Ulcer cure lies in its detection

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Did you know that a peptic ulcer (commonly known as a stomach ulcer) is one of the most common diseases of the gastrointestinal (GI) tract and that the economic impact of the disease is huge? Though such data is not available for India, the illness costs nearly $6 billion annually in the USA!

A disease that finds mention as way back as in the Charak Samhita, its symptoms are described as the manifestation of the Pitta Dosha. A peptic ulcer commonly affects the duodenum and stomach, causing sores or a breach of mucosal continuity larger than 5 mm in size.

A backgrounder
Understanding a peptic ulcer has seen a paradigm shift in the last century. Early 20th century scientific literatures emphasised the role of diet, spices and stress in its causation, but since then these have been shown to be of relatively minor importance. It was the seminal work of Nobel Prize winners, Robin Warren and Barry Marshal that established the role of spiral bacterium helicobacter pylori as the cause of a peptic ulcer.
To prove the point, Dr Barry Marshall, an Australian physician, drank a mixture of helicobacter pylori and self-induced an ulcer!
Today we know that 90 per cent of duodenal ulcers and 70 per cent of stomach ulcers are caused by this bacterium. The other major contributors to peptic ulcers are alcohol, aspirin, NSAIDs (e.g. ibuprofen, diclofenac, nimesulide etc.). The combination of several of these risk factors greatly increases the risk of ulcers.
The most common manifestations of an ulcer are upper abdominal pain that is burning in nature, which may become worse on an empty stomach or at night in the case of a duodenal ulcer, while it may be precipitated by meals in the case of a stomach ulcer. Sometimes an ulcer may have serious consequences like bleeding, perforation at the site of the ulcer and obstruction of the GI tract due to scarring. But many times, the symptoms are non-typical and may be mimicked by other diseases like cancer of the stomach, gallstones and pancreatitis. It is thus advisable for persons older than 45 to undergo an endoscopy so that such ulcers and infection by bacterium can be detected if the symptoms are suggestive or to rule out any other diseases like cancer.
The treatment
The treatment of ulcers has improved since the discovery of acid-suppressing medication, endoscopy and ulcer-causing bacterium. Many of the complications of ulcers like bleeding and obstruction can now be treated by endoscopy as well. Today, surgery is for those who have a perforation or uncontrolled bleeding and obstruction even after endoscopic treatment. The most common medications used for this disease are H2 blockers (like rantidine, famotidine) or proton pump inhibitors (PPI) like omeprazole, pantaprazole, esomeprazole etc. along with antibiotics.
Since the discovery of the ulcer-causing bacterium, the cure for ulcers includes antibiotics and acid-suppressing medicines. The eradication of bacteria greatly reduces the chances of a recurrence. However, today we also face drug resistance and reinfection, especially in developing countries like ours. This is because in Third World countries transmission mainly occurs via the oral-fecal route by contaminated food, water etc.
The incidences of duodenal ulcers have dropped significantly during the last 30 years, while the incidences of gastric ulcers have shown a small increase, mainly caused by the widespread use of NSAIDs. Great strides have been made in animal models which hold great promise for the future. The future of ulcer eradication would be in the development of a vaccination against helicobacter pylori. If safe, effective and affordable vaccines were available in the prevention or cure of chronic helicobacter pylori infections, one would witness a huge downward spiral in ulcers.

The writers are Head, Gastroenterology and Consultant, Gastroenterology respectively at the Asian Institute of Medical Sciences