Dr Matthew Olumuyiwa Bojuwoye, a consultant gastroenterologist at the University of Ilorin Teaching Hospital, in this article by SADE OGUNTOLA, speaks to common misconceptions about peptic ulcers and why it is a condition that is commonly diagnosed in Nigeria. Excerpts:
W HAT causes peptic ulcers? Are peptic ulcers preventable?
Peptic ulcer, in simple terms, refers to having a wound in the stomach or intestine (specifically along the stomach lining or that of the small intestine, especially the first part of the small intestine that is referred to as the duodenum). These are the two most common sites. In some instances, the ulcer may be found in unusual places like the oesophagus and second part of the small intestine. The sore or wound in the stomach or in the duodenum is usually as a result of the action of the stomach acid and the enzyme called pepsin. This enzyme, produced by cells in the stomach, helps with the digestion of protein.
Naturally, a layer of mucus in the stomach protects the lining of the stomach from the action of the acid and the pepsin. However, there are instances where this protective layer of the stomach is either depleted or overwhelmed by excessive acid production; then there’s a tendency that an ulcer may form. The formation of the ulcer may not be a sudden thing. It may start as inflammation, which then progresses to the erosion and ulceration of the lining of the stomach.
The main cause of peptic ulcer is an organism (a bacterial agent) named Helicobacter pylori. The organism has perfected a way of surviving in the stomach despite its acidic environment, where you don’t expect many infectious agents to survive. The activity of this organism in the stomach tends to weaken that protective mucous layer. The organism is an independent cause of peptic ulcer. Another independent cause of peptic ulcer is the use of non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, diclofenac, piroxicam and aspirin, which are commonly used for pain relief.
However, there are many misconceptions about the cause of peptic ulcers. Some factors that people assume to cause peptic ulcers, like eating spicy foods, prolonged fasting and stress, actually aggravate symptoms in those who already have peptic ulcers. They also increase the frequency of symptoms. On their own, they are not causes of peptic ulcer disease. An imbalance between aggressive factors (which include the stomach acid, Helicobacter pylori, bile, etc.) and the protective factors (mucous, prostaglandins, adequate blood flow, etc.) of the stomach increases the tendency for ulcer formation.
There are some ulcers called stress ulcers. These are quite different from the peptic ulcers that we are talking about. They differ in their cause and timing: stress ulcers are acute, appearing rapidly due to severe physiological stress like major illness or injury, and often manifest as multiple lesions, whereas peptic ulcers develop gradually over time.
Which groups of people are more predisposed to having peptic ulcers?
People that are predisposed to having peptic ulcers include those who have a Helicobacter pylori infection. About 50% of the world population has the infection, but the truth is that not all persons who have a Helicobacter pylori infection will develop peptic ulcers. There are some other factors that are at play, such as genetics and the presence of other risk factors. That is why some persons with Helicobacter pylori infection will develop peptic ulcer disease, and others with the same infection will not.
Other groups of people that are predisposed to having ulcers are cigarette smokers, individuals with chronic liver disease, and those that self-medicate with or abuse non-steroidal anti-inflammatory drugs or steroids or consume herbal concoctions. Herbal concoctions may have corrosive effects on the lining of the stomach. Excessive alcohol consumption also has an adverse effect on the protective layer of the stomach. It has also been observed that those that are blood group O tend to have an increased risk of developing peptic ulcers.
Back in the 70s, we used to think that probably ulcers were due to stress and all these things. But two Nobel Prize scientists showed the world that a Helicobacter pylori infection actually can cause peptic ulcer disease and that once we eradicate the infection, there’s a tendency that the ulcer will not reoccur.
That’s why now when we are treating peptic ulcer disease, we actually use two antibiotics with another one that is meant to suppress the stomach acid. That will encourage the ulcer to heal. They are also asked to stop cigarette smoking and excessive alcohol consumption. Otherwise, there might be a delay in the ulcer healing.
What are the typical symptoms individuals with peptic ulcers experience, and are they different from the symptoms of other gastrointestinal problems?
The symptoms of peptic ulcer include upper abdominal pain or epigastric pain, just below the breastbone. And for some, it may be located within other regions of the abdomen. This pain tends to be chronic or recurrent, peppery, burning or sometimes dull in nature. But what gives it away is that it tends to get better whenever the person takes an antacid. Antacids are medications that come in liquid formulations that patients with peptic ulcers use to neutralize the stomach acid, thus providing rapid relief of stomach pain.
Some may actually experience the pain relief whenever they take milk and other dairy products like yoghurt. This is expected since the milk can also neutralize the stomach acid. The intake of milk is, however, often discouraged because after the initial pain relief it provides, the calcium in the milk may further increase the stomach acid secretion; hence, the pain cycle is not broken. Antacids, on the other hand, will neutralize the acid and do not cause further increase in acid secretion. That is why the use of antacids is recommended for immediate pain relief, not milk or other dairy products.
So how are the symptoms for peptic ulcer differentiated from those due to other gastrointestinal conditions?
It is through taking a careful history of the individual. We usually ask specific questions to give us a good idea of the cause of the pain. We ask about things that aggravate the pain and what things relieve the pain. But beyond that, we often go on and do some specific tests to confirm the presence of an ulcer. There are instances where the patient who is suspected to have peptic ulcer disease might even have a more sinister condition or something more dangerous, such as stomach cancer.
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No doubt, when anybody has stomach pains, the first thing that most people think about is peptic ulcer. Most of them have not even had any investigation to confirm this to be due to a peptic ulcer. So it is a condition that has been over-diagnosed.
Sometimes people might have reflux disease; we call it gastro-oesophageal reflux disease. It may sometimes mimic or masquerade as ulcer pain. Also, stones in the gallbladder may cause pain that is different from that of an ulcer. In essence, not all abdominal pain is due to peptic ulcer.
Individuals who have symptoms that suggest the presence of an ulcer but in addition have other symptoms such as significant weight loss, vomiting blood or passage of tarry black stool, or an obvious abdominal swelling are said to have alarm features or red flag signs. Other alarm features include new onset of ulcer-like symptoms at the age of 45 years or older, a family history of gastric cancer, jaundice and unexplained anaemia. When any of these alarm features is present, it is important not to assume that one is dealing with a peptic ulcer. The question needs to be asked: are we dealing with gastric cancer as opposed to a peptic ulcer?
It now becomes important to perform some specific investigations to find out what exactly is going on; are we dealing with a cancer or a complication of a peptic ulcer? Sometimes those who have been labeled as having peptic ulcer disease turn out to have inflammation of the gastric lining, or sometimes normal findings after specific investigations.
What tests are used in the diagnosis of peptic ulcer?
The gold standard for the diagnosis of peptic ulcer disease is an upper gastrointestinal tract endoscopy. This involves inserting a flexible tube that has a camera and a bulb at its tip through the mouth to the first part of the small intestine. As the flexible tube is navigated from the mouth, through the gullet and the stomach to the duodenum, the image of the innermost lining of these parts is displayed on a screen. In this way, abnormalities such as peptic ulcers are detected. The procedure also offers an opportunity to take tiny pieces of tissue, called biopsies, from detected lesions for histologic diagnosis.
But when there is no access to this facility, a barium meal can also be used for diagnosis. However, with a barium meal, it does not offer the opportunity for taking biopsies from observed lesions. If a lesion is detected with a barium meal test, further investigations are often required, such as an upper gastrointestinal endoscopy.
An abdominal ultrasound scan has its limitations, but sometimes on ultrasound a peptic ulcer may be appreciable, especially when it is located in the duodenum. Other tests used in the investigation of peptic ulcer disease include tests for Helicobacter pylori infection, such as the stool antigen test, serologic tests and the urea breath test.
Can over-the-counter medications be used to cure peptic ulcers? Is surgery the only solution, especially when it is severe?
Treatment of peptic ulcer can be divided into medical treatment and surgical treatment. Medical treatment is mostly adopted; it is often the first line of treatment. Ninety per cent of those who have duodenal ulcers have the Helicobacter pylori infection. The first-line treatment for peptic ulcer is what we call a triple regimen: two antibiotics and then a group of medicines called proton pump inhibitors.
The majority of duodenal ulcers are benign, that is, non-cancerous. Sometimes a gastric cancer can present in the form of an ulcer, but not all gastric ulcers are cancerous. Surgical treatment is often required when complications of peptic ulcers occur, such as perforation, severe bleeding (especially when unresponsive to medical treatment, which includes endoscopic treatment), and gastric outlet obstruction from kissing ulcers.
Can peptic ulcers increase one’s risk of other health conditions like stomach cancer?
The H. pylori is a known cause of peptic ulcer. H. pylori infection is also known to be caused by cancer-causing bacteria; it is actually a class 1 carcinogen (cancer-causing agent). So H. pylori infection can lead to cancer of the stomach.
A gastric ulcer can increase the risk of developing stomach cancer, particularly if it is caused by H. pylori infection, which is a common cause of ulcers and also a significant risk factor for stomach cancer. However, having an ulcer does not guarantee you will get cancer.
How can individuals reduce their risk of developing peptic ulcers, especially if it seems to run in the family?
We know that there are some genetic predispositions for peptic ulcers because you may find one or two persons in the same family having peptic ulcers. And of course, increased predisposition for peptic ulcer in those with the blood group O also has a genetic basis. However, like other conditions such as hypertension, the fact that a family member has an ulcer does not mean that it is sacrosanct that his/her relatives must have an ulcer. Individuals with a family history of peptic ulcer disease and those with disease conditions associated with an increased risk of developing peptic ulcer disease may be targeted for screening for H. pylori infection given that the infection is curable. Abuse of NSAIDs should be avoided.
The common notion out there is that all ulcers will obviously give you discomfort; is that so?
A: It is not a must, and the reason is not farfetched. Take someone that uses NSAIDs for body pains regularly; such a person may develop an ulcer and may not feel pain or discomfort because of the pain-relieving property of the medications. The danger here is that the ulcer continues to get deeper, and it may get to a point when it erodes into a blood vessel. In this situation, the first presenting symptom might be vomiting of blood or passage of tarry black stool, which is indicative of a bleeding complication. People also have different pain thresholds; some people may have a high pain threshold, hence may not experience any pain until they develop a complication.