By Dr. ANUMA KALU ULU
In medical terms, an ulcer is a wound so a skin ulcer will mean a skin wound and in the same vein, a stomach ulcer would mean a wound in the stomach.
However, ‘stomach’ ulcers as known in Nigeria are actually medically called peptic ulcers and comprise stomach ulcers and duodenal ulcers. Duodenum here stands for the C-shaped first part of the small intestine into which the stomach opens. These ulcers are called peptic ulcers as derived from pepsin, the acidic enzyme secreted by the stomach to aid in digestion of foods, mostly proteins. In excess amount or in the absence of food or other substrates in the stomach, this enzyne can eat into the stomach lining, causing ulcers. Stomach ulcers are also called gastric ulcers.
Although we are talking about peptic ulcers today, i shall not fail to mention other maladies that mimic peptic ulcers and which form a spectrum from the most benign to the most sinister, with similar treatment to peptic ulcers. They include dyspepsia (indigestion), esophagitis, gastritis and gastro-esophageal reflux (GERD). Their causes are similar and include peptic acid, alcohol, cigarettes, medications, some foods, invasive procedures causing direct injury to the lining of their walls and infections with organisms like Helicobacter pylori. I shall define each of these separately because although their symptoms are similar, they also have a few individual subtleties and I shall proffer their remedies subsequently.
Dyspepsia simply means indigestion and can present with bloating, a sense of abdominal fullness with early satiety as well as upper abdominal and chest pain. It is caused by poor digestion of foods with resulting prolonged accumulation of the food in the stomach and its sequelae.
Esophagitis means irritation of the esophagus (called oesophagus in Nigeria) which is the part of the alimentary canal between the mouth and the stomach, and mostly caused by peptic acid. There are other causes like medications including bisphosphonates useful in calcium metabolism, like alendronate. The pain here is described as heartburn
Gastritis is irritation of the stomach wall and is caused mostly by alcohol and cigarettes and to a lesser extent by other things like medications including many pain killers such as cataflam, brufen (ibuprofen), naproxen, etc; H.pylori infection, invasive surgical procedures, etc. It usually presents with vomiting which could be bloody, coffee-grounds, bilious or just watery.
GERD is usually caused by a weak gastro-esophageal sphincter (the valve in the lower end of the esophagus at its junction with the stomach which normally prevents stomach contents from flowing back into the esophagus) with resulting flow back or reflux of gastric acid from the stomach into the lower esophagus. The stomach lining is thick (remember the meat delicacy called ‘towel’ which is actually the stomach wall) and can withstand the gastric acid to a large extent with no resulting injuries but when this same gastric acid flows back into this lower esophagus with relatively thinner and more fragile wall (remember your meat delicacy called round-about which includes this part of the alimentary canal), it eats away at this exposed esophagus resulting in the irritation and injury known as GERD.
I shall take peptic ulcers (stomach ulcers and duodenal ulcers) together since they are mostly differentiated by location as their causes and general presentation are similar. A typical Nigerian thinks ulcers are only caused by not eating in time and this is so far from the truth. All the causative factors for the spectra of diseases listed above are also implicated in ulcers but the final common pathway is via increased activity of peptic acid secreted by the stomach. It could be by hypersecretion of the acid overwhelming and eating into an intact stomach wall resulting in the ulcer and this type is not significantly modulated by timing of meals, as in a syndrome called Multiple Endocrine Neoplasia-1 ( MEN-1) This hypersecretion can also be elicited by eating a large amount of food with resulting distension of the abdominal wall, setting off a reflex that induces the stomach to secrete copious amount of acid, since the distension senses the presence of food. This increased acid can also eat into the stomach lining causing ulcers. At regular intervals, there is a basal acid secretion from the stomach which is unrelated to the presence of food and are usually not deleterious, but when people do not eat with set frequency but in a haphazard fashion, the basal acid not encountering any substrates in the stomach can accumulate and start eating into the stomach lining. This is the type we know much of in Nigeria
For duodenal ulcers, the cause is chiefly overflow of gastric acid from the adjoining stomach especially in hypersecretory states. Usually, the duodenum receives the liver secretion (bile) and pancreatic secretion and these 2 secretions are alkaline so they neutralize the acidic contents from the stomach once they reach the duodenum. In situations of decreased secretion of above alkaline fluids or blockage of their outflow or in situations of excessive stomach acid secretion and invariably an astronomical overflow into the duodenum, then the acid can eat into the duodenal wall causing ulcers. As a rule of thumb, people with stomach ulcers try to avoid eating because the churning of such foods in the stomach physically scrapes at the ulcer causing increased pain and discomfort, and as such they tend to be thin. On the other hand, those with duodenal ulcers eat a lot because their pain is worse when hungry, because there is no food in the stomach for the basally-secreted acid to work on, so more free acid flows into the duodenum causing injury and pain. These people usually look buxom because they eat a lot and their pain is usually worse in the early mornings like say 4am, 5am etc because there has not been any food in the stomach since dinner.
Apart from already enumerated symptoms of peptic ulcer, sufferers could present with their abdomen feeling hot and making loud noises, also with burning abdominal and chest pain, or squeezing upper abdominal or chest pain or even throat pain, like somebody having a heart attack. They can also present with back pain or a sharp pain to the sides as if hooked by something. This is because the stomach moves around and can float to any of these places though still anchored, carrying its symptoms to these destinations. In fact, most of the cases termed worm infestations in Nigeria are actually peptic ulcers.
The gold standard here is endoscopy, which is passage of a camera mounted on a slender instrument down the mouth into the stomach to physically visualize the lesions, but this is not readily available everywhere in Nigeria, so what do we do? The next best thing is barium swallow, where somebody drinks an opaque substance and plain x-rays are taken to show a filling defect. This too requires some preparation and wont be available everywhere, like in the villages. The rampant practice in Nigeria of sending people for occult blood in stool and diagnosing them with peptic ulcer just because of the presence of blood in their stools is totally asinine and defies all reasonable postulation. This abracadabra presupposes either that all peptic ulcers cause bleeding or that the only causes of gastrointestinal bleeding are peptic ulcers, both postulations being so far divorced from reality!! For starters, there are more frequent causes of gastrointestinal bleeding than peptic ulcers including hemorrhoids ( which we call piles in Nigeria), rectal prolapse, colonic polyps, diverticulosis, colon cancers, rectal fistulae, anal fissures and anal tears. On the hand , the incidence of bleeding ulcers is so low compared to the total incidence of ulcers, and occurs only when the ulcer physically erodes a blood vessel, just like skin ulcers will bleed if a blood vessel is compromised.
So how do I diagnose peptic ulcers in my village Obiene Ututu in Abia State or my medical mission sojourns to Obinofia in Ezeagu and Akpugo both in Enugu state devoid of other ancillary services. Simply, clinically by asking about symptoms and eliciting pain when I press down on the epigastric region, being the first part of the stomach just immediately below the sternum ( breast bone). At this point it does not matter if it is dyspepsia, esophagitis, gastritis, GERD, stomach or duodenal ulcer since all are treated similarly and give same epigastric pain when palpated. You do not need to give your stool to anybody for diagnosis of peptic ulcer!! Some gastritis can be caused by infection with Helicobacter pylori and this organism can be obtained from biopsy taken during endoscopy or from stool sample ( the only time stool is needed!) or less reliably from the blood, and in specialized centers only.
Avoiding the causative factors like alcohol, cigarettes, etc is the key but in cases where an established disease exists, remedies exist:
Sleeping with head raised on say at least 2 stacked pillows helps to reduce the severity of GERD, since it can help to prevent the acud reflux from the stomach into the esophagus.
Eating in between meals or even nibbling at biscuits etc in between breakfast, lunch and dinner ensures that there is always food in your stomach for the continually-produced stomach acid to act on but you should not eat a large quantity at one time to avoid reflex increased acid production from stretched abdominal wall. Avoid eating uncooked raw peppery food because the pepper can cause burning and stinging in the ulcer resulting in increased discomfort, akin to putting pepper into a skin wound. Same goes for very hot food, as it can burn the ulcer and lead to more discomfort.
Medications will include coating agents that physically cover the ulcer, preventing further damage from foods, stomach acid, etc and include Mistmag trisilicate and Gestid in Nigeria as well as TUMS, Rolaids and Maalox here in the USA. Underneath these, the protected ulcer can heal at its pace.
In the past, Histamine-2 blockers like Ranitidine (Zantac) at 150mg 2x/day or 300mg once daily or Famotidine (Pepcid)20mg once daily or Cimetidine (Tagamet) 400mg 2x/day was used to decrease acid production. Though some still use the medications above especially in the rural areas in Nigeria, proton-pump inhibitors (PPI) like omeprazole 20mg once daily, lansoprazole 30mg once daily, pantoprazole 40mg once daily, esomeprazole 40mg once daily, etc, have revolutionized ulcer treatment. Taken for initial 4 to 8weeks they have good result in healing the ulcers, and occasional flare ups can be quelled with a burst of same medications at intervals. The coating agents above also help. In confirmed H.pylori infection, a combination of 2 antibiotics and a PPI taken for 2 weeks is usually eradicative. This could include Metronidazole (Flagyl) 500mg 2x/day with Clarithromycin (Biaxin) 500mg 2x/day or Amoxicillin 1000mg 2x/day with flagyl 500mg 2x/day. There are other combinations too.
Finally, bleeding ulcers are very rare but when they occur will require surgical evaluation. I hope this will be helpful to the the reader.
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