So You Think You Have an Ulcer?
YOU’VE just walked out of the doctor’s office—with more questions than answers. ‘He thinks I have an ulcer! Unbelievable! How would I have got that? More importantly, what can I do about it?’
The problem of peptic ulcer disease is not a small one. In the United States alone, it is estimated that each year eight million people are treated for ulcer disease at a cost of approximately four billion dollars. Furthermore, in recent years medical discoveries about ulcers have caused traditional treatments to be challenged. What would you say? Is milk good for ulcers? Is alcohol bad? How about spicy foods? What is the most prescribed drug in the United States today? The answers may surprise you.
What Is an Ulcer?
An ulcer is a local defect, or excavation, of the surface of an organ or tissue, and it is produced by the sloughing of inflammatory necrotic tissue. Peptic ulcer disease can be classified into two basic categories, gastric ulcers (ulcers that occur in the stomach) and duodenal ulcers (ulcers that occur in the first part of the intestine just outside the stomach). To put it simply, an ulcer represents a sore, or an erosion, in the lining of the wall of the stomach or the duodenum. This sore is caused by the action of strong chemicals produced by the stomach, namely, hydrochloric acid and pepsin (hence the name, peptic ulcer). If the ulcer is severe it may extend clear through the wall of the stomach, a very serious complication called a perforation. Serious hemorrhage can occur if the erosion of the ulcer involves a major artery in the area. In long-standing disease a duodenal ulcer may be further complicated by extensive scarring and stricture so that the lower end of the stomach is obstructed.
What Causes an Ulcer?
Many researchers are fond of saying that peptic ulcer is “multifactorial,” meaning there are many factors contributing to the disease. Much has yet to be learned. It has been observed for decades, for example, that the incidence of ulcer rises markedly in the spring and in the fall—just why, nobody knows.
Nevertheless, there are several factors that have been proved to contribute to the development of an ulcer. Heredity, for example, plays an important role. A number of family studies and studies of twins indicate that there is about a threefold likelihood of duodenal ulcer in close relatives of patients with duodenal ulcer. Cigarette smoking, too, is a proved cause of ulcer disease. The bulk of evidence indicates that cigarette smokers have an increased incidence of both gastric and duodenal ulcer. Furthermore, smokers have slower healing of their ulcers than do nonsmokers, and they have more ulcer-related complications such as hemorrhage or perforation, as well as a higher ulcer-related death rate.
What about alcohol? There is no evidence to indicate that moderate alcohol intake is associated with an increased incidence of ulcer. In fact, G. D. Friedman and associates reported that those patients who drank minimal quantities of alcohol had a lower incidence of ulcer than did those who were nondrinkers. It is interesting how this verifies Paul’s counsel to Timothy at 1 Timothy 5:23: “Use a little wine for the sake of your stomach.”
This leads us into the topic of diet as both cause and cure of ulcer disease. For many decades folklore taught that ulcers were caused by a diet of hot, spicy foods and were cured by a bland diet. But recent medical studies have tended to dispute these commonly held views. There is no evidence that certain ethnic groups (for example, Mexican-Americans) who tend to eat highly seasoned food have more ulcer disease than do those who avoid highly seasoned food. Certainly coffee, decaffeinated or regular, and cola beverages are potent stimulators of gastric acid, but their role in the cause of ulcers remains unsettled.
As far as drugs are concerned, it is often difficult to prove that a certain drug actually caused an ulcer. Aspirin is the drug that has been studied most thoroughly and has been clearly shown to be associated with an increased incidence of gastric ulcer.
What about emotional factors? It has been commonly held that stress and tension are strongly associated with the development of peptic ulcer. Recently the Scriptural thought that “a heart that is joyful does good as a curer, but a spirit that is stricken makes the bones dry” has been proved true. (Proverbs 17:22) Medical studies have shown that in many ulcer patients stressful events either immediately preceded the clinical appearance of peptic ulcer or may have been present for many years beforehand.
In any event, whether from too much stress, too much smoking, too much caffeine or from heredity, the final common pathway leading to the formation of an ulcer is too much acid.
What Are the Symptoms?
The primary symptom is pain—pain usually in the upper abdomen, often described as burning in nature, occurring a few hours after meals, or awakening the patient at 1:00 or 2:00 a.m. The pain sometimes is relieved by meals or antacids, but this is not a clear-cut indicator. In fact, in one hundred hospitalized duodenal ulcer patients, 40 percent said meals made the pain worse. Careful analysis of ulcer patients indicates that the most sensitive symptom is stomach pain that awakens the patient at night.
As you may have deduced by now, it is difficult to make the diagnosis of ulcers from the symptoms alone. The basic screening test for finding out whether one does or does not have an ulcer is the stomach X ray, or UGI (Upper Gastro Intestinal), in which the patient drinks a radiopaque, milklike substance to outline the esophagus, stomach and duodenum. A newer study, which has been found to be more precise, although slightly more uncomfortable and more expensive, is endoscopy. The patient swallows a small lighted tube, through which the doctor can actually see and take samples from the ulcer.
What Is the Treatment for Ulcers?
As a rule, an ulcer is not a serious, life-threatening thing. In fact, nowadays a patient usually need not be hospitalized for treatment of his ulcer. It must even be mentioned that many ulcers will heal on their own (34 percent in one study, with no medical treatment). But the goals of treatment with medicines are to diminish pain, speed healing, decrease complications and prevent recurrences. There are two types of medications that have been proved effective in accomplishing these goals.
The first of these is the antacid, which simply serves to neutralize excess stomach acid. In fact, in spite of all the new medications, antacids, if properly used, still seem to be the best treatment for most ulcers. Although there are many kinds of antacids, most are equally effective if taken in proper dosages—usually two tablespoons of the liquid one hour after eating, three hours after eating, and at bedtime. Though some find it a nuisance to take the medication in this way, on the whole, antacids are very safe and effective.
In the past few years a major new advance in the medical treatment of ulcers has been the development of a drug called cimetidine, known by the brand name Tagamet. This medicine comes in pill form and is generally recommended to be taken four times a day. It works not by neutralizing the acid that is formed in the stomach but by blocking the production of acid. It is very effective, has high patient acceptance and very few side effects. As with any other effective medication, there is a tendency for it to be overused, and this is now becoming worrisome to some physicians. What did you suspect was the most prescribed drug (in terms of dollar cost to the patient) in the United States last year—Valium, Librium or one of the other tranquilizers? No. Surprisingly, it was Tagamet. Thus the concern is that the medication is too easily prescribed for any kind of stomach pain.
Yet, for the patient who does have peptic ulcer, Tagamet is quite effective in rapidly diminishing the pain and speeding the healing. In essence it is as effective as the antacids and is much easier to take, although more expensive.
What about diet therapy for ulcers? The days of milk diets or even bland diets to cure ulcers may well be passing. Some studies have even shown that milk can actually be harmful in some ulcer patients because, although milk temporarily relieves the symptoms, it leaves the stomach quickly and can then cause the stomach to pour out more acid. Thus, today most doctors don’t put their ulcer patient on any strict diet. They tell him to eat a well-rounded diet and enjoy his food, and caution him only to avoid foods that seem to bother him.
A few comments on the role of surgery for the patient with peptic ulcer. The principal indication for operation in ulcer patients is for the treatment of complications, such as perforation, bleeding or obstruction. Although any surgical decision must be individualized, in general the safest, most effective ulcer operation is the selective gastric vagotomy, which involves cutting only those tiny nerves to the stomach that cause acid to be secreted. But surgery for ulcer is really a last resort since most ulcers can be taken care of with medications.
How Can I Keep From Getting an Ulcer?
Certainly any genetic tendency toward ulcers that we may have inherited through our imperfection is beyond our control. Keeping in mind the above principles, however, there are a few measures that may be highlighted to help prevent this painful medical problem. First and foremost, avoid the unhealthy habit of tobacco smoking. Second, avoid abusing over-the-counter medications, especially those containing aspirin. Third, if one has noticed that certain foods, such as highly seasoned spicy foods or caffeine, seem to bother the stomach, it would be wise to avoid them.
A word of caution: Although antacids may be safely used for a mild stomach upset, if the pain continues and the patient loses weight and has a change in bowel habits, he should seek medical attention promptly. These may be symptoms of another problem more serious than simple ulcer disease.
Finally, perhaps most importantly, the patient who is prone to ulcer problems would do well to pay attention to the wise Biblical admonition at Proverbs 14:30, “A calm heart is the life of the fleshly organism.”
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A Word of Caution
Although antacids are often used for a mild stomach upset, if the pain continues and you lose weight and have a change in bowel habits, you should seek medical attention promptly. These may be symptoms of another problem more serious than ulcers.
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To Help Prevent Ulcers:
1. Foremost, avoid the unhealthy habit of tobacco smoking.
2. Avoid abusing over-the-counter medications, especially those containing aspirin.
3. If one has noticed that certain foods, such as spicy foods or caffeine, seem to bother the stomach, it would be wise to avoid them.