Stomach Ulcer: An Interview with Dr. Prasan Kumar Hota

Stomach Ulcer: An Interview with Dr. Prasan Kumar Hota
Stomach Ulcer

In an interview with Dr. Prasan Kumar Hota, Prof. General Surgery – Mamata Medical College, Andhra Pradesh, here are a few answers for our readers who face Ulcer in stomach and need a doctor’s opinion on the same:

What is ulcer?

An ulcer in the stomach, commonly known as “Peptic ulcer” is defined as “a circumscribed ulceration of the gastrointestinal mucosa occurring in areas exposed to acid and pepsin and most often caused by Helicobacter pylori infection”. Ulcers are usually defined as a breach in the mucosa of the alimentary tract, which extends through the muscularis mucosa into the submucosa or deeper. Peptic ulcers are chronic most often solitary, lesions that occur in any portion of gastrointestinal tract exposed to the aggressive action of acid-peptic juices.

What are the causes of ulcer?

The main etiological factors of peptic ulcers are

(1) Helicobacter pylori infection and (2) Non-steroidal anti-inflammatory drugs (NSAIDs).
However, other factors in acid-peptic disease are as follows:
(a). Cigarette smoking
(b). Genetic predisposition
– 1st degree relatives of Duodenal ulcer patients are liable to develop the disease three times more commonly as compared to the general population.
– Blood group – O & non-secretor are at a: higher risk as H.pylori binds to group O antigens
(c). Psychological stress is considered with conflicting study results
(d). Diet has not also shown any convincing study results.
(e). Chronic disorders as mentioned below are considered as etiological factors in causing peptic ulcer diseases.
– Systemic mastcytosis
– α1-AT def
– Chronic pulmonary disease
– Cirrhosis of liver
– Hyperparathyroidism
– Chronic renal failure
– Coronary artery disease
– Nephrolithiasis
– Polycythemia vera
– Chronic pancreatitis
(f). Gastrinoma may cause multiple peptic ulceration as in Zollinger Ellison syndrome. In this case, peptic ulcer is caused due to high gastrin level and excess acid production.
The etiological factors differ in different types of peptic ulcers, viz.- Duodenal ulcer and Gastric ulcer. Summarized differentiations in causative factors in these two types of peptic ulcers are given below.

Duodenal ulcer:

– Duodenal ulcer sites are 4 times more common than gastric sites.
– Most common in middle age (peak 30-50 years).
– Male to female ratio is 4:1.
– Genetic link: 3 times more common in 1st degree relatives.
– More common in patients with blood group O.
– Associated with increased serum pepsinogen.
– H. pylori infection common i.e. up to 95%.
– Smoking is twice as common.

Gastric ulcer:

– Common in late middle age.
– Incidence increases with age.
– Male to female ratio is 2:1.
– More common in patients with blood group A.
– Use of NSAIDs – associated with a three – to four-fold increase in risk of gastric ulcer.
– Bile reflux is also known to cause gastric ulcer.
– Less related to H. pylori than duodenal ulcers – about 80%.
– 10 – 20% of patients with a gastric ulcer have a concomitant duodenal ulcer

What are the symptoms a person with ulcer faces?

– Pain in the epigastric region is the main symptom. It is described by the patient as ”gnawing”, “aching”, or “burning” type. This pain is related to food intake differently in duodenal and gastric ulcers.
– Duodenal ulcers: Pain occurs 1-3 hours after a meal and may awaken the patient from sleep. Pain is relieved by food, antacids, or vomiting.
– Gastric ulcers: Food may exacerbate the pain while vomiting relieves it. Hence pain usually comes immediately after a meal.
– Other symptoms like, nausea, vomiting, belching, dyspepsia, bloating, chest discomfort, anorexia or loss of appetite, haematemesis (vomiting with blood), &/or melena (black colored tarry stool) may also occur.
– Nausea, vomiting, & weight loss more common with Gastric ulcers

Is there any tests needed to identify ulcer?

(a). Upper GI Endoscopy is the gold standard for diagnosis of the peptic ulcer diseases. This is the most preferred diagnostic test as it is highly sensitive for diagnosis of ulcers and allows for biopsy to rule out malignancy and rapid urease tests for testing for H. Pylori.
(b). Other tests are as follows.

– Radiographic study (Barium study) – single-contrast study and double-contrast study.
– H.pylori work-up
– Serum gastrin & gastric acid analysis
– Screening for aspirin or NSAIDs (blood or urine)
– Stool for fecal occult blood

Which are the different types of ulcers that are commonly found?

There are two types of peptic ulcer.

(1) Duodenal ulcer – occurs in the 1st part of the duodenum.
(2) Gastric ulcer – occurs anywhere in the stomach.

Besides these sites, peptic ulcer can occur as stomal ulcer (Gastric stoma following Gastrojejunostomy) etc and also in Meckel’s diverticulum in ileum.

What are the treatment options available for ulcer problem?

I. Medical treatment is the treatment of choice for peptic ulcer diseases.
(a). Anti H.pylori treatment is given in cases positive for H.pylori infection with a combination therapy for a period of 7 to 14 days. A course of PPI like Pantoprazle is given for a period of 4 – 6 weeks after the completion of anti H.pylori regime. This duration depends on the response of the patient. Pre pack combination therapy (anti H.pylori kits) is available in the market. The usual combination therapy for H.pylori is;
1. PPI (Omeprazole 20mg bid/ Pantoprazole 40mg bid/ Rabeprazole 20mg bid)
2. Amoxicillin(500mg/1gm bid) / Clarythromycin (500mg bid)
3. Metronidazole(400mg bid)
(b). In non H.pylori infection cases the patient should be treated with PPI like Pantoprazole or Rabeprazloe for a period of 6-8 weeks. Other drugs like, H2 receptor antagonists (Ranitidine 150mg bid) may be given instead of PPI.

(c). In addition to the medical therapy certain life style modifications are advised as follows.
– Discontinue NSAIDs and use Acetaminophen for pain control if possible.
– Acid suppression should be done with antacids
– Smoking should be stopped.
– No dietary restrictions unless certain foods are associated with problems.
– Alcohol in moderation may be advised
– Men under 65: 2 drinks/day
– Men over 65 and all women: 1 drink/day
– Stress reduction

II. Surgical treatment is indicated only in complications like; Gastro intestinal bleeding, Perforation of the ulcer and Gastric outlet obstruction.

Are there any dietary restrictions for ulcer patient?

There are no dietary restrictions unless certain foods are associated with the problems.

How severe can be the disease?

Unless otherwise peptic ulcer is treated in time with proper medical management, it may be life threatening with complications like massive bleeding from the ulcer site; perforation of the ulcer leading to peritonitis, which may be life threatening with high morbidity and mortality; and gastric outlet obstruction causing vomiting and other problems. Gastric ulcer may turn into malignancy.

Do the intake of pain relievers or aspirin causes ulcer?

Yes. As discussed earlier, NSAIDs like aspirin cause gastric ulcers.

Is there anything else which you would like to share?

– Peptic ulcer disease is a chronic disorder, which can cause high morbidity and mortality if not treated in time. Unsolicited use of over the counter pain killers must be discouraged.
– Steps should be taken to reduce the risk factors for H.pylori infection like, domestic crowding, unsanitary living conditions, unclean food or water, and exposure to gastric contents of an infected individual. Poor economic status and less education are the important factors for H.pylori infection, which should be addressed for.
– When a patient has to be on NSAIDs like aspirin etc, consider prophylactic therapy with PPI like Pantoprazole in following situations:
– Patients with NSAID-induced ulcers who require daily NSAID therapy.
– Patients older than 60 years.
– Patients with a history of peptic ulcer disease or a complication such as GI bleeding.
– Pts taking steroids or anticoagulants or patients with significant comorbid medical illnesses.

Special Thanks To:

Dr. Prasan Kumar Hota

Dr. Prasan Kumar Hota

Dr. P K Hota,
MS,FMAS,FICS,FAIS
Professor in Surgery,
Dept. of Surgery,
Mamata Medical College,
Khammam – 507002
Andhra Pradesh
E-mail – hota.dr@gmail.com

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