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What is a peptic ulcer?
A peptic ulcer is a sore on the lining of the stomach or duodenum,
which is the beginning of the small intestine. Peptic ulcers are
common: One in 10 Americans develops an ulcer at some time in his
or her life. One cause of peptic ulcer is bacterial infection, but
some ulcers are caused by long-term use of nonsteroidal
anti-inflammatory agents (NSAIDs), like aspirin and ibuprofen. In
a few cases, cancerous tumors in the stomach or pancreas can cause
ulcers. Peptic ulcers are not caused by stress or eating spicy
food, but these can make ulcers worse.
What is H. pylori?
Helicobacter pylori (H. pylori) is a type of bacteria. Researchers
believe that H. pylori is responsible for the majority of peptic
ulcers.
H. pylori infection is common in the United States. About 20
percent of people under 40 years old and half of those over 60
years have it. Most infected people, however, do not develop
ulcers. Why H. pylori does not cause ulcers in every infected
person is not known. Most likely, infection depends on
characteristics of the infected person, the type of H. pylori, and
other factors yet to be discovered.
Researchers are not certain how people contract H. pylori, but
they think it may be through food or water.
Researchers have found H. pylori in the saliva of some infected
people, so the bacteria may also spread through mouth-to-mouth
contact such as kissing.
How does H. pylori cause a peptic ulcer?
H. pylori weakens the protective mucous coating of the stomach and
duodenum, which allows acid to get through to the sensitive lining
beneath. Both the acid and the bacteria irritate the lining and
cause a sore, or ulcer.
H. pylori is able to survive in stomach acid because it secretes
enzymes that neutralize the acid. This mechanism allows H. pylori
to make its way to the "safe" area—the protective mucous lining.
Once there, the bacterium's spiral shape helps it burrow through
the lining.
What
are the symptoms of an ulcer?
Abdominal discomfort is the most common symptom. This discomfort
usually
- is a dull, gnawing ache
- comes and goes for several days or weeks
- occurs in the middle of the night—when the
stomach is empty
- is relieved by eating
- is relieved by antacid medications
Other symptoms include
- weight loss
- poor appetite
- bloating
- burping
- nausea
- vomiting
Some people experience only very
mild symptoms, or none at all.
Emergency Symptoms
If you have any of these symptoms, call your doctor right away:
- sharp, sudden, persistent stomach pain
- bloody or black stools
- bloody vomit or vomit that looks like coffee
grounds
They could be signs of a serious
problem, such as
- perforation—when the ulcer burrows through
the stomach or duodenal wall
- bleeding—when acid or the ulcer breaks a
blood vessel
- obstruction—when the ulcer blocks the path of
food trying to leave the stomach
How is
an H. pylori-related ulcer diagnosed?
Diagnosing an Ulcer
“H. pylori” bacteria.
H. pylori bacteriaTo see whether symptoms are caused by an ulcer,
the doctor may do an upper gastrointestinal (GI) series or an
endoscopy. An upper GI series is an x ray of the esophagus,
stomach, and duodenum. The patient drinks a chalky liquid called
barium to make these organs and any ulcers show up more clearly on
the x ray.
An endoscopy is an exam that uses an endoscope, a thin, lighted
tube with a tiny camera on the end. The patient is lightly
sedated, and the doctor carefully eases the endoscope into the
mouth and down the throat to the stomach and duodenum. This allows
the doctor to see the lining of the esophagus, stomach, and
duodenum. The doctor can use the endoscope to take photos of
ulcers or remove a tiny piece of tissue to view under a
microscope. This procedure is called a biopsy. If an ulcer is
bleeding, the doctor can use the endoscope to inject drugs that
promote clotting or to guide a heat probe that cauterizes the
ulcer.
Diagnosing H. pylori
If an ulcer is found, the doctor will test the patient for H.
pylori. This test is important because treatment for an ulcer
caused by H. pylori is different from that for an ulcer caused by
NSAIDs.
H. pylori is diagnosed through blood, breath, stool, and tissue
tests. Blood tests are most common. They detect antibodies to H.
pylori bacteria. Blood is taken at the doctor's office through a
finger stick.
Urea breath tests are an effective diagnostic method for H.
pylori. They are also used after treatment to see whether it
worked. In the doctor's office, the patient drinks a urea solution
that contains a special carbon atom. If H. pylori is present, it
breaks down the urea, releasing the carbon. The blood carries the
carbon to the lungs, where the patient exhales it. The breath test
is 96 percent to 98 percent accurate.
Stool tests may be used to detect H. pylori infection in the
patient's fecal matter. Studies have shown that this test, called
the Helicobacter pylori stool antigen (HpSA) test, is accurate for
diagnosing H. pylori.
Tissue tests are usually done using the biopsy sample that is
removed with the endoscope. There are three types:
- The rapid urease test detects the enzyme
urease, which is produced by H. pylori.
- A histology test allows the doctor to
find and examine the actual bacteria.
- A culture test involves allowing H. pylori to
grow in the tissue sample.
In diagnosing H. pylori, blood,
breath, and stool tests are often done before tissue tests because
they are less invasive. However, blood tests are not used to
detect H. pylori following treatment because a patient's blood can
show positive results even after H. pylori has been eliminated.
How are H. pylori peptic ulcers treated?
H. pylori peptic ulcers are treated with drugs that kill the
bacteria, reduce stomach acid, and protect the stomach lining.
Antibiotics are used to kill the bacteria. Two types of
acid-suppressing drugs might be used: H2 blockers and proton pump
inhibitors.
H2 blockers work by blocking histamine, which stimulates acid
secretion. They help reduce ulcer pain after a few weeks. Proton
pump inhibitors suppress acid production by halting the mechanism
that pumps the acid into the stomach. H2 blockers and proton pump
inhibitors have been prescribed alone for years as treatments for
ulcers. But used alone, these drugs do not eradicate H. pylori and
therefore do not cure H. pylori-related ulcers. Bismuth
subsalicylate, a component of Pepto-Bismol, is used to protect the
stomach lining from acid. It also kills H. pylori.
Treatment usually involves a combination of antibiotics, acid
suppressors, and stomach protectors. Antibiotic regimens
recommended for patients may differ across regions of the world
because different areas have begun to show resistance to
particular antibiotics.
The use of only one medication to treat H. pylori is not
recommended. At this time, the most proven effective treatment is
a 2-week course of treatment called triple therapy. It involves
taking two antibiotics to kill the bacteria and either an acid
suppressor or stomach-lining shield. Two-week triple therapy
reduces ulcer symptoms, kills the bacteria, and prevents ulcer
recurrence in more than 90 percent of patients.
Unfortunately, patients may find triple therapy complicated
because it involves taking as many as 20 pills a day. Also, the
antibiotics used in triple therapy may cause mild side effects
such as nausea, vomiting, diarrhea, dark stools, metallic taste in
the mouth, dizziness, headache, and yeast infections in women—most
side effects can be treated with medication withdrawal.
Nevertheless, recent studies show that 2 weeks of triple therapy
is ideal.
Early results of studies in other countries suggest that 1 week of
triple therapy may be as effective as the 2-week therapy, with
fewer side effects.
Another option is 2 weeks of dual therapy. Dual therapy involves
two drugs: an antibiotic and an acid suppressor. It is not as
effective as triple therapy.
Two weeks of quadruple therapy, which uses two antibiotics, an
acid suppressor, and a stomach-lining shield, looks promising in
research studies. It is also called bismuth triple therapy.
Drugs Used to Treat H. pylori Peptic
Ulcers
Antibiotics: metronidazole, tetracycline, clarithromycin,
amoxicillin
H2 blockers: cimetidine, ranitidine, famotidine, nizatidine
Proton pump inhibitors: omeprazole, lansoprazole,
rabeprazole, esomeprazole, pantoprozole
Stomach-lining protector: bismuth subsalicylate
Why don’t all doctors automatically check
for H. pylori?
Changing medical belief and practice takes time. For nearly 100
years, scientists and doctors thought that ulcers were caused by
stress, spicy food, and alcohol. Treatment involved bed rest and a
bland diet. Later, researchers added stomach acid to the list of
causes and began treating ulcers with antacids.
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