Ulcers in the stomach or duodenum were attributed for years to excess stomach
acid and treated with antihistamines which reduce acid secretion and antacids. In the
past, milk was recommended, but dairy products can be the cause of the problem and are
often contra-indicated; milk allergy may be an original cause of gastritis which
leads to ulceration.
A common cause of stomach ulcers is the regular use of ASA or related
anti-inflammatory drugs - NSAIDs. If ulcer symptoms occur while taking these drugs, their
use should be discontinued.
An acute duodenal ulcer will present with pain high and central in the abdomen; the
pain comes on as the stomach empties 3 or 4 hours after eating and during the night.
Eating food, especially bland foods, milk or antacid tends to relieve the pain.
Antihistamines ( H2 blockers - examples are tagamet, pepcid and zantac) have been
prescribed for years to treat ulcers and acid reflux into the esophagus and are now
available as over-the counter medications.
Helicobacter Pylori
In the past decade, evidence of bacterial infection in ulcer disease has
accumulated. Now, it is reasonably certain that recurrent or chronic duodenal
ulcers are related to the bacteria, Helicobacter pylori; the bacteria may also play a role
in causing stomach ulcers and chronic gastritis.
The puzzling aspect of H Pylori (HP) is that 90% of the people who harbor the
bacteria in their stomachs do not have ulcer disease; however the presence of the bacteria
predisposes to dyspepsia and the eventual development of cancer of the stomach. The 10% of
people who develop ulcers in the presence of H. Pylori, however, may have recurrent ulcers
and need treatment to eradicate the bacteria.
If you look for H. pylori in the general population, you will find that it is common.
In Canada 20-40% of the population harbor the bacteria (the incidence increases with age).
In developing countries 80% of the population may have the bacteria. The incidence of
infection increases with poor living conditions.
The Canadian Helicobacter pylori Consensus Conference has made recommendations
of the diagnosis and treatment of HP; They offered a number of guidelines reviewed here:
Test for HP be done only when treatment is planned ( i.e. when symptoms are convincing
and prolonged or when an ulcer has been demonstrated by X-ray examination. The urea breath
test or antibody tests are recommend for people who have chronic dyspepsia - upper
abdominal pain and discomfort lasting more than three months - and treated, if
positive.
No tests be done in asymptomatic people unless there is a strong family history of
stomach cancer.
Urea Breath tests have "excellent sensitivity and specificity". (1) A carbon
isotope (C13) can be used and is stable so that breath samples can be collected in an MDs
office and mailed to a lab for analysis. A positive breath test indicates active infection
and treatment is indicated.
Test for antibodies to H pylori are available but the accuracy is in doubt; these test
are relatively inexpensive and easy to do and may add further conviction to start
treatment when the clinical evidence is strong.
The question of who should have endoscopy - a look with a fiberoptic scope with biopsy
and culture is more difficult to answer. This invasive procedure is expensive, has risk as
associated and (at least in Canada) may involve delay waiting for specialist consultation
and bookings in endoscopy suites. The consensus was that treatment can proceed without
endoscopy, although patients over 50 and patients with alarming associations such as
anemia or weight loss should be scoped to look for cancer.
Test for HP is recommended in patients taking NSAIDs with ulcer.
In the majority of cases there is no need for follow-up tests after appropriate
eradication therapy. antibody tests should not be used to confirm eradication of HP.
HP Eradiation Therapy
Clarithomycin 500 mg and amoxacillin 1000 mg twice a day for 7 days
or Clarithomycin 500 mg and metronidazole 500 mg twice a day for 7 days
plus omeprazole 20 mg twice a day for 7 days followed by omeprazole 20 mg every morning
for another 21 days.
Second line quadruple therapy involves less but is more complicated and takes longer:
tetracycline or erythromycin 500 mg four times a day for 14 days; plus metronidazole 250
mg four times a day for 14 days; plus Pepto Bismol - 2 tablets four times a day for 14
days; plus tagamet or zantac for 42 days.
Self Treatment of Symptoms
Self-therapy of milder symptoms - dyspepsia and eary ulcer-like symptoms consists of
retreating to Alpha Nutrition Phase 1 foods, using brown rice instead of white rice with
the option of taking tagamet or zantac as recommended by the manufacturer. Remember
that the bedtime dose is very important because your stomach will spend 8 hours or more in
a near-empty condition vulnerable to the action of accumulating acid. Phase 1of the Alpha
Nutrition should be sustained for 2 weeks or until all symptoms are gone and
then food is reintroduced using the medium track - foods from Phases 2 and 3 are
reintroduced next.
If adequate diet revision does not resolve symptoms promptly and/or prevent recurrent
gastritis or ulcers, you need medical assessment and treatment.
