  
|  |
|
| Peptic ulcers - treatment |
|
|
Reviewed by Dr Stephen C P Collins, GP
|
A lot has happened in the treatment of ulcers in the past few
years. Ulcer disease used to be a major disease of recurrent ill health with
many relapses and which required long-standing medical treatment. Surgery was
often necessary.
Today, it is a condition that can be cured within a few weeks.
However, it is important that the cause of the ulcers is accurately
diagnosed.
What causes ulcers?
Most
peptic ulcers develop
as a result of:
-
bacteria in the stomach
(Helicobacter pylori) - very common.
-
the use of antirheumatic medicine,
NSAIDs, or
aspirin (eg Disprin) - less
common.
-
stomach cancer - rare.
-
there are other types of peptic ulcers but these are very
rare.
How are ulcers treated when the cause is Helicobacter
pylori?
The treatment is targeted at eradicating the bacterial
infection; the ulcer then heals and relapses are prevented. Generally, three
different medicines are taken two to three times daily for a short course -
usually seven days.
They are a combination of:
-
one
proton pump inhibitor (omeprazole (eg Losec),
lansoprazole (Zoton), pantoprazole (Protium), rabeprazole (Pariet) or esomeprazole (Nexium)).
-
two antibiotics (amoxicillin (eg Amoxil), clarithromycin (Klaricid)
or
metronidazole (eg Flagyl)).
Possible combinations could be:
-
omeprazole + amoxicillin + clarithromycin.
-
omeprazole + metronidazole + clarithromycin (if penicillin
allergic).
-
HeliClear (lansoprazole, amoxicillin, clarithromycin) – a one-pack treatment now available on prescription
that contains all the necessary treatments in a one-week course.
A less common type of treatment is three to four different types
of medicine four times daily for a total of 14 days (proton pump inhibitor +
bismuth subcitrate
+ amoxicillin + metronidazole). This treatment form is only
used under special circumstances.
The treatment types listed above are both effective and not too
difficult to take.
Can Helicobacter pylori be resistant to the
treatment?
Yes, but it is uncommon, and a check-up after treatment to see
if the bacteria have been eliminated is generally not recommended
because:
-
you cannot feel if the bacteria has been eliminated, and the
physician cannot find out by taking a
blood test because Helicobacter
antibiotics persist even after the infection is cured.
-
to check effectively would involve another
gastroscopy for more samples from the
stomach's lining, or a 'breath-test'.
Will the ulcer heal after one week of treatment?
In many cases, one week of treatment is sufficient. It is
enough time to remove all the ulcer bacteria.
In some cases, the wound is not fully healed and it is
necessary to continue for a few weeks with further acid-inhibiting
treatment.
Does the ulcer treatment have to be monitored?
If the ulcer is located in the stomach, there is a slight
possibility that it is stomach cancer.
It is therefore necessary to perform another gastroscopy after
four to six weeks of treatment. It is then possible to confirm that the ulcer
is healing and, at the same time, take repeat
biopsies from the area
affected.
If the ulcer is located in the duodenum (the outlet from the
stomach), then it is not necessary to monitor the healing of the ulcer because
ulcers in this area are virtually never cancerous. Only if the symptoms
reappear should an examination be considered.
How are ulcers treated when aspirin or NSAIDs have caused
them?
-
First of all, it is necessary to stop taking these
medicines.
-
Under special circumstances, the physician may find it
necessary for the patient to continue with NSAIDs (see next
section).
-
If Helicobacter pylori are present in the
stomach, the bacteria are treated as described earlier.
If there are no signs of Helicobacter
pylori, the ulcer is treated with a
histamine H2 antagonist or a
proton pump inhibitor.
Stomach ulcers are examined again with gastroscopy after six
weeks.
Is it necessary to discontinue the medication that has caused an
ulcer?
If there are complications (bleeding ulcers or perforated
ulcers), then treatment with this medication should be stopped and never
resumed.
There are often good alternatives to NSAIDs or
aspirin.
Substantial medical reasons should be present to justify
resuming such medication. Under these circumstances, the ulcer should be
treated as mentioned earlier. The medication that triggered the ulcer should be
changed as follows:
-
NSAID: a low-risk preparation at lowest possible dose should be
used. Selective cox-2 inhibitors are a recently introduced type of NSAID that
have a lower likelihood of causing ulcers.
-
aspirin: the lowest possible dose should be used (75mg
daily).
This medication can be combined with a proton pump inhibitor.
Alternatively, it is possible to combine the NSAID with
misoprostol (Cytotec), which
counters the harmful effect that NSAIDs and aspirin have on the stomach's
lining (mucosa). There may be a positive effect when combining a proton pump
inhibitor and misoprostol with NSAIDs, but this has not yet been
established.
How are bleeding ulcers treated?
A bleeding ulcer is a serious condition and requires emergency
attention in hospital; a blood transfusion is often required. Treatment with
NSAIDs and aspirin should be discontinued immediately. A gastroscopy is
performed urgently to:
-
find the cause of bleeding, and make the diagnosis.
-
estimate the risk of new bleeds.
-
inject a substance into the mucosa adjacent to the ulcer to
minimise the chance of a significant recurrence of bleeding.
-
stop fresh arterial bleeding if possible.
In such circumstances, the patient remains hospitalised for some
days after an episode of bleeding. In rare cases, when heavy bleeding occurs
that cannot be stopped at gastroscopy, emergency surgery is then required.
During surgery, any small bleeding vessel is tied up and the
ulcer is 'oversewn'. This procedure is very effective in treating
serious loss of blood that cannot be staunched with less invasive techniques.
How is a perforated ulcer treated?
A perforated ulcer is a serious condition that requires
emergency attention. To make a diagnosis, an
X-ray of the stomach area is required (seeking air
under the diaphragm). A perforated ulcer requires emergency
surgery.
How is scarring of the duodenum treated?
A chronic ulcer can cause scarring of the stomach outlet (the
pylorus and the duodenum), causing restricted emptying of the stomach. The
symptoms may include vomiting and weight loss. This condition is often treated
surgically by creating a shortcut around the scarred or narrowed duodenum to
facilitate gastric emptying
('gastro-enteric-anastomosis').
When is a chronic ulcer treated surgically?
Treating a chronic ulcer with surgery is rarely seen today. An
exception is surgery for bleeding or perforated ulcers and in cases where the
stomach outlet or the duodenum has become deformed and restricted by scar
tissue.
It was quite common some years ago to treat chronic ulcers
surgically (because effective acid-suppressing medicine did not exist, and
Helicobacter pylori had not yet been discovered). The
surgical procedure depended on the ulcer's position.
Generally, three different types of surgery were
used.
-
The nerves to the stomach were cut (vagotomy).
-
A part of the stomach was removed (partial
gastrectomy).
-
Combinations with adjustment to the duodenum's attachment
to the stomach.
Side effects were frequent and included stomach upsets, reflux
and abdominal pain, fatigue, diarrhoea, and weight loss. The operations used at
the time must be seen from the perspective that no other treatment options were
available.
In rare cases, it is possible today to require one of these
surgical procedures - but only when medication has failed.
|
Based on a text by Dr Torben Nathan, Dr Carl J Brandt and Dr Dr Ove Schaffalitzky de Muckadell
|
Last updated 01.08.2005
|
 |
|
|
 |
| |      |
|
