Ulcers can be cured!
by Frank Kim, MD
What is an ulcer?
An ulcer is a break, or sore, in the lining of the stomach or upper intestinal tract which can cause pain, bleeding, or other serious complications. The pain is usually described as a burning or gnawing pain in the pit of the stomach just beneath the breastbone. It may be worse on an empty stomach and temporarily relieved by food or antacids. A bleeding ulcer may cause weakeness and black bowel movements. This is not a minor problem. Twenty-five million Americans suffer from ulcer disease. Each year ulcers lead to over one million hospitalizations and over 6000 Americans die of ulcer complications. The annual health care costs of ulcer disease is estimated at $6 billion. In many individuals, ulcer disease can be recurrent with disabling attacks several times a year. The exciting breakthrough is that we now know ulcers are often an infectious disease and most can now be cured by antibiotic therapy.
Can an ulcer be caused by infection?
Over twenty years ago, that seemed as unlikely as Tom Hanks from "Bosom Buddies" winning an OSCAR. All doctors and medical scientists believed that ulcers were largely caused by lifestyle factors such as spicy food, stress, heavy drinking, too much caffeine, and smoking. However, medical research has clearly demonstrated that most ulcers are NOT caused by lifestyle factors, but rather, by a tiny bacteria which infects the stomach called Helicobacter pylori, or H. pylori for short. The bacteria was called Helicobacter pylori because it has three tails that whip around; sort of like a helicopter,
The history of Helicobacter
Did this "ulcer bacteria" just suddenly appear out of thin air? Actually, it was first noted in the 1800's by a pathologist who saw some bacteria in the stomachs of cadavers. Other pathologists also noted the bacteria over the next hundred years or so, but it was always felt that these bacteria were probably due to contamination and not really the cause of any disease.
In 1982, Dr. Barry Marshall, an Australian scientist, was able to successfully grow this bacteria from samples taken from living patients that had a lot of digestive problems. He proposed a theory that the H. pylori was an "ulcer bacteria" and the cause of most ulcers.
In the beginning, the medical community considered Dr. Marshall's "infection causes ulcers" theory impossible. The idea that a bacteria could cause an ulcer was revolutionary and Dr. Marshall was ridiculed as a heretic. Other scientists didn't believe him until he deliberately swallowed a test tube full of the H. pylori bacteria and became ill. Tests were then performed showing severe inflammation and ulcers of his stomach. When he received treatment to kill the bacteria, the ulcers disappeared. Only then did others finally believe that H. pylori infection could be a cause of ulcers. Further scientific research proved him to be right. The long approved theory that most ulcers were caused by stress, poor diet, too much caffeine, heavy drinking, and smoking was disproven.
We now know that most ulcers are caused by H. pylori infection. The minority of ulcers that are not caused by this infection are usually the result of too much aspirin or other anti-inflammatory pain medications such as those taken for chronic arthritic pain.
How common is H. pylori?
H. pylori is quite common and, in fact, may be the most common infection in the entire world. At least a third of people worldwide are infected with H. pylori, although most infected individuals have no symptoms. In developing countries, as many as 80% of inhabitants have been exposed to this infection, most probably acquired as children. The rate of infection is lower in the United States, and most common in older people.
How does one get H. Pylori?
It is not clear why some people are infected and others are not. The exact method of transmission is currently unknown, but it is probably carried from person to person and is related to the general sanitation of the country.
H. pylori and stomach cancer
In a small percentage of those infected, the consequences can be deadly. In addition to deaths caused by severe ulcer disease, there is an association of H. pylori with stomach cancer and lymphoma of the stomach. This does not mean that every person who has this infection will develop cancer. In fact, in this country, very few people develop stomach cancer. However, it is thought that if H. pylori is left untreated for decades, it may be one of the risk factors which could lead to stomach cancer.
Who should be tested for H. pylori?
Certainly, any individual with persistent symptoms of gnawing abdominal pain, gas, bloating, indigestion or nausea should talk to their doctor. Those with a history of ulcers should definitely be tested. Some people feel that first-degree relatives and household contacts of a person who's had stomach cancer should also be tested.
How is H. pylori diagnosed?
Only a medical doctor can diagnose infection with H. pylori and recommend a treatment plan. Three tests are generally available. One test is a serology or a blood test. This test checks for antibodies that react to H. pylori. Unfortunately, it can't tell if a person is currently infected or just showing residual antibodies from previous infection. Thus, a normal blood test is helpful in excluding infection, but an annormal result doesn't tell if a person has an active ongoing infection, or just a past exposure.
The PyTest breath test is the simplest and least invasive way to test for H. pylori. The patient is asked to swallow a small capsule which contains a trace amount of radioactive C14. Ten minutes later, the patient is asked to simply exhale into a balloon. If H. pylori is present, the exhaled carbon dioxide will contain C14 and is measured on a type of geiger counter. If no H. pylori is present, the C14 leaves the body through the urine and is gone in a few hours. A positive breath test means that there is an current active infection in the stomach with H. pylori. This test is safe and exposes the patient to about the same amount of radiation as 1/20th of a chest x-ray. Fifteen glasses of orange juice contain the same amount of C14. This amount of radiation is so small that it is felt to be harmless by the Nuclear Regulatory Commission and there are no special precautions.
Finally, H. pylori can be diagnosed by testing biopsies of the stomach lining taken during a stomach "scope test," or gastroscopy. This test is also very accurate and has the advantage of allowing direct inspection and biopsy of the stomach or duodenum.
Who should be treated for H. pylori?
In the past, one of the most frustrating problems with ulcers was that, for reasons unknown, ulcers would usually come back within a year after treatment. Many individuals suffered attacks several times a year. The most compelling evidence that H. pylori infection causes ulcers is the fact that by treating the infection, the chance of an ulcer coming back drops significantly, from around 80% to 6%. Thus, after treatment, most patients can now be cured for life. This is a major breakthrough.
It is recommended that all ulcer suffers should be tested for H. pylori and those positive, treated. Eradication of the bacteria markedly reduce the risk of ulcer recurrence. Since this infection is so common in the world, some physicians feel that it's not necessary to treat people if there are no symptoms. More research is needed, but we feel that since the World Health Organization has listed H. pylori as a carcinogen since 1994, that if a diagnosis of H. pylori is made, it should be treated.
How is H. pylori treated?
Unfortunately, curing H. pylori infection in not an easy task. Because of the location of the bacteria within the mucus layer above the stomach, it's very difficult to kill the bacteria with routine antibiotics. Current therapy usually includes at least two antibiotics and powderful acid blockers for several weeks. There are several different multi-drug treatments available. Each case is different and the doctor can best decide which treatment regimen is appropriate. Side effects (nausea, diarrhea, metalic taste, and yeast infection) are common during treatment and may be limiting. Taking a probiotic during treatment such as Yogurt or lactobacillus tablets several times a day may help limit side effects.
How does the patient know when it's gone?
They won't, but if the organism is not resistant to therapy, the infection can be cured in over 90% of the cases. Additional tests can be performed to see if the infection was successfully eradicated. Either a stomach biopsy during a scope test or a PyTest breath test can be used. Both of these tests should be performed at least four weeks after therapy is finished to best assess cure. The blood test is not useful to assess cure because it may remain positive for many years after successful treatment. A stool test for H. pylori is still being investigated, and may be useful in the future.
Will H. pylori come back after treatment?
No one is sure since the source of infection and its exact mode of transmission are unknown. However, the rate of re-infection in adults after successful treatment seems to be very low - probably less than 1% per year.
Can H. pylori infection be prevented?
Not at the present time, however, much research is being done on the development of a vaccine to help prevent it. Hopefully, this will be available in the future. When available, a vaccine will probably be administered as part of the routine child immunization.
The Helicobacter Foundation
National Digestive Diseases Information
Helicobacter Pylori and Ulcers
This photo taken with a high powered electron microscope shows the tiny H. pylori bacteria (pink) attacking the gastric cells which line the inside of the stomach. This is the "ulcer bacteria" that was re-discovered by Dr. Barry Marshall in Australia in 1982. Each year, over 7 million Americans suffer from H. pylori related disease.
This is a photograph taken during a gastroscopy "stomach scope" test. It shows a deep ulcer crater which was located in the first portion of the small intestine called the duodenum. Thus, this is an active duodenal ulcer. Without treatment, the ulcer could bore deep enough to hit an artery and cause a major ulcer hemorrhage. Symtoms would be weakness and black tarry bowel movements. The ulcer could also eat completely through the intestinal wall and cause peritonitis, a life-threatening infection of the abdomen.
Useful Digestive Links
Functional GI Disorders
Crohns and Colitis
H. pylori Foundation
Amer Gastro Assoc
Amer Cancer Society