Don’t give yourself an ulcer
We have all had indigestion, heartburn reflux or dyspepsia
(Greek: dys – bad; peptein – digest).
The trouble is, we all have some pain in the front of our
stomachs – which sometimes goes back up toward the throat –
associated with food, and we will assume that is the acid from the stomach
causing burning pain. Pain in this area could also be from the heart, or lots
of other things, so it is a challenge for doctors to work out what’s
wrong. It is so hard just to describe what we all think we know about, and so
many people use antacids (Quickeze, Mylanta) that it is the most common thing
taken in Australia – something for indigestion.
A formal definition of dyspepsia is: “Upper abdominal or
retrosternal pain, discomfort, heartburn, nausea, vomiting or other symptoms
considered to be referable to the proximal alimentary tract.” The common
cause of dyspepsia is the acid from the stomach (gastric acid) burning into the
oesophagus (food pipe) and so it is known as gastro-oesophageal reflux disease
(GORD), or reflux.
This problem is so common that, if you ask people if it has
happened to them, about one in three will describe having had some symptoms in
the preceding three months. About half of these people would have seen a doctor
about the problem because it is so bad, but most people would be taking
something for the symptoms. The cost of treating reflux in Australia accounts
for about 10 per cent of our national drug budget.
Pain in the stomach region has long been talked about as being
caused by ulcers. Thirty years ago, a stomach or duodenal ulcer (peptic ulcers)
was common and people died from bleeding into the stomach from the ulcer.
Our culture is full of stories about how stress causes ulcers,
and thousands of diets have been invented to treat ulcers. The stomach normally
produces acid (hydrochloric acid) and the normal pH is 5 (Neutral is pH7). It
had always been believed that the acid in the stomach would burn through the
lining and cause the ulcer. Stress and acid, or spicy foods, were thought to be
the reason the acid would burn through the stomach, and so most diets
considered good for ulcers were made up of bland food.
Alkaline foods and milk products were thought to be good for
acid indigestion or ulcers because they neutralized the hydrochloric acid in
the stomach. In fact they are worse for the stomach and acid production because
the stomach will immediately produce more acid to overcome the neutralizing
effect of any food and drink.
Ulcers became less of a problem in the 1970s when new tablets
blocking acid production became available (known as H2 antagonists). But the
real breakthrough came in the 1980s with the discovery of an infection in the
stomach called Helicobacter pylori (H pylori). This amazing bacterium lives in
the hydrochloric acid of the stomach and seems to be the cause of just about
all the cases of ulcers.
Gone are the causes of ulcers that we all for so long believed
caused the stomach ulcer. No longer can we blame stress or spicy food, or
lifestyle. Once we can get rid of this infection from our stomachs we will not
get the ulcer, and the only relatively minor problem is to get rid of the
infection with large doses of antibiotics and other tablets called eradication
therapy.
So, if you have stomach pain or dyspepsia, the first thing is
to check if you have a stomach ulcer. Once this is proven not to be the case,
you might still be disappointed to find that you have GORD.
This is a disease that is still a challenge for you and the
doctor, because there are still differences of opinion about the best way to
look after this problem.
First, there is the question about investigating the
dyspepsia. Until recently, it had been suggested that every case of indigestion
needed to be investigated with an endoscopy (a fibre optic tube stuck down
one’s throat to look at the upper part of the digestive system) or a
barium meal (an x-ray taken as one swallows barium, which goes around the
stomach). The trouble is that most times doing the test did not help discover
the problem.
So it seems that it is not always necessary to investigate
every form of dyspepsia.
A new form of treatment called the proton pump inhibitors has
been available for just over 10 years. Hydrochloric acid comes from the
hydrogen and chlorine in the stomach forming the acid. The hydrogen (or acid)
is pumped into the stomach by the cells in the stomach. Because the hydrogen in
this form is also known as a proton, the tablets that stop the hydrogen being
pumped into the stomach are called proton pump inhibitors (PPIs).
So the best way to treat the dyspepsia might be to test for H
pylori, eradicate the infection if present and, if not, just treat the symptoms
hence saving everyone a lot of time and trouble. It is suggested that it is
still worth looking at some of the known causes of dyspepsia and that sometimes
fixing those might help. And it is still worth giving up smoking, excess
alcohol, high fat intake and certain foods.
Most of the research these days points to these things
affecting the valve on top of the stomach. In the past, we used to think these
things might be “burning” the lining of the oesophagus or stomach,
but it is obvious that the acidity of the stomach is hundreds of times more
than the acidity of the food we eat. So it seems more important to see that the
valve on the top of the stomach closes properly. If it does not close properly,
acid will reflux up into the oesophagus.
The present guess is that 20 per cent of people will be able
to fix their dyspepsia by modifying their lifestyle. An extra 20 per cent will
have some improvement with the conventional antacids. The now older H2
antagonists (available on prescription and over the counter) will probably help
half of the people with dyspepsia. For the rest, a dose of PPI is probably
needed, and you need to see a doctor for this treatment.
There is also interesting work showing that you can sometimes
“heal” the problem with higher doses of PPIs, so it maybe that two
months of this treatment will “cure” you.
So the old and simple problem of indigestion or dyspepsia
actually has some new and interesting perspectives. It got its name because the
ancient Greeks recognized that a lot of people suffered from this discomfort.
Modern science has changed our whole thinking and, since the 1970s, ulcers have
just about become a thing of the past.
There are still issues around chest pain and dyspepsia that
need careful sorting out to make sure you are receiving the right treatment. Do
not miss the opportunity to see your GP and discuss with him or her some of the
new and possible “cure” treatments now available.
