Peptic ulcer disease and Helicobacter pylori gastritis
Dr. Widjaja Luman
Consultant Gastroenterologist and General Physician
B Sc (St. Andrews), MB ChB (Man), MRCP (UK), M.D. (Edin),
CCST (UK), FRCP (Edin)
(Ahli penyakit pencernaan dan hepar)
Dyspepsia is a medical term which has been defined as the presence of persistent or recurrent pain or discomfort centred in the upper abdomen. In Singapore, patients often describe this complaint as having “gastric” pain.
There are many causes of dyspepsia. Common causes are :
- peptic ulcer disease
- non ulcer dyspepsia
Peptic ulcer disease
A peptic ulcer is a break in the lining of the stomach or the duodenum, very much like a mouth ulcer. Gastric ulcers occur in the stomach and duodenal ulcers occur in the duodenum, the first part of the intestine after the stomach.
What are the symptoms?
There may be no symptoms at all and the ulcer may be discovered while investigating another problem for example anaemia ( shortness of red blood cells).
Other patients may present with dyspepsia or commonly associated by most people as ‘gastric pain’. This discomfort have been described variously as ‘burning, pulling, bloating or sharp’ pain. Classically, pain of duodenal ulcer occur before meals and tend to be relieved by food. Sufferers also tend to wake in the middle of the night with pain. Weight loss is uncommon.
What are the causes of peptic ulcer disease ?
The stomach produces acid and pepsin, which helps in the digestion of food. These two substances could equally digest the lining of the stomach or duodenum just as they do to the food we consumed. In the healthy state, there are several defence mechanisms which protect the lining from such an attack. Ulcers occur when these substances are able to break the defences and ‘corrode’ away the lining of the stomach and duodenum.
A very important cause of developing an ulcer is a germ or bacterium called Helicobacter pylori, also known as H. pylori. This is found in the lining of the stomach of about 30% of the adults in Singapore, with even much higher incidence in the older age group. The exact mechanism how this germ causes ulcers is still uncertain but it could increase the making of too much acid and pepsin in some people. Patients with duodenal ulcer almost always have this germ present and at least 80% of gastric ulcer patients also have it.
Another important cause of ulcers is the group of drugs used in the treatment of pain, particularly arthritis and rheumatism, called the Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). Aspirin also belongs to this group. These drugs cause ulcers by reducing the formation of the protective layer coating the stomach lining, thereby allowing acid and pepsin to injure the stomach lining. Low dose aspirin is nowadays often prescribed for patients with heart disease or strokes. Risk of ulcer occurrence is small with the low dose used but if you are known to have ulcers previously or develop symptom after taking the aspirin, please consult your doctor for alternative agents.
Stress probably does not cause ulcers but worsen the symptoms from ulcers, possibly because the stomach produces more acid in response to stress.
What would my doctor do to confirm that I have got peptic ulcer disease?
Your doctor can order gastroscopy to confirm the diagnosis.
How would my doctor find out that I have got Helicobacter pylori?
The noninvasive test that your doctor can order are blood test or Urea breath test. Your doctor can check your blood for the presence of antibody against Helicobacter pylori. If the result is negative, it means that you do not have the Helicobacter pylori. However, if the test result is positive, it indicates that you either had the infection in the past and the bacteria is no more present in your stomach or you still have the infection. Your doctor would then need to order confirmatory test with either Urea Breath test or gastroscopy. Urea breath test is a non invasive test that involves drinking some solution containing radioactive carbon which will be released in your breath if the bacteria is present in your stomach. However, Urea Breath test only confirms the presence of bacteria in the stomach. It does not inform whether you have peptic ulcer disease causing your symptom.
Gastroscopy is the only test that confirms the diagnosis of peptic ulcer disease. Gastroscopy is a slim flexible tube with a small camera at the tip which enables the lining of the gullet, the stomach and duodenum to be seen. Before the procedure is carried out, a mild sedative and/or a numbing agent for the back of the mouth may be used. A sample of the lining of the stomach (biopsy) can be taken to test for Helicobacter pylori.
What treatment would my doctor give me for my ulcer?
If the ulcer is caused by aspirin or NSAID’s, your doctor would definitely ask you to stop these drugs and you would be given acid reducing agents such as proton pump inhibitor (PPI; omeprazole, rabeprazole ). PPI reduces acid productions and accelerate ulcer healing process. If your ulcer is related to Helicobacter pylori, your doctor would give Helicobacter pylori eradication therapy ( triple therapy ( three drugs) to eradicate the bacteria). Generally, triple therapy can eradicate successfully in up to 80 to 90% of cases. Triple therapy consists of PPI and two antibiotics taken for one to two weeks. Common side effects are nausea, vomiting and diarrhoea which are generally mild. Severe side effects are kidney failure and inflammation of the large bowel. Fortunately, severe side effects are very uncommon.
Most ulcers heal in four to eight weeks and future relapse is likely only if Helicobacter pylori infection is not successfully treated. If the germ is killed by treatment, the chances of recurrence are low. Where this is not achieved, or the ulcer is not caused by infection then another way of preventing ulcer recurrence is to continue taking acid reducing drugs (such as PPI) long term.
Surgery is rarely needed nowadays because we now have effective medical treatment. However, surgery may still required for complication of ulcers such as bleeding, perforation or problems from scarring of the ulcers.
Smoking and alcohol have also been shown to impair ulcer healing. Consumption of cigarette and alcohol should be stopped if possible. Foods such as chilli, sour foods, coffee do not predispose a person to peptic ulcer disease, nor do they interfere with ulcer healing.
When should I request to see a doctor urgently if have gastric pain?
You should see a doctor urgently in the following situations:
- recent unintentional weight loss.
- persistent vomiting after food. This indicates that there may be area of narrowing obstructing the drainage of food due to the ulcer.
- if you vomit blood or pass out black and soft stool. This means that your ulcer is bleeding.
- severe, excruciating upper tummy pain suggesting that your ulcer has perforated i.e. burst through the bowel wall.