Originally published in The Ottawa Citizen December 10, 2002
Original Title: It’s my heartburn and I’ll cry if I want to

Part II – Ulcer treatment uses medicine and prevention

A common complaint in the family practice setting is bloating and heartburn. Usually the patient suffers with this condition for several months with the hope that it will spontaneously resolve.

Indeed many become chief financial supporters of the TUMS and Rolaids companies before they conclude that they may need more definitive help. As one who has experienced first hand the gnawing, bloating and searing pit-in-your-stomach pain at three o’clock in the morning, all you want to do is to jump out of your body to escape the pain and discomfort. It is a truly helpless feeling.

Many people believe that stomach (peptic) ulcers occur because of an elevation of acid levels. While this is true for some people, it does not tell the whole story.

The stomach is a food reservoir. Its function is to secrete moderately strong acid and enzymes to predigest proteins and sugars. It regulates the rate that this gruel squirts into the initial portion of the small intestine (duodenum) for further digestion and absorption.

The cells lining both the stomach and duodenum have a number of ways of preventing the acid from digesting itself. They secrete a layer of mucous creating a protective barrier against the ravages of the acidic digestive juices. Another defense mechanism is the secretion of an acid neutralizing substance.

With damage to this lining, the acid can cause ulcerations to the stomach and duodenum. The acid can splash up into the lower portion of the esophagus, the tube connecting the throat and stomach, eroding tissue that has no protection from acid at all. Each year, millions of North Americans develop ulcers.

Some people wait longer than they should before consulting their doctor’s advice because the symptoms can be infrequent or are relieved by over-the-counter medications. The problem is that temporary relief does not necessarily prevent ulcer formation.

• Signs and symptoms of ulcers or excessive acid production include:
• Pain or discomfort (usually in the upper abdomen)
• Bloating
• An early sense of fullness with eating
• Lack of appetite
• Nausea
• Vomiting
• Vomiting digested blood that looks like coffee grounds
• Black and tarry-looking stools (melena) due to a rapidly bleeding ulcer
• Anemia (blood loss)

Many of the symptoms described above can be due to other diseases. Your doctor will be able to help you determine which condition is responsible.

Although there is a by-the-book symptom list for duodenal ulcers, burning, gnawing, aching pinpoint pain just below the bottom tip of the breastbone, it does not need to be so. Symptoms tend to get better after eating and return about an hour and a half thereafter. These symptoms may worsen after midnight when the stomach usually produces the most acid.

People with stomach or gastric ulcers report more severe pain soon after meals. Eating a meal or taking an antacid does not provide much relief.

The common causes of peptic ulcers are infection and anti-inflammatory medications (NSAIDS) such as Ibuprofen (Advil, Motrin) or Acetylsalicylic Acid (ASA) found in Aspirin and other products.

A bacterium frequently found in the stomach, Helicobacter pylori (H. Pylori), is the most common cause of stomach and duodenal ulcers. About half the world’s population harbours it. It causes the release of some toxic substances and enzymes that disrupt the normal protective mucous layer. The cells erode due to the stomach acid leading to chronic inflammation and for some, ulcers.

NSAIDS are responsible for many instances of peptic ulcer disease (not due to H. Pylori) especially in the elderly. The development of NSAID-induced ulcers depends upon the dose, duration and individual patient medical history.

Smoking, alcohol, and caffeine can irritate the stomach lining through direct chemical damage and stimulating acid production. Alcohol and cigarettes interfere with ulcer healing. Various foods do not seem be a contributing factor to ulcer disease. Although some foods are acidic, they are much weaker than stomach acid and contribute little to ulcer formation.

Ulcers can spontaneously heal or continue to erode and potentially hemorrhage: the most serious complication of peptic ulcers. NSAID-induced ulcers in the elderly may not have many symptoms. Unlike younger adults, they have little reserve capacity to deal with rapid blood loss.

Ulcers can perforate allowing the stomach contents to directly empty into the abdomen.

The diagnosis of peptic ulcer disease is not straightforward because there are disease symptoms that mimic peptic ulcers. These conditions range include non-ulcer dyspepsia (ulcer-like symptoms without a specific cause), abnormal stomach emptying, acid reflux (acid splashing up into the esophagus), gallbladder disease and more rarely, stomach cancer. A thorough medical history and appropriate use of tests can lead to the proper diagnosis.

Next week’s column will review some of the tests, therapies and preventive measures available to treat this common disease. Pass the salsa, extra chilies.

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© Dr. Barry Dworkin 2002