Ulcers

Origins

In general, ulcers are caused by an imbalance in the stomach, either too much stomach acid or pepsin, the major digestive enzyme, or too little protective mucous and protein secretions. This imbalance allows the stomach acids and enzymes to, in effect, turn on the digestive tract itself, producing small ulcers. But there is not, as is commonly thought, a direct relationship between excessive acid secretion and ulcers. Many people with duodenal ulcers, for example, secrete large amounts of acid, but others do not. This has led many experts to suspect that poor tissue resistance and other factors, particularly cigarette smoking, that interfere with the flow of neutralizing secretions may contribute to ulcer development. Stress and emotional pressure are also frequently cited as causes of duodenal ulcers.

In the case of gastric ulcers, excessive acid secretion appears to be even less of a factor than in other forms of ulcer, since many patients have normal and even low levels of stomach acid. Again, external factors or substances have been implicated in the origin of gastric ulcers, the two major ones being alcohol and apsirin. Both are known to injure the stomach lining, and it is thought they increase the stomach's vulnerability to the acid that is present.

Symptoms

Pain--centered in the pit of the stomach, just below the rib cage--is the most characteristic ulcer symptom, and it usually follows a distinct pattern. It normally begins several hours after eating or during the night, developing when the stomach is empty. The pain can manifest itself as a chronic gnawing or aching; it may grow worse during or immediately after meals; or there may be no pain at all, just belching--any ongoing stomach discomfort should be called to a doctor's attention.

Complications

Gastrointestinal bleeding is one of the most common complications of ulcers. This may manifest itself as vomiting fresh, bright red blood or passing bloody or tarry stools. Weakness, fatigue or, in the case of severe hemorrhage, loss of consciousness and shock also may result from bleeding ulcers. Ulcers always should be suspected when gastrointestinal bleeding occurs, even if there is no pain or other symptoms.

One serious complication is a perforated ulcer, which develops as acid deepens the ulcer and goes through the intestinal wall, spilling acid and bacteria into the abdominal cavity. This is always a medical emergency requiring immediate treatment, usually surgical. The pain is sudden, intense and steady, and even the slightest movement seems to increase it. The major danger is peritonitis, a severe infection of the abdominal cavity. A second danger is caused by excessive scarring or adhesions. Usually, however, this only occurs in older ulcers where several layers of scar tissue have had a chance to accumulate. Piled on one another, these may block the digestive tract.

Treatment

While some ulcers heal on their own, most patients require some sort of treatment. But recent important changes in the three major areas of ulcer therapy--diet, drugs and surgery--allow today's patients a freedom that would have been unimaginable to earlier generations of ulcer victims. In any case, ulcer patients who smoke should make every effort to stop. Avoidance of alcohol and aspirin, especially during a flare-up, also is recommended.

Diet

Milk and cream diets are still prescribed, as are small, frequent feedings of up to six meals a day. But today, these mainstays of dietary therapy are used much more judiciously than in the past. Since both seem to effectively relieve ulcer pain, they are routinely prescribed during flare-ups. But because there is no evidence that either actually promotes healing, once the pain has been relieved, patients are usually allowed to resume their normal diets.

Drugs

The discovery of a new drug (cimetidine) that inhibits the flow of digestive acids and enzymes and thereby permits ulcers to heal has markedly changed ulcer therapy. Blocking drugs are now widely used in treating ulcers.

Another new approach is to administer drugs (e.g., sucralfate) that actually form a protective coating over the ulcer, giving it a chance to heal without disrupting the flow of gastric acids. Until the introduction of these new drugs, the approach had been to give drugs that neutralize acids already present rather than block acid secretion.

Many older drugs remain an important and valuable part of ulcer therapy, particularly the antacids. As acid neutralizers, they not only relieve discomfort, but actively promote duodenal ulcer healing. Selected patients also may be treated with slow down stimulation of secretions and other involuntary functions. In any instance, treatment should be tailored to the needs of an individual patient--something only your phyisician is equipped to do.

Surgery

For the majority of ulcer patients, the sucess of dietary therapy, drug therapy or a combination of the two makes surgery unnecessary. But an estimated 10 to 15 percent of ulcer patients do eventually require surgery. Indications for surgery usually include perforation, obstruction due to scarring and bleeding. Intractable pain also may justify surgical intervention, but usually only after other treatment alternatives have been tried.

Summing Up

While the causes of ulcers are still not completely understood, new therapies have dramatically improved the outlook for most ulcer patients. These include a more liberal attitude towards diet, new drugs and improved diagnostic procedures. Stopping smoking and attempting to avoid undue stress also are recommended for ulcer patients.