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ULCERS

Ulcers of the upper GI system are a leading cause of upper abdominal (belly) pain. Ulcers can be found in the stomach (gastric ulcers) or in the first part of the small intestine just past the stomach (duodenal ulcers).  There has been a real change in our understanding of ulcers in the past ten years.  While dietary factors and stress were once thought to be the major cause of ulcers, we now know that the vast majority of ulcers are associated with either an infection of the stomach lining, or with the use of medicines like aspirin and ibuprofen.   

The discovery of Helicobacter pylori (H. pylori), a bacteria that lives in the stomach lining in many with ulcers has led to treatments that get rid of the bacteria in most patients, drastically speeding up ulcer healing and keeping ulcers from coming back.  Many who take medicines like aspirin and similar medicines, called non-steroidal anti-inflammatory drugs (NSAIDs) are also prone to ulcers. The most common NSAIDs are aspirin, ibuprofen (Advil), and naproxen (Aleve, Naprosyn), although many others are available.  While the direct contact of these medicines with the stomach can indeed cause damage, the main way these medicines cause ulcers is by keeping the stomach from making special protective mucus containing prostaglandins, leading to easier damage to the stomach lining caused by acid and bile. Normally the stomach has three defenses against digestive juices: mucus that coats the stomach lining and shields it from stomach acid, the chemical bicarbonate that neutralizes stomach acid, and blood circulation to the stomach lining that aids in cell renewal and repair. NSAIDs hinder all of these protective mechanisms, and with the stomach's defenses down, digestive juices can damage the sensitive stomach lining and cause ulcers. For this reason "safety-coating"  of preparations of aspirin and similar products does little to decrease the long-term ulcer risk from these medicines.  NSAID-induced ulcers usually heal once the person stops taking the medication. To help the healing process and relieve symptoms in the meantime, the doctor may recommend taking antacids to neutralize the acid and drugs called H2-blockers or proton-pump inhibitors to decrease the amount of acid the stomach produces.

Symptoms of ulcers are usually a gnawing or burning pain in the mid-abdominal area, often made better by eating and the use of antacids.  The pain can range from annoying to intense.  Complications of ulcers can include bleeding, blockage of the food path (obstruction) and a through-and through hole through the stomach or duodenum into the abdomen (perforation). These symptoms can be life-threatening.  Rarely in older patients ulcers in the stomach can contain cancer.  Careful examination and endoscopy can usually rule out a cancer in susceptible patients.

Tools for diagnosing ulcers are better today than ever before.  Endoscopy is the most sensitive test for upper GI ulcers, is safe and well tolerated, and can be done in a hospital, outpatient setting, or even sometimes in the doctor's office.  This test allows for biopsy (obtaining a small tissue sample) to look for the H. pylori bacteria and other problems.  Barium X-ray (upper GI series) can also spot ulcers in many patients.  Tests for presence of the H. pylori infection can be done on biopsies, on the blood, or even on exhaled breath (breath test).  All these tests can be useful in spotting and characterizing an ulcer.

Initial treatment of a gastric ulcer is suppression of acid production in the stomach, to allow the damaged stomach lining to heal.  This is most effectively done with PPIs (proton pump inhibitors), prescription drugs that block most all the acid produced in the stomach.  In some other cases H2 blockers like Pepcid are given for ulcer treatment.  Most all treatment plans for ulcer patients today who test positive for H. pylori include a regimen of medicines to get rid of the bacteria.  This according to the experts decreases the chances of ulcer recurrence.  Most of these regimens include antibiotics and proton pump inhibitors.  Other regimens include preparations of bismuth (like Pepto-Bismol or other precription bismuth-containing compounds).  The bismuth is effective in decreasing the bacteria's ability to live in the stomach, letting the antibiotics do a better job in getting rid of the organism.  Often if NSAIDs need to be given to a person while they are being treated for an active ulcer, synthetic prostaglandins can be useful in preventing ulcer recurrence.  Sucralfate can be effective in healing duodenal ulcers, and also has a very favorable side effect profile

Modification of diet, cessation of smoking, avoiding alcohol, and stress reduction can be important factors in healing ulcers, too.  Contrary to popular legend, neither milk nor a bland diet has a proven role in healing ulcers.  A high fiber diet can be a useful adjunct.  Smoking both delays the healing of already identified ulcers and makes it more likely for ulcers to recur.  Anyone taking NSAIDs who experiences symptoms of peptic ulcer should see a doctor for prompt treatment. Delaying diagnosis and treatment can lead to complications and the need for surgery.