Ulcers – small, open breaks or craters in the lining of the upper gastrointestinal tract – typically develop in one of two sites. The most common form in the upper portion of the small intestine and are known as duodenal ulcers; less common are those in the stomach itself, which are gastric ulcers. Surprisingly, 15 to 20 percent of bleeding ulcers occurs initially without pain.
In general, ulcers are caused by an imbalance in the stomach, either too much stomach acid or pepsin, the major digestive enzyme, or too little protective mucous and protein secretions. This imbalance allows the stomach acids and enzymes to, in effect, turn on the digestive tract itself, producing small ulcers. But there is not, as is commonly thought, a direct relationship between excessive secret secretion and ulcers. Many people with duodenal ulcers, for example, secret large amounts of acid, but others do not. This has led many experts to suspect that poor tissue resistance and other factors, particularly cigarette smoking, that interfere with the flow of neutralizing secretions may contribute to ulcer development. Stress and emotional pressure are also frequently cited as causes of duodenal ulcers.
In the case of gastric ulcers, excess acid secretion appears to be even less of a factor than in other forms of ulcer, since many patients have normal and even low levels of stomach acid. Again, external factors or substances have been implicated in the origin of gastric ulcers, the two major ones being alcohol and apsirin. Both are known to injure the stomach lining, and it is thought they increase the stomach's vulnerability to the acid that is present.
Pain – centered in the pit of the stomach, just below the rib cage – is the most characteristic ulcer symptom, and it typically follows a distinct pattern. It usually begins several hours after eating or during the night, developing when the stomach is empty. The pain can manifest itself as a chronic gnawing or aching; it may grow worse during or immediately after meals; or there may be no pain at all, just belching – any ongoing discomfort discomfort should be called to a doctor's attention.
Gastrointestinal bleeding is one of the most common complications of ulcers. This may manifest itself as vomiting fresh, bright red blood or passing bloody or tarry stools. Weakness, fatigue or, in the case of severe hemorrhage, loss of consciousness and shock also may result from bleeding ulcers. Ulcers always should be suspected when gastrointestinal bleeding occurs, even if there is no pain or other symptoms.
One serious complication is a perforated ulcer, which develops as acid deepens the ulcer and goes through the intestinal wall, spilling acid and bacteria into the abdominal cavity. This is always a medical emergency requiring immediate treatment, usually surgical. The pain is sudden, intense and steady, and even the slightest movement seems to increase it. The major danger is peritonitis, a severe infection of the abdominal cavity. A second danger is caused by excessive scarring or adhesions. Usually, however, this only occurs in older ulcers where several layers of scar tissue have had a chance to accumulate. Piled on one another, these may block the digestive tract.
While some ulcers heal on their own, most patients require some sort of treatment. But recent important changes in the three major areas of ulcer therapy – diet, drugs and surgery – allow today's patients a freedom that would have been unimaginable to earlier generations of ulcer victims. In any case, ulcer patients who smoke should make every effort to stop. Avoidance of alcohol and aspirin, especially during a flare-up, also is recommended.
Milk and cream diets are still prescribed, as are small, frequent feedings of up to six meals a day. But today, these mains of dietary therapy are used much more judiciously than in the past. Since both seem to effectively treat ulcer pain, they are routinally prescribed during flare-ups. But because there is no evidence that either actually promotes healing, once the pain has been relieved, patients are usually allowed to resume their normal diets.
The discovery of a new drug (cimetidine) that inhibits the flow of digestive acids and enzymes and thereby permits ulcers to heal has markedly changed ulcer therapy. Blocking drugs are now widely used in treating ulcers.
Another new approach is to manage drugs (eg, sucralfate) that actually form a protective coating over the ulcer, giving it a chance to heal without disabling the flow of gastric acids. Until the introduction of these new drugs, the approach had been to give drugs that neutralize acids already present rather than block acid secretion.
Many older drugs remain an important and valuable part of ulcer therapy, particularly the antacids. As acid neutralizers, they not only relieve discomfort, but actively promote duodenal ulcer healing. Selected patients also may be treated with slow down stimulation of secretions and other involuntary functions. In any instance, treatment should be tailor to the needs of an individual patient – something only your phyisician is equipped to do.
For the majority of ulcer patients, the success of dietary therapy, drug therapy or a combination of the two makes surgery unnecessary. But an estimated 10 to 15 percent of ulcer patients do ever require surgery. Indications for surgery usually include perforation, obstruction due to scarring and bleeding. Intractable pain also may prescribe surgical intervention, but usually only after other treatment alternatives have been tried.
While the causes of ulcers are still not fully understood, new therapies have dramatically improved the outlook for most ulcer patients. These include a more liberal attitude towards diet, new drugs and improved diagnostic procedures. Stopping smoking and trying to avoid undue stress also are recommended for ulcer patients.