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Ulcers & indigestion

MagazineSeptember 1998 (Vol. 9 Issue 6)Ulcers & indigestion

A step by step programme for better digestion and how to avoid chronic dyspepsia or ulcers caused by the Helicobacter pylori bug

A step by step programme for better digestion and how to avoid chronic dyspepsia or ulcers caused by the Helicobacter pylori bug.

Until quite recently, the accepted medical view was that ulcers were triggered mostly by stress (which disturbed the production of stomach acid) or by medications such as NSAIDs (non steroidal anti inflammatory drugs) or aspirin, and were probably aggravated further by spicy or smoked foods and excess alcohol.

Ulcers can occur in the oesophagus, stomach or duodenum (upper part of the small intestine). Statistics from the US show that one in every 10 people develops an ulcer; half a million new cases are diagnosed every year; and more than a million people end up in hospital, often as a result of complications and/or late diagnosis. Left untreated, the lining of the stomach or intestines will be destroyed, risking internal bleeding, vomiting of blood or blood in the stools. Even more serious is the possibility of perforation, where a hole in the membrane allows previously contained contents (partially digested food, for example) to spill into the abdominal cavity, causing contamination, infection, inflammation and life threatening trauma.

The remedy most favoured, the milk based diet, is now recognised as being a poor protector against ulcer attack. Although it may soothe for a few seconds, once milk hits the stomach, it stimulates the secretion of even more acid, akin to pouring pints of acid over a raw wound, causing intense pain and further damage to the ulcerated area. Barbiturates, antacids, semi comatose bed rest, stress management techniques, psychodrama and, latterly, more sophisticated (and expensive) attempts have all come (and gone) as the treatments of choice.

Dedicated research by Australian doctors Barry Marshall and Robin Warren has now turned established practice on its head. They found a common bacterium called Helicobacter pylori nestling in the gut of a significant number of ulcer sufferers and dared to suggest that this bug could be the actual cause of ulcers. Similar work was carried out by a team at the Western Infirmary in Glasgow led by Dr Kenneth McColl.

Helicobacter pylori, a new name for an old bug, is still sometimes known as Campylobacter pylori. It sets up home in the narrow space between stomach lining and the mucous covering that tries to protect the stomach wall from damage. Worryingly, it is now considered a more prolific bug than salmonella and is now classified a class A carcinogenic, equal to asbestos and cigarettes.

Marshall and Warren tried to interest the medical establishment in their discovery but met with a wall of apathy and indifference. Doctors have believed for years that bacteria can't survive in stomach acid. In fact, this belief was so firmly held many medics didn't follow even basic hygiene rules, unwittingly passing the bacteria from patient to patient during surgery. No one imagined for a moment that ulcers could be contagious.

Marshall and Warren caused further furore by suggesting that short term treatment with the right kind of antibiotics (usually a cocktail of two different ones with bismuth and sometimes antacids referred to as the "triple therapy") cured 95 percent of cases. So convinced was Dr Marshall that (at Freemantle Hospital in Western Australia) he used himself as the first guinea pig, swallowed a heavy suspension of the offending bacteria, gave himself an ulcer and then cured it with antibiotic therapy.

This was almost panacea enough to those who thought they would be on anti ulcer medication for life. But maybe not, say some sceptics, to the drug companies who were already making millions of pounds and dollars a year from the sale of acid blocking drugs estimated to be one of the biggest medical money spinners of all time.

As a short term remedy for heartburn, these drugs can be effective. But, using them to try and eradicate bacterial ulcers is now regarded as nothing more than a sticking plaster approach. Not only are the ulcers extremely likely to recur, a greater danger lies in that fact that such medications can mask more serious disorders such as early signs of oesophageal and stomach cancers. Now that these drugs are easily obtained without prescription, the American College of Gastroenterologists (representing some 5000 specialists in more than 30 countries) is concerned that sufferers may delay seeing their physicians.

Researchers have also found that, because this medication suppresses stomach acid (which kills bacteria), those taking it face a tenfold increase in the risk of developing stomach ulcers and, more seriously, gastroenteritis.

A further concern is that, although more than 90 out of every 100 people with ulcers harbour Heliobacter, the bug also occurs in patients who never develop ulcers. But the possibility of the ulcer causing infection being passed from one family member to another is so strong that screening programmes are being recommended to test and treat relatives before H pylori gets out of hand. It isn't a question of catching the bug and contracting an immediate ulcer. H pylori can lurk in the gut for years, waiting until the "right" conditions prevail such as other illness or lowered immunity.

There is no getting away from the fact that, on "conventional" anti ulcer medication, symptoms recur in 80 per cent of people. However, ongoing treatment is good for the company's balance sheet since the drugs bill for one ulcer patient can run into thousands of pounds or dollars.

A one off antibiotic cocktail to kill the bacteria and cure the ulcer costs a comparatively piffling lb25 to lb30. An excellent example of how the sensible use of antibiotics can be lifesaving.

As a result of the H pylori discovery, it seems likely that the widespread use of orthodox anti ulcer drugs will diminish. However, their value for short term use should not be denied since they can provide welcome relief from the stress and discomfort caused by an isolated attack of acid reflux, stomach irritation or non ulcer dyspepsia. For example, aspirin based drugs and other non steroidal, anti inflammatory drugs can cause ulcers themselves.

Dr Marshall himself discovered that it can be beneficial to use acid reducing drugs to relieve symptoms whilst the antibiotics go to work on the pylori perpetrator. Even patients who are not H pylori positive but have problems with over acidity may benefit from a short course of antibiotic therapy and a few days on cimetidine (Tagmet), ranitidine (Zantec) or omeprazole (Losec), followed by a course of repopulating probiotic supplements. It is possible that they may have a low level infection and/or small ulcers which have not been spotted in routine tests.

In other words, if you have a persistent or recurring problem with dyspepsia or gastritis, it might still be beneficial for you to go the antibiotic route, even though your tests for bacteria proved negative. If you are concerned, chat with your GP or ask for a referral.

Talk to your doctor, too, if you have any suggestion of a heart condition or a family history of heart problems, especially if you are also troubled with digestive disorders. Peptic ulcers have a strong association with heart disease. An inflamed and infected gut is likely to disturb your health in some other way, too. Researchers are looking into the possibility that the inflammation this bacteria causes may be responsible for some cases of coronary heart disease. It has been estimated that those infected with Helicobacter pylori (who remain untreated) are twice as likely to suffer heart disease and six times more likely to develop stomach cancer.

Dr Michael Menial of St George's Hospital in London believes that the rise and fall of figures for heart disease can't be explained away by cholesterol control or advice to quit smoking. It's suspected that H pylori infection may raise the clotting factor of the blood, increasing the risk of clogged arteries and heart disease.

In some people the symptoms of under acidity can be identical to those of over acidity. As we age, our stomach acid production slows down. This means that some food may not be broken down properly, leading to distension, pain, gas production and explosive belching. There can still be burning discomfort (called pyrosis), even in the absence of acid. Bad breath, foul smelling wind, constipation, sore tongue and metallic tastes are other symptoms. Helicobacter pylori has even been implicated by one study as a possible cause of food allergies.

Dr Marshall has found that patients infected with H pylori can produce up to six times more acid than normal (the body's natural response to the infection) but also that, in some patients, the bacteria itself inhibits that production of stomach acid, increasing the likelihood of achlorhydria or hypochlorhy dria non existent or limited levels of acid.

If your present medication is not helping you or if the condition returns immediately the drugs are stopped talk again with your GP. A simple test which can determine whether you are producing too much or too little hydrocholoric acid, along with a speedy and easy breath test for Helicobacter pylori is now available.

Another possible cause of stomach upsets is lactose intolerance. This occurs when there is a deficiency of the lactase enzyme, needed to break down lactose, the natural sugar content of milk. The condition may be inherited (known as primary intolerance) or acquired, due to stomach surgery, infections or ageing as we grow older, our bodies produce progressively less lactase. Those with coeliac disease, Crohn's disease, leaky gut syndrome or ulcerative colitis may find it difficult not only to deal with lactose but also to digest cow's milk protein. Allergic reactions to cow's milk seem increasingly common in young children, too.

When lactose is allowed to pass through the digestive system untouched by lactase, it's left to the Lactobaccillus bacteria to do the digesting. (The same kind of bacteria used outside the body to make yoghurt from milk.) Unfortunately, it's often the case that those with digestive troubles already have reduced levels of the friendly bacteria. The upshot is that any leftover lactose is likely to be leapt upon by not so friendly gas forming bacteria who leave abdominal bloating, colic and diarrhoea in their wake. Many of these symptoms are similar to those of IBS.

Where the production of lactase is limited but not lacking completely, the condition is sometimes referred to as lactose maldigestion.

The figures for lactose intolerance, say some researchers, are grossly exaggerated. The difference between the two conditions, we're told, is that maldigesters can still digest some milk products.

In addition, if there is an ample supply of Lactobacilli in the gut, some milk sugar will be broken down even if the lactase enzyme isn't there. But as disturbed gut flora is common in those with digestive difficulties, this doesn't always happen.

!AKathryn Marsden

Adapted from Hotline to Health by Kathryn Marsden (Pan, 1988, lb5.99).


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