Peptic Ulcer

Your diagnosis is an “ulcer.” An ulcer of the duodenum, the first part of the small intestine, just beyond the stomach. An ulcer, which is a hole or sore in the tissue lining, can occur almost anywhere in the digestive tract, but is found most frequently in the duodenum. Duodenal ulcer is about 10 times more common than gastric ulcer – ulcer of the stomach. Together, they are medically known as peptic ulcer – which is what we generally refer to by the simple term, ulcer.

How common is peptic ulcer?
So common that it is of epidemic proportion. About 10 percent of our population – over 20 million Americans  – are affected. That is, they now have, have had or sometime in their lives will have an occurrence or recurrence of this chronic disease. The expression “once an ulcer, always an ulcer” means that you can never be sure an ulcer, once healed, won’t reappear. Every day, another 4,000 or so Americans develop an ulcer. Men are affected more often than women, although in recent years the percentage of afflicted women seems to be increasing.

All age groups, including infants and children, are involved. The disease strikes hardest at those between the ages of 25 and 40, persons in their most productive years. In lost hours of work and medical expenses, it causes more than $1 billion annual drain on the nation’s economy.

How serious a disorder is it?
About 12,000 Americans die each year from its complications. However, this is a very small percentage of ulcer patients. With proper medical supervision and care, the great majority of patients live much the same lives as they would without the ulcer.

What causes ulcers?
There are many theories about this but none have been decisively proved. Since ulcers do not occur in the absence of acid secreted by the stomach, the theory that is most widely accepted is that the hole or crater-like sore in the thin membrane lining of the stomach or duodenum is caused by the powerful digestive juices, hydrochloric acid and pepsin, secreted by the stomach to break down food and prepare it for absorption in the bloodstream.

Normally, the lining of the stomach and duodenum is protected from the digestive juices in some manner that is not known. Ulcers occur in the duodenum when there is an excessive secretion of acid, which breaks down the resistance of the intestinal lining, or in the stomach when the lining is vulnerable to even normal amounts of acid and pepsin. Of these two factors, the first, “excessive acid,” is the one that lends itself more readily to medical treatment.

Are ulcers inherited?
The hereditary factor is unknown. However, statistics indicate that ulcer is about three times more common in close relatives of afflicted persons than in the general population. Since prevention is the best form of treatment, research efforts are being directed toward the development of simple tests that accurately identify ulcer prone persons.

Aren’t certain personality types more prone to ulcers?
No, not really. That is largely a myth. Studies have shown that low-key lackadaisical people get ulcers just as often as high-pressured hard-driving people, that farmers and factory workers are affected as often as business executives and writers. Few popular beliefs about ulcer-prone types are supported my clinical investigation.

What part does stress and tension play in the development of ulcers?
Emotional stress – anxiety, aggravation, worry – can trigger the vagus nerve, which connects with the stomach, to stimulate secretion of excessive acid and pepsin. Some studies indicate increased anxiety in ulcer patients; other studies show that acute psychic stress preceded the onset of ulcers. However, many people under prolonged stress do not develop ulcers and others develop ulcers when they are apparently under no undue stress.

Psychological factors probably play a role in ulcer disease, but other factors of a physiological nature must be present for the development of this complex disease. No matter how tense a person may be, without stomach acid he will not get an ulcer.

How do you know you have a ulcer?
Pain in the pit of the stomach is the most common symptom of ulcer. Usually, the pain is not sharp but, rather, a gnawing or burning sensation, somewhat similar to a hunger pang. The cause of the pain is unclear, but may be caused by the corrosive action of acid and pepsin on the open sore in the empty stomach or duodenum. It is often relieved by eating or taking an antacid which neutralizes the acid.

How are ulcers diagnosed?
An X-ray examination is made of the gastrointestinal tract, particularly the stomach and the duodenum. If there is an ulcer, in 70-90 percent of cases, it will show up on the X-ray film. Other tests of the blood, stool and gastric juices confirm the diagnosis. An alternative and more accurate method is endoscopy – the use of a flexible fiberoptic instrument to examine the stomach and duodenum.

If the disorder is in the stomach, further tests will be taken to make certain it isn’t stomach cancer, which often looks like peptic ulcer on X-ray film. With endoscopy, the stomach can be entered and photographed and a sample can be taken of the affected area and tested for malignancy. About 5 to 10 percent of suspected stomach ulcers are actually malignancies and these must be treated by surgery. Needless to say, the sooner this is done, the better the chances of survival.

Could my duodenal ulcer possibly be a malignancy?
No. Duodenal cancer is very rare and does not resemble duodenal cancer at all. Further – and this should be a reassuring note – there is no medical evidence that a benign ulcer, either duodenal or gastric, ever becomes malignant. Other complications may develop, yes. But not cancer.

How are ulcers treated?
The purpose of treatment is to facilitate the healing of the ulcer by reducing the amount of acid secreted by the stomach. Treatment, of course, varies somewhat with the individual, but in most cases the keystone measure is intensive antacid therapy. Antacids, which neutralize hydrochloric acid, have been found most effective when taken one hour after meals and at bedtime. Often the antacids must be taken hourly or every two hours when the patient is acutely ill. Prilosec is a relatively new drug that is largely effective in reducing acid secretion.

Other medications sometimes prescribed include anticholinergic drugs, which inhibit acid secretion by the stomach, and antispasmodic agents, which relax the muscles of the stomach and intestine. In cases where there is considerable anxiety or worry, sedatives may be prescribed. General ways to ease tension, such as rest and relaxation, are encouraged.

As for diet, patients usually benefit from small frequent feedings, such as six small-sized meals a day instead of three full-sized meals. This keeps some food in the stomach throughout the day to absorb and neutralize acid.

Alcohol, caffeinated drinks such as coffee, tea, and cola, which are potent stimulants of acid secretion, and aspirin, should be avoided. There are recent studies that show that smoking increases the time of healing in gastric ulcer, and that there is an increased incidence of duodenal ulcer in smokers regardless of alcohol and coffee ingestion.

Aren’t there any other dietary restrictions?
No. The traditional ulcer diet of milk, crackers and other soft bland foods, which was rigidly prescribed for decades, has largely been scrapped in recent years. In the early stages of treatment, a bland diet may be quite helpful.

Do you mean I can eat anything I want? Like?
If the pizza doesn’t bother you, yes. When your ulcer is acting up, you probably will not wish to eat certain foods. At other times, eat whatever you prefer – within reason, of course. If it bothers you, leave it alone.

Does psychotherapy help?
Unless there is severe deep-seated neurosis compounding the problem, psychotherapy plays no role in the treatment of peptic ulcer. Psychological factors, however, are of importance and ideally the patient should understand the stressful factors involved in his/her condition – a conflict at home or at work, a tendency to bottle up emotions – and to remedy or modify them as far as possible.

Can surgery cure an ulcer?
There is no 100 percent cure. But in a small percentage of cases, complications occur that require surgery. When the ulcer becomes so deep that there is a perforation of the stomach or duodenal wall and bleeding, or when the stomach outlet to the duodenum, the pylorus, becomes obstructed by ulcer scar tissue or muscle spasm, an operation may be necessary.

One type of operation for ulcers involves removal of portions of the stomach that secrete acid and pepsin, also removal of the glands that produce gastrin, a hormone that stimulates acid secretion.

In another type of operation, called vagotomy, the vagus nerve, which links the brain with the stomach and stimulates acid production, is cut. This blocks the excessive production of acid, but may result in some undesirable side effects as the vagus nerve has other important functions that are disrupted.

In the future, it is hoped that the unwanted side effects of vagotomy will be avoided by a promising new operation that is now being evaluated. In this type of operation, only those branches of the vagus nerve that go to the acid secreting portions of the stomach are severed.Thus, there is no interference with other functions.

Generally, when surgery is required, there is a 90-95 percent chance that the ulcer will not recur. Thus, although surgery should be avoided until necessary, the operation is highly successful in preventing recurrence of the ulcer.

With present treatment methods, can I indulge in sports and other strenuous activities?
By all means. Sports, which relieve tension, are good for you. Some of our leading athletes are ulcer patients. Millions of people who have had recurrent ulcers for 10, 20, 30 years lead vigorous, productive lives. With proper care, there is no reason why you can’t do the same.