Peptic ulcer

Peptic ulcers occur when the production of gastric acid in the stomach increases. They also occur when the protection of stomach wall is compromised. Whenever the balance between the acid and the mucosal protection is lost, an ulcer is formed. Commonly-used painkillers weaken the defence of the stomach and are a common cause of ulcers.

Symptoms: Burning abdominal pain is the cardinal symptom of peptic ulcer—pain usually occurs a few hours after meals. In most cases, the pain awakens the affected person at night. Occasionally, those with peptic ulcer are devoid of symptoms and directly experience complications like bleeding. The bleeding can be severe and manifests as blood vomiting or passing of blood in the stools.

Diagnosis: This is done by flexible endoscopy. Endoscopy also helps to detect complications of peptic ulcers such as bleeding and obstruction.

Remedy: Pain is usually relieved by eating some food or taking an antacid. In severe cases, surgery is the only option.

Treatment: Once peptic ulcer has been diagnosed, using painkillers [especially Nonsteroidal Antiinflammatory Drugs or NSAIDS] is prohibited. Antacids like omeprazole or rabeprazole, which minimise the acid secretion, are administered in high doses. Tests are done to diagnose and cure all factors [stomach infections] that may be weakening the stomach wall. During the treatment, eat bland food and abstain from tobacco and alcohol.

Gastro oesophageal reflux disease [GERD]

GERD is caused by a reflux of stomach contents into the oesophagus. This is the commonest GI problem; almost 15 per cent of people have heart burn at least once a week.

Symptoms: A burning sensation is experienced in the chest or abdomen, which may move up and down the chest like a wave. When severe, it may radiate to the sides of the chest, the neck and the angles of the jaw. Occasionally, a patient may have difficulty in swallowing solid food [dysphagia] due to narrowing of the oesophagus. The reflux of stomach contents into the wind pipe and lungs may also cause chronic cough and throat hoarseness.

Diagnosis: In most patients, the diagnosis is made by history alone. Diagnostic tests are required in patients with persistent symptoms or those who have complications like bleeding or dysphagia. Diagnostic tests include an upper GI endoscopy to look for injury of the oesophagus wall or even a 24 hour pH metry [a test that monitors acid exposure . Those with severe GERD may develop complications such as Barrett’s oesophagus, which is a premalignant condition. Such patients require undergoing routine surveillance endoscopy.

Remedy: Sitting in an upright position and drinking plenty of water helps. Taking antacids is a more reliable remedy. Drugs like omeprazole and rabeprazole help in reducing acid secretions. Occasionally, surgery may be required to strengthen the anti-reflux barrier.

Treatment: GERD can be managed by modifying certain lifestyle habits—taking small frequent meals, weight reduction [if obese], abstaining from tobacco, alcohol and fatty foods. Not consuming mint and orange juice also helps. You may also need to avoid some drugs like calcium channel blockers and beta blockers for hypertension.

Acute viral hepatitis

This disease is caused by hepatitis A, B, C and E viruses of which A and E are food or waterborne viruses. The hepatitis A virus is transmitted by contaminated food, water, milk or sometimes, even person-to-person. This virus commonly affects children. By adulthood almost everybody is exposed to hepatitis A virus.

Symptoms: Although symptoms of viral hepatitis are variable, they often include—anorexia, nausea vomiting and fever. Jaundice usually follows a few days later. Itching develops later and can be quite troublesome. It can also cause hepatic [liver] failure, but only in rare cases.

Diagnosis: Liver function tests [which are blood tests] and viral markers help diagnose viral hepatitis.

Remedy: There is no temporary relief available. As sanitation and hygiene improves in a community the incidence of hepatitis A infection reduces.

Treatment: This is a self-limiting disease and treatment is usually only to control the symptoms. Vaccines are available against A and B virus. The best precaution is to ensure the food and water we consume is not contaminated.

Acute gastroenteritis

Gastroenteritis is caused due to a bacterial or viral infection. Bacterial infections which are seen in association with poor hygiene and sanitation are more common. Viral gastroenteritis lasts for one or two days, but the bacterial cases can last longer.

Symptoms: Fever, vomiting, diarrhoea and abdominal pain are common symptoms. More serious symptoms include blood vomiting, blood in the stool, very high fever and extreme dehydration.

Diagnosis: The doctor usually diagnoses acute gastroenteritis by physically examining the patient and enquiring about his/her medical history. If symptoms persist, blood and stool tests may be needed.

Remedy: Maintain strict personal hygiene and keep a watch on what you eat or drink. Avoid unhygienic places and eat hot home-cooked food.

Treatment: Antibiotics are given depending upon the cause of gastroenteritis. In case of severe dehydration, oral rehydration therapy [ORT] is prescribed and in extreme cases intravenous fluids are administered.

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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.

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