surgery.

The newest type of operation involves cutting selected branches of the vaugs nerve instead of severing it entirely. This produces fewer side effects but is somewhat less effective in preventing ulcer recurrence.

Elective surgery for peptic ulcers in declining. Doctors are putting more patients on maintenance drug therapy and trying non-surgical methods for non-emergency complications. Lasers, elctric probes and baloon dilators now can be sent down to the stomach or duodenum through an endosecope. The first two “sizzle” tissue and stop an ulcer from bleeding, while the baloon helps open up obstructed passages.

For more information on peptic ulcer disease, write: National Digestive Diseases Clearinghouse 1555 Wilson Boulevard Suite 600 (FD) Rosslyn, Va. 22209

COPYRIGHT 1984 U.S. Government Printing Office

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