Tummy trouble

Peptic ulcers are holes in the lining of the gastrointestinal tract. They are commonly referred to as ulcerations of the stomach and duodenum. However, if exposed to acid and pepsin, ulcers can develop in other parts of the gastrointestinal tract as well.

The good news is that nowadays, the common use of antacids has helped in reducing the frequency of ulcers.

Common symptoms

Abdominal pain is the cardinal symptom of a peptic ulcer. The pain starts 2 to 3 hours after meals and is relieved by food or antacid. In 60 per cent of patients, the pain is so much that it awakens them at night. Some individuals may also lose weight. Occasionally, it is found that there are no symptoms at all, and the patient presents directly with complications.

Another common symptom is dyspepsia [indigestion]. If the dyspepsia is persistent—for more than three weeks or it keeps relapsing—you may have developed an ulcer.

Causes of peptic ulcers

In the early 20th century, stress and diet were considered as the most important factors that cause peptic ulceration. Hence, people were advised hospitalisation, bed rest and a bland diet. However, now it has been cleared that the main culprit behind ulcers is an organism known as the Helicobacter pylori.

Here are some of the main factors that cause peptic ulcers:

• Gastric acid production is the most important cause for peptic ulcer. The stomach produces acid, which is required for normal functioning of the digestive system. Normally, even though the acid is concentrated, a special protective mechanism lining the wall of the stomach prevents damage to the mucosa. But whenever the balance between the acid and the mucosal protection is lost, the walls of the stomach get damaged. This damage increases if the balance is not restored, and an ulcer is formed.
• Non-steroidal anti-inflammatory drugs [NSAID] consist of the commonly used painkillers such as ibuprofen, diclofenac, and aspirin. These drugs are commonly used for arthritis and other chronic pain problems. They weaken the defence of the stomach and are a very common cause of ulcers.
• The bacterium, Helicobacter pylori causes an infection of the stomach. Present in the stomach lining, it weakens the defence mechanism. It is now the commonest cause of peptic ulcer. When peptic relapse after healing, the relapse usually happens because of this bacterium.
• Cigarette smoking is a risk factor for acid peptic disease and its complications. Tobacco impedes the healing of peptic ulcer and predisposes to relapse but does not directly cause the ulcer.
• Contrary to popular belief, spicy foods are unlikely to cause ulcers, though it causes pain in patients with ulcers.
• Emotional stress also contributes to ulcers.

The complications

Complications of peptic ulcer are bleeding, perforation and obstruction.

• When the peptic ulcer burrows into blood vessels, bleeding occurs. This complication is commonly associated with the prolonged use of aspirin and painkillers. The bleeding can be severe and manifests as vomiting of blood or passing of blood in stools. In patients with significant bleeding, there is 5 to 10 per cent mortality.
• Perforation or rupture in the gastrointestinal tract is associated with severe unremitting pain. It usually requires immediate surgery.
• Obstruction is when the peptic ulcers deform the stomach and duodenum causing pain, bloating, vomiting and loss of weight.

Diagnosis

Peptic ulcers are diagnosed with the help of flexible endoscopy. In this procedure, a flexible endoscope about one centimetre in diameter is passed through the throat into the stomach to directly see the oesophagus, stomach and duodenum. The ulcer is identified easily as a white patch surrounded by red inflamed stomach. It is a safe procedure of about 4 to 5 minutes, performed under local anaesthesia. There are hardly any complications and it is rare for an endoscopy to miss an ulcer. Endoscopy also helps to detect complications of peptic ulcers like bleeding and obstruction. Perforation is detected by an x-ray examination.

Biopsies are taken from the stomach to rule out cancer. The biopsies also detect a Helicobacter pylori infection. Earlier, barium x-rays were used to diagnose ulcers, but now with the advent of endoscopy, it's no longer used.

The treatment involved

History of regular use of NSAID and cigarette smoking increases the probability of having a peptic ulcer. In such a situation, medical consultation is required. If symptoms persist despite treatment, endoscopy should be done to diagnose peptic ulcer. Most of the patients with dyspepsia would have only a mild inflammation of the stomach on endoscopy and not a peptic ulcer.

Ulcers are healed with potent antacids, which reduce the acid secretion to almost zero. This helps heal the ulcer in more than 98 per cent of patients in 12 weeks. In case of a Helicobacter pylori infection, antibiotics are prescribed. Patients are advised to have bland food initially, and then allowed to have normal, non-spicy food.