Peptic Ulcer Disease (stomach ulcers)
The last part of this article was written in 1970 for patients with ulcers. Since that time there have been important new developments: two groups of medications that greatly reduce the flow of acid digestive juice and the discovery of Helicobacter pylori, a bacterium which inhabits the lining of the stomach in many cases without producing symptoms, but still responsible for about 85% of peptic ulcer disease. The new medications are potent enough to have very nearly eliminated the need for surgery for ulcers. And now treatment of H. pylori with antibiotics cures nearly 85% of the cases so that this group becomes normal with no need for continuing medication.
Here is a summary of the discovery of H. pylori. Stomach ulcers are an example of a disease recently passing from the unknown cause group to that of known cause. We were taught that ulcers were due to excess acidity, aggravated by irregular habits, alcohol, tobacco, caffeine and life stresses such as overwork and the scapegoat mother-in-law. The tendency to ulcers was thought to be at least partly inherited, seemingly confirmed by the fact that on skid row, less than half the residents have ulcers. Advice about regular habits and treatment with antacids did help most sufferers temporarily.
Enter Barry Marshall, MD of Australia and the Lancet, a private British medical journal that has remarkably maintained its original persona for 150 years, competence accompanied by fierce independence. In 1981, Barry Marshall discovered Helicobacter pylori, a bacterium which inhabits the lining of the stomach especially in people with stomach ulcers. The Lancet kept publishing Barry’s stuff, even when not much of anybody was listening. Barry kept writing. He even drank a culture of H. pylori causing inflammation of his stomach lining. This he cured with an antibiotic, which had inhibited the germ in culture. Now, in most cases, antibiotics cure (not suppress) stomach ulcers worldwide.
Recently I have encountered several people with severe ulcer problems from the 15% that cannot be successfully treated with antibiotics. The following Instructions for Patients with Peptic Ulcer from 1970 is pertinent to this group with the part about medications updated:
The tendency to develop ulcers is a lifelong personal trait. It can be detected in ulcer patients even before their first attack and in some of their relatives, who have not yet had ulcers. This can be shown by testing the acid production of the stomach. People with this tendency produce increased amounts of acid digestive juice. Compared to normal people, the production of this acid is especially large after meals, or with the use of caffeine containing drinks, alcohol, or in the presence of psychological stress.
Normally the acid production is closely controlled, so that only that which is needed for digestion is produced. In ulcer disease, failure of the stomach to stop acid production after a meal is an important difference from the normal. It is easy for the wall of the stomach, or the first part of the intestine, where the stomach empties, to be attacked by the strong acid.
The presence of almost any kind of food in the stomach neutralizes some of the acid. For this reason the pain of ulcers is most severe when the stomach is empty and is at least partially relieved by food. The ulcer hurts when it is enlarging and stops hurting at the very beginning of healing. Recurrence of pain means that the fragile new lining has been destroyed, before it had time to be completed.
Great care is required in the beginning of treatment to permit the ulcer to heal completely. After complete healing, it does not form again as easily as when the healing was only just started. This means that treatment of each attack of ulcers must be prolonged for many weeks after the last pain. For recurrence of pain, the treatment must begin all over again.
Our efforts at treatment must be directed at control of acid in the stomach.
When we say that psychological stress aggravates ulcers, this does not man that the ulcer patient is weak psychologically. It is his stomach and not his mind, which is different from other people. Psychiatric treatment does not help ulcers, unless there is a problem obviously requiring treatment, even if ulcers were not present.
In general, a patient whose ulcers do not heal while he follows a regimen and continues his regular work, should be in the hospital. In these cases the same diet and medications, which failed to heal the ulcer in the patient’s home, may succeed in the hospital.
While there he is removed from the stresses of his job and his family life. It is not because he shirked, but because of the insistence of the doctor, so that he and his boss and his family all understand that his illness is an important one.
To control the acidity in the stomach we use the following methods:
1. We ask the patient to eat all his meals on time.
· On a regular routine of rest, work, and eating, the acid production of the stomach is most likely to occur when it contains food.
· When we are late for a meal, some of the extra acid production occurs with the stomach empty, so that no food is present to neutralize it.
· Less obviously, when the ulcer patient drinks milk in response to pains, this is really eating between meals.
· After snacks we have the same problem as after meals—acid production continuing for a longer time than is needed.
Bedtime snacks require a special comment. The patient with an active ulcer may get to sleep more easily, if he eats at bedtime, relieving his pain long enough for him to get to sleep. But, after the snack is digested, some extra acid production continues. Perhaps not enough to cause a severe pain and awaken the patient, but enough to retard healing at the very time his stomach could be completely inactive. For this reason, antacids at bedtime are much better than food.
2. We ask the patient to take chemical antacids every hour between meals at first and one to two hours after meals, for a longer time to neutralize the extra acid before pain occurs.
· Non-absorbable antacids should be used because they do not cause alkalosis or kidney stones.
· Some of these non-asorable antacids are constipating and some cause loose stools, but there is always some mixture that does not upset the bowels.
· In other words, do not use baking soda for ulcer pains – and do take medication on a schedule – not just when pain occurs.
· When we say to use antacids every hour between meals, we mean that they are not needed at mealtime, because the food itself is an effective antacid.
· It is usually not necessary to disturb sleep by taking antacids every hour at night, especially if bedtime snacks are avoided.
· However, if you are awake during the night for some other reason, it is good to take a dose.
3. The new and potent medications to reduce the flow of acid secretions were discovered in the 1970s and 80s. One of the first, Zantac (ranitidine), is now available without prescription. It was potent enough to replace surgery for the vast majority of patients. Zantac is quite free of side effects and can be taken more or less indefinitely if necessary. Members of the second group of medications are called “proton pump inhibitors.” Examples are Prilosec, Prevacid, Protonix. Used for the first month or two of treatment, they result in the most prompt relief of symptoms. These medications alone or used with other changes in life style now control ulcer disease without surgery almost all the time and usually without a hospital stay. Carafate comes as a very large chewable pill. It coats the stomach lining in soothing way. Recently it is seldom needed.
4. We ask patients under treatment for ulcers to give up alcohol and caffeine containing beverages for two or three months.
· Caffeine is present in coffee, tea, all brands of cola drinks, Dr..Pepper and Mountain Dew.
· You will hear that certain alcoholic beverages do not aggravate ulcers. Some “helpful” friend will say, “Beer makes my ulcers much worse, but scotch always relieves them”.
· Alcohol is a powerful stimulant of acid production in all persons. All forms of it severely aggravate ulcers.
· The expression that so-and-so “wasn’t feeling any pain” may have some pertinence here.
· When coffee aggravates ulcer pain, it usually does so promptly. The effects of alcohol in increasing the pain may seem greater the next day, than at the time.
· Many medications aggravate ulcers by a variety of mechanisms. Doctors treating you should always know that you have had ulcers. Even years after the last attack, this may be important so that the doctor can take precautions to prevent a recurrence. He may ask you to take antacids during the time you are taking some medication, which is needed, but is known to cause ulcers.
· You should know that most headache pills and cold medications sometimes cause ulcers, so that you can minimize their use and take antacids with them, when they must be taken.
· Above all – do not take medications such as aspirin, ibuprofen, or Aleve for ulcer pains, because they increase acid secretion and besides – it is much more logical to take antacids, which get at the cause of the pain.
5. We ask the patient to do all these things carefully for many weeks after the last pain.
· Any recurrence of pain means that the entire program is in effect starting all over again from the beginning.
· In response to all recurrences some thought should be given to how to be more careful with the next effort at treatment. If no defects in the prior treatment can be discovered, it is usually time to consider hospital treatment.
6. Between attacks of ulcers, remember that ulcers are a lifelong disease and some recurrences are inevitable.
· If you do everything right for two or three months after each attack, this is not quite enough cure. We suggest that after each recurrence you make some permanent change in your life designed to reduce the frequency of future recurrences.
· It is not necessary or even always logical to do the most effective things first. Those changes, which are most easily made should be first.
· After several recurrences, you will arrive at a way of life, which controls your particular case of ulcers, with the least possible personal hardships.
Try not to approach treatment as if it were punishment. This may result in the attitude that the treatment should be very severe and difficult, in order to get it over with as quickly as possible. Indirectly this approach leads to many recurrences and much greater risk of complications requiring surgery.
Ulcer surgery is major surgery comparable in its risks to surgery of the gallbladder or lung. When perforation, obstruction or hemorrhage occur, surgery may be life saving. But, most of these complications could have been avoided by the application a few years before of the principals of treatment to control acid production in the stomach.
Many of the patients, who are careless in their treatment, because they think that surgery will solve their problem any way, are disappointed to find many new problems after surgery, not from ulcers any more it is true, but from surgery itself.
The most common of these include inability to eat even a moderate sized meal, weight loss, diarrhea, and faintness after meals, or even just from fruit juice or soft drinks.
You are probably wondering why we have not mentioned special diets or the use of tobacco. The reason is that they are not nearly so important as these other things that we have talking about.
Sometimes a patient, who has had many recurrences of ulcers in spite of considerable care all the time, will be able to get along with fewer recurrences after he stops smoking. The benefits may not be immediate because of the nervous tension, which accompanies efforts to stop smoking.
Regarding diets—foods that have upset you in the past should be eaten only in small quantities. Remember that almost any food at all taken at mealtime, is better than missing a meal. There are some special diet restrictions useful for certain complications of ulcers, but most ulcer patients will do well without knowing these details.
In summary—peptic ulcer disease is a lifelong problem, best solved by gradually finding the least inconvenient changes in your life, which are sufficient to control most of the recurrences.
See also: Mark Twain’s Moral Pauper under Miscellaneous Writings and
John A. Frantz, M.D. An “Undiscovered” Vitamin, Now Vitamin B12 under Staying Healthy
March 22, 1970, Revised June 16, 2003