CENTRAL  SOUTH  DAKOTA  MEDICAL NEWS
THE CLINICAL VIEW
By: Phillip E. Hoffsten, M.D.
25  JANUARY 2001

NEW TREATMENTS FOR STOMACH ULCERS

 One of my favorite pastimes is reading old medical books regarding the treatments that were used for various diseases years ago. I have a medicine book that was published in 1880 when the symptoms of ulcer disease were well known. Under the treatment section, it was recommended that the person not eat anything and use broth enemas and bedrest for several weeks. In those days, there were no controlled studies where a group of people were treated one way and another group of people were treated another way to see which treatment was the best. Instead, the treatments recommended were the best opinions of the "authorities" in those days.

Fortunately, today's recommendations by your healthcare professionals are based upon studies where one large group of people is treated one way and another large group of people is treated another way to see which treatments work the best. Since the broth enemas of the 1880s, treatment for ulcer disease has evolved and we now have very good information regarding the cause of ulcers and very good tested treatments to relieve the symptoms of ulcers.

By 1920, it was recognized that people that have stomach ulcers seemed to be very anxious. No wonder if my stomach hurt all the time, I would be anxious too. In those times, doctors felt that if the ulcer patient could be made less anxious, their ulcers would get better. A drug called phenobarbital was used to treat ulcer disease. This drug was our first "tranquilizer" and was the best answer for ulcer disease for many years.

At about this same time, doctors began to realize that ulcers were associated with more stomach acid than normal. There was thus born the idea that ulcers came from too much stomach acid and the way to treat ulcers was to neutralize the acid. Thus, was born Turns and Maalox and Mylanta to neutralize the acid in the stomach. Indeed, these steps seemed to work for some patients but the problem would persist for years. The poor ulcer patient was doomed to be taking this white medicine in greater or lessor amounts all the time.

Through the time from the 1920s through about 1980, one of the most common treatments for ulcer disease was surgical. The surgeon removed two-thirds of the stomach where most of the acid-producing cells were and cut the vagus nerve so that a message to make stomach acid was no longer sent to the stomach.  This surgery was more or less successful and was by far the most common surgery done by many surgeons from the 1940s through the 1970s. An interesting statistic relates to my practice of internal medicine in Pierre for 20 years. Not even one of my patients has had a gastric removal to treat stomach ulcers in the last 20 years.

This is because by 1970 a new drug called Tagamet (cimetidine) first became available on the market. This drug decreased the amount of acid that the stomach made and healed the ulcer disease for many, many people. This drug was soon followed by Zantac, then Pepcid and finally Axid which decreased the amount of acid that the stomach makes. I thought in1985 after these drugs were available that there was no further need to study ulcer disease because we had the best medicines conceivable. That was completely wrong.

About 1980, a doctor working in Australia discovered that stomach ulcers are very frequently caused by bacteria that infects the stomach wall. One of the questions asked of medical students is why stomachs do not digest themselves. After all, you can put meat and potatoes and peas and corn in your stomach and they soon become soup and then a clear liquid that your body absorbs and uses for nutrition. Your stomach is made of meat; why doesn't it digest itself? The answer to this question was that the stomach makes various chemicals that coat the stomach and protect it from itself. This bacterial infection which was discovered in 1980 weakened the lining of the stomach and thereby allowed the stomach to digest itself, thereby causing an ulcer. This explains why decreasing stomach acid benefitted the symptoms of the ulcer patient but did not cure the ulcer disease which recurred when the antacids were no longer used.

In 1988, a drug called Prilosec first became available and was much more effective at turning off stomach acid than Tagamet, Zantac, Pepcid and Axid. Unfortunately, this drug is very expensive at about $3.50 per day. In spite of the fact that it has now been joined by three other competitors called Aciphex, Prevacid and Protonix, the price is still very substantial.

By the 1990s, antibiotic combinations to effectively cure the stomach bacterial infection were developed. It was found that 93% of the individuals who had an infection in their stomach could be cured of this infection and the need for further treatment for stomach ulcers was just stopped. Now, even though the person made lots of stomach acid, the lining of the stomach was strong enough to resist this and the need for drugs was gone.

Unfortunately, not all stomach ulcers come from this bacterial infection. A major proportion of them are related to the use of aspirin, ibuprofen (Motrin, Advil, Nuprin), Naprosyn (Aleve), and ketoprofen (Orudis). These drugs dissolve the protective lining of the stomach and again allow the stomach to digest itself causing the ulcer. The way to treat this problem is to stop the drug that caused the problem to begin with. Indeed, antacids may be necessary initially to allow the ulcer to heal but to prevent recurrence one simply stops using the drug that causes the problem.

Two last points are worth mentioning. First, most of the aspirin family of drugs are used to treat arthritis symptoms. The most common form of arthritis is called osteoarthritis or "wear-and-tear" arthritis that comes from overuse of joints. For years people have used the "nonsteroidal anti-inflammatory drugs (NSAID's)." The belief was that the anti-inflammatory drugs would decrease the inflammation in the joint in people with wear-and-tear arthritis. This is probably not true. The use of the aspirin family of drugs works primarily by stopping pain but has relatively little effect on stopping inflammation. Thus, the use of Tylenol is something to try in place of the aspirin family if the person has a tendency to develop abdominal pain. Your local healthcare provider can prescribe various pain medications which may be a better help than Tylenol and less corrosive for your stomach than aspirin products.

Lastly, there are about 10% to 15% of people who have abdominal pain which is ulcer­like but really do not have ulcers or too much stomach acid. This group of individuals are best treated with a variety of other medications that can be prescribed by your local healthcare provider. Suffice to say, ulcer treatments have come a long way from the broth enemas of the 1880s and maybe in 100 years what we are doing today will look equally foolish. Be that as it may, right now we have remarkably good treatments to treat ulcers and a number of diagnostic and therapeutic steps to help those individuals with abdominal pain who do not have ulcers. Your local clinic can be a substantial help in diagnosing and treating these problems.