Bellyaches

By Peter Galvin, MD

The upper intestinal tract, which includes the lower esophagus, stomach, and proximal small intestine (duodenum), has a mucosal lining, or barrier, that protects the tissues from the very strong acids and bile salts that digest consumed foods. A break in that lining, known as a peptic ulcer, may occur in any part of the upper intestinal tract. The two most common types of peptic ulcers are gastric ulcers, which occur in the stomach, and duodenal ulcers, which occur in the first, or proximal, part of the duodenum. About 1% of the U.S. population has peptic ulcer disease (PUD), and an estimated 10,000 people die every year from PUD.

Infection with a bacterium called Helicobacter pylori causes about 42% of PUD, although only about 10% of those with H pylori develop a peptic ulcer. About 36% of PUD is associated with the use of non-steroidal anti-inflammatory medications (NSAIDs) such as aspirin or ibuprofen. Other risk factors for PUD include cigarette smoking, psychological stress, a family history of PUD, and adverse living circumstance like crowded living conditions and poor water quality. Some people with PUD have no symptoms, but about 81% of people will have upper abdominal pain or discomfort, called dyspepsia (as a side note, Pepsi cola was originally developed as a treatment for dyspepsia). Classically, the pain associated with duodenal ulcers will improve immediately with eating, only to return several hours later. Heartburn or acid regurgitation occurs in 46% of those with PUD, and 29% have bleeding ulcers.

Complications of PUD include gastrointestinal bleeding, which may lead to vomiting blood (hematemesis); obstruction, which prevents food from passing through and causes abdominal pain, bloating, and recurrent vomiting; and ulcer perforation, which causes sudden, severe pain and can quickly lead to shock and death if not treated with emergency surgery. PUD is diagnosed by upper endoscopy, which allows direct visualization of the ulcer and can be used to apply topical treatments if the ulcer is bleeding. It can also take tissue samples to test for the presence of H pylori. H pylori can also be tested for using stool or breath tests.

The mainstay of PUD treatment is the reduction or elimination of stomach acid, which allows the ulcer to heal. Primarily, this is accomplished by the use of proton-pump inhibitors (PPIs), such as omeprazole or lansoprazole. With treatment, most ulcers will heal within four weeks, but larger ulcers may require an additional two to four weeks to heal. Antacids are appropriate only for temporary symptom relief. Patients with H pylori infection should receive a PPI, bismuth (i.e., Pepto-Bismol), and up to three antibiotics, which are selected based on patterns of H pylori antibiotic resistance in the local area.

For those who develop PUD due to the use of NSAIDs, stopping that medication leads to healing of the ulcer in 95% of cases. For those who need to continue to use an NSAID, options include switching from an oral to a topical NSAID, using a different anti-inflammatory drug (for example a COX-2 inhibitor such as meloxicam, which has a much lower incidence of ulcers and bleeding), or adding a PPI.

For more information go to the website of the American College of Gastroenterology at www.gi.org

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