A breakthrough in ulcer treatment

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Try answering the following questions.

1. The major cause of ulcers is

a) drugs such as aspirin

b) stress

c) spicy foods and caffeine

d) bacteria

e) a genetic predisposition

f) b & c

2. The most effective treatment for the great majority of ulcers involves

a) antacid drugs such as Mylanta and Tums, which neutralize stomach acid

b) antibiotics

c) drugs that suppress acid secretion in the stomach, including agamet and Zantac

d) a combination of a & c

e) a special diet combined with stress reduction and c

3. True or false? Once an ulcer is cured, recurrence is unlikely.

If you missed one or more (the answers are at the bottom of the page), you're not alone. Even many of the 25 million Americans who suffer from ulcers are lacking in awareness about the causes and treatment of the problem--a knowledge gap that often stands in the way of a successful cure. According to a recent survey of ulcer sufferers, 90 percent mistakenly believe stress causes the problem, and 60 percent incorrectly think it's poor diet.

Most disturbingly, 90 percent have never even heard of the real culprit behind ulcers, the discovery of which has revolutionized treatment. To boost awareness and understanding of the disease, the American Digestive Health Foundation, which represents more than 10,000 gastroenterologists nationwide, recently launched the Ulcer Education Campaign. The goal is to set the record straight on a number of issues that have a major impact on the lives of ulcer sufferers. Who is at risk of getting an ulcer? What kind of dietary regimen is appropriate for people with ulcers? How is stress involved? What is the best course of treatment?

It's not spicy food or your boss
Mention ulcers, and most people think red-hot foods and high-pressure jobs. It's no wonder. For most of this century the origin of ulcers was believed to be dietary factors such as spicy foods and stress, so for decades one of the cornerstones of ulcer management was a restrictive diet made up of bland foods along with stress reduction. These strategies were thought to help minimize the stomach's secretion of acid,which in turn would promote the healing of ulcers.

The rationale made sense, considering that ulcers are irritations or sores that occur either in the lining of the stomach, a part of the small intestine called the duodenum, or, less commonly, the esophagus. In a normal gastrointestinal tract the secretion of stomach acid is perfectly innocuous (it aids in the digestion of food), but in a GI tract with an ulcer it's akin to repeatedly pouring acid over an open wound. Each burst of acid can cause pain and further erode the area in and around the ulcer.

Left untreated, so much of the stomach or intestinal lining is eaten away that the ulcer may begin to bleed, leading to vomiting of blood or blood in the stools. In extreme cases, hemorrhaging can be fatal.

Alternately, an ulcer can become perforated, an emergency medical situation in which the ulcer "breaks through" the lining of the stomach or the intestine--in effect making a hole in the organ's wall. The contents of the stomach or intestine spill into the entire abdominal cavity (which houses the intestines, pancreas, and other organs) and contaminates the area, causing life-threatening shock and inflammation.

To prevent such catastrophes, ulcer sufferers were advised to avoid not only spicy foods but also coffee (even decaffeinated blends) and tea, all of which were thought to trigger excess acid secretion. In addition, they were often told to eat several small meals throughout the day and drink plenty of whole milk. Food, particularly milk, was thought to neutralize the acid and buffer the stomach's lining.

Bed rest, hospitalization, and other means of providing relaxation were also encouraged because stressful situations were thought to boost acid production. And alcohol, which may irritate the stomach lining, was off-limits.

Today, however, experts hold that special diets do nothing to help heal ulcers. Research has shown that even such highly seasoned foods as hot sauce and jalapeno peppers do not cause the secretion of more acid than other foods. As for milk, in the 1980s it was shown that the beverage ranks as a poor buffer of stomach acid because, like other foods, once it hits the stomach it stimulates acid secretion. When it comes to alcohol, coffee, and tea, even moderate amounts have never been shown either to cause ulcers or to prevent them from healing.

Of course, "if a food bothers you, don't eat it," advises C. Mel Wilcox, MD, vice chair of the Ulcer Education Campaign and associate professor of medicine at the University of Alabama at Birmingham. But there's no reason for ulcer sufferers to follow any particular eating plan.

As for stress, again, experts say that its role in ulcer development has long been misunderstood. "Sure, if you put someone in a room with a tube in their stomach to check acid and subject them to stress, their acid output will probably increase," says Dr. Wilcox. But that kind of rise in acid isn't enough to lead to an ulcer or even aggravate an existing one, he says. Admittedly, chronic stress can cause stomach pain as well as back pain and a host of other physical ills. But it doesn't necessarily signal an ulcer.

What it boils down to is that simply decreasing the amount of acid in the stomach---even via antacids and acid-suppressing drugs such as Tagamet and Zantac--is nothing more than a Band-Aid approach to the treatment of most cases of ulcers. While these and other medications do promote the healing of ulcers, the hitch is that with this treatment alone they keep coming back. It takes a different course of intervention to help get rid of an ulcer once and for all.

Pinpointing the bugs in the system
In 1982, two scientists named J. Robin Warren and Barry Marshall discovered something that would change the face of ulcer treatment forever. a tiny, spiral-shaped bacterium nestled in the narrow space between the surface of the stomach lining and the thin overlay of mucous gel covering it. They also observed the bug, dubbed Helicobacter pylori, in stomach tissue that was irritated and inflamed. It came as a surprise because for more than 20 years researchers had kicked around the idea that disease-causing organisms might reside in the stomach, but the consensus had been that bacteria could not withstand the stomach's acidic environment. H. pylori, however, thrives in such hostile surroundings because it is a prolific producer of an enzyme called urease, which neutralizes acid in the immediate area and wreaks havoc on the mucous layer of the stomach or intestine, apparently weakening the area and setting the stage for corrosion. Even the H. pylori's spiral shape gives it an edge because it allows the bug to "corkscrew" into the stomach's mucous membrane.

The discovery of H. pylori sparked a spate of studies that ultimately linked it to a number of GI disorders, including most instances of duodenal ulcers, many cases of stomach ulcers, and, very likely, numerous cases of gastric cancer. In fact, H. pylori is nearly always present when the stomach is inflamed. Fortunately, with the right treatment, H. pylori and the problems it causes can be completely eliminated.

Getting the bugs out
Scientists have rarely been able to find the H. pylori bacterium in water, food, or animals other than humans, but they suspect that it is transmitted from person to person by the fecal-oral route and may be related to lack of sanitation. In fact, experts believe that around the turn of the century a much larger percentage of the U.S. population carried H. pylori; today, rates of both ulcers and stomach cancer are much lower than they were at that time. What's more, virtually everybody in developing countries, where sanitation standards are low, is infected with the bug.

In the United States, as many as 60 percent of older adults and about 95 percent of people with duodenal ulcers are infected with H. pylori. But not everyone who carries the bug experiences symptoms, for reasons that aren't yet clear. It may be that there are different strains of H. pylori, some of which are more virulent than others. Or it may be that some people are more vulnerable to the bug than others, or a combination of the two circumstances. Over time, as researchers learn more about the bug, they may be able to identify carriers of the most dangerous strains and give them treatment to eliminate it. But at this point, experts convened by the National Institutes of Health Consensus Development Panel on H. pylori recommend that only patients who harbor the bacterium (see the blue box) and have an ulcer undergo a course of antibiotic therapy to get rid of it.

As for treatment, the number of different antibiotic regimens that physicians use are "like alphabet soup," according to Dr. Wilcox, but the standard therapy is an aggressive drug program involving taking three medications--about a dozen pills--every-day for two weeks. The reason is that H. pylori is a tough bug to kill. It burrows into the stomach's or intestine's mucous layer, which makes it difficult for the antibiotics to get at it. In addition, the high-acid environment of an ulcer sufferer's GI tract can reduce the effectiveness of many antibiotics.

The therapy aims at lowering the acid content of the stomach as much as possible and then dousing it with antibiotics. For example, a typical regimen includes a potent acid-suppressing drug taken once a day and Pepto-Bismol four times a day, both of which minimize stomach acid, along with one or two antibiotics three or four times a day.

Admittedly, this fairly rigorous pill-popping routine can be a hassle, and the antibiotics can cause unpleasant side effects such as diarrhea and stomach upset, particularly in the "downtrodden" GI tracts of ulcer sufferers. Still, the therapy lasts only two weeks, and in 75 to 90 percent of cases the ulcer is completely cured and won't come back.

Given that at least nine out of 10 people with duodenal ulcers harbor H. pylori, most sufferers of that type of ulcer are candidates for antibiotic therapy. An estimated 70 to 80 percent of people with gastric (stomach) ulcers, on the other hand, have the problem primarily as a result of chronic ingestion of anti-inflammatory medications such as aspirin or ibuprofen (the active ingredient in Motrin and a number of other over-the-counter drugs), which are extremely irritating to the stomach. Even for these ulcer sufferers, however, the NIH panel recommends that if they are infected with H. pylori, they should also be given antibiotics to eradicate the bug. If they must continue taking anti-inflammatory drugs such as aspirin because of a health problem such as arthritis, then they may have to continue taking antacids or acid-suppressing drugs over the long haul to minimize the drug-induced damage to the stomach.

1) d. 2) b. 3) True.

TESTING FOR H. PYLORI

A physician can test for H. pylori, the bacterium responsible for most ulcers, using several different methods:

Blood test --When H. pylori settles into a person's GI tract, the body's defense mechanisms respond to the invasion by producing antibodies specifically aimed at the unwelcome guest. These antibodies can be detected in the blood of H. pylori carriers.

Endoscopy --To conduct this test, a tube with a light on the end is passed through the patient's mouth and esophagus, and then into the stomach and/or duodenum. The endoscopic tube allows the physician to view the interior of the stomach or intestine and remove a small sample of the organ's lining. Scientists can then analyze the tissue to check for H. pylori--as well as for the presence of ulcers themselves.

Urea Breath Test (UBT) --For this procedure, for which FDA approval is pending, the patient swallows water to which a harmless substance called urea has been added. He then exhales into a tube hooked up to sophisticated equipment that measures components of the breath. If H. pylori is present, it produces urease, an enzyme that breaks down urea to substances that can be detected by the equipment.

ILLUSTRATION: Ulcers can occur in the esophagus, stomach, or duodenum and most commonly appear at the sites shown. One in 10 Americans develops an ulcer, and some 500,000 new cases are diagnosed annually. In addition, ulcers lead to more than a million hospitalizations a year.

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