Wisdom on Ulcers Isn’t Conventional

One of the most difficult--and exciting--aspects of medicine is that “the facts” are constantly changing. Peptic ulcer disease is a good example of this evolution.

For decades, medical students were taught that stress and dietary factors, such as spicy foods, caused most ulcers. Patients were put on bland diets and instructed to rest and eliminate stress from their lives. This approach did provide some relief from the abdominal pain and nausea, but it rarely cured the ulcers themselves.

Next, the focus turned to stomach acids. These fluids not only break down food but erode the delicate lining of the stomach as well. Several drugs were developed to counter this effect. Some reduced the production of stomach acid; others created a protective barrier between acid and the stomach lining. These medications caused a great deal of excitement because most ulcers healed rapidly and completely when patients took them.

Unfortunately, as soon as the drugs were stopped, many of the ulcers recurred--even those that had healed completely. For some people, the only way to keep new ulcers from developing was to stay on the drugs permanently.

But Australian researchers recognized the real reason these ulcers recurred. About 20 years ago, they began to find bacteria called Helicobacter pylori (or H. pylori) in the stomachs of so many ulcer patients that they suspected the bacteria of causing ulcers. It did not take long for them to prove their theory correct. And so it is that today’s medical students are taught that H. pylori is the principal factor for most ulcer disease. (Studies suggest that the bacteria play a role in more than 80% of all ulcer cases.)

Outside the medical field, few people are aware of the connection between H. pylori and ulcers. A survey reported by the Centers for Disease Control and Prevention in the late 1990s found that only 27% of people were aware of this relationship. About 60% still believed that ulcers were caused by stress; 17% believed that spicy foods caused ulcers.

So what is H. pylori and how does it cause ulcers? For starters, it’s a unique bacteria, because it can survive in the stomach despite the high acid levels there. It’s also very common. In the United States, approximately 20% of people under the age of 40 and half of those older than 60 harbor the bacteria in their stomachs, according to recent estimates. In most of these people, the bacteria do not cause any symptoms; in fact, most people never know they are infected.

The most common problem caused by H. pylori infection is the development of an ulcer in the lining of the stomach or duodenum (the portion of the small intestine closest to the stomach). It is believed that the ulcer develops because the bacteria weakens the protective barrier of mucus that normally lines the inside of the stomach wall. This, in turn, allows stomach acids to penetrate the mucus layer and irritate the stomach wall itself.

Anyone who has a stomach ulcer should be tested for H. pylori infection. The infection can be diagnosed in several ways, including a blood test and a breath test. The blood test measures antibodies to the bacteria; the breath test detects a substance in expelled air. The diagnosis can also be made by obtaining a biopsy of the stomach lining and studying the tissue under a microscope for the presence of this bacteria.

Once infection has been documented in a person with an ulcer, every attempt to eliminate the bacteria should be made. Successfully treating the infection can speed ulcer healing and dramatically reduce the risk of recurrences. Unfortunately H. pylori is stubbornly resistant, and two weeks of treatment with three or four medications are usually required to achieve success. The regimen typically includes antibiotics, as well as bismuth (Pepto-Bismol) or drugs that inhibit stomach acid production.

Even the most effective drug combinations fail to work about 10% of the time. (Taking all of the medications for the prescribed period of time is critical to success; stopping the drugs early can allow the bacteria to survive and become resistant to them.)

For some people, the story of H. pylori and ulcers serves as an excuse for questioning anything doctors learn in medical school. We prefer to look at it another way: It proves that good scientists--and good doctors--never stop questioning, and never stop learning.

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Dr. Jonathan Fielding is the director of public health and the health officer for the Los Angeles County Department of Health Services. Dr. Valerie Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. Their column appears the second and fourth Mondays of the month. Send questions by e-mail to [email protected]. They cannot respond to every query.