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Peptic Ulcers

One in 10 men and one in 15 women will develop a peptic ulcer. It's not known exactly why they occur, but today, thanks to modern drugs, they are almost always treatable without surgery.

An ulcer is an open sore in the skin or in one of the many protective mucous membranes that line parts of the body, including the digestive tract. You can get an ulcer almost anywhere - in your mouth, on your leg or in the lining of your gut.

WHERE THEY FORM
A peptic ulcer is any sort of ulcer that results from the action of the gastric, or stomach, juices, and usually occurs in the stomach or in the duodenum - the tube that exits
from the stomach.

Peptic ulcers affect up to one million people every year in the UK alone. Most of these people are cured relatively quickly and simply, though recurrences are common.

However, in some cases, a peptic ulcer can have serious consequences and treatment may involve emergency surgery. In the worst circumstances, a peptic ulcer can be fatal, accounting for 4,000 deaths a year in the UK, more than twice the number caused by cervical cancer.

Peptic ulcers may occur in the oesophagus - the muscular tube that carries food into the stomach - but are more common in the stomach or duodenum where food is broken down. Digestion begins in the stomach where hydrochloric acid and the enzyme pepsin are released. Food churns around in these gastric juices and begins to break down.

ACID RESISTANT
To ensure that the stomach or duodenum are not digested as well as the food, they are lined with a mucous membrane which is resistant to acid and enzyme attack.

Ulcers occur when the digestive juices break through this protective lining and eat into the underlying tissues. More rarely, they develop in the oesophagus or in the small intestine. Ulcers in any of these areas are collectively known as peptic ulcers because of the involvement of pepsin.

People with duodenal ulcers produce too much acidic juice, while those who develop gastric ulcers usually produce normal amounts of acid but have a faulty stomach lining.

At one time, gastric ulcers were more common than duodenal ulcers. Now, gastric ulcers have become far less prevalent, affecting about one in 30, while duodenal ulcers affect as many as one in 10. Men are more likely to develop ulcers than women, and there is more chance of them occurring if you are over 40.

There is also some evidence that peptic ulcers run in families and that they are most common in Europe, North America and certain parts of India.

NEW DISCOVERY
No-one knows exactly why this has happened or why some people seem particularly prone to peptic ulcers. However, doctors have recently focused their suspicions on a bacterium called helicobacter pylori (h. pylori) which they now think plays an important role in causing ulcers and other stomach and duodenal problems, possibly even stomach cancer.

What doctors do know is that heavy alcohol intake, especially of spirits, can encourage ulcers to develop or make existing ones worse. If you smoke, you are more likely to develop ulcers, too. Smoking also inhibits ulcers from healing and makes them more likely to recur.

Drugs such as aspirin and some other NSAIDs (non-steroidal anti-inflammatory drugs) used to treat arthritis, can predispose some people to ulcers. In addition, some ulcer sufferers find their symptoms worsen under stress - possibly because stress stimulates the stomach to produce more acid.

THE SYMPTOMS
Some people with peptic ulcers have no symptoms at all. Others complain of a gnawing pain in the upper part of their abdomen. This condition is known as dyspepsia. With duodenal ulcers, the pain is often worse at night.

The pain often causes a burning sensation and tends to occur in bouts lasting a week or two. Eating usually brings temporary relief until the food has passed out of the stomach, But eating certain foods may make the pain worse; trial and error will soon identify the culprits.

Diagnosis is carried out either by X-ray or using a very thin, flexible fibreoptic instrument which is known as an endoscope.

If you are recommended for X-ray diagnosis, you first will need to eat a 'barium meal'. This involves drinking a small amount of a special liquid or eating a piece of food, usually a piece of bread or a biscuit, soaked in the metallic element barium. This makes the soft tissue of the stomach show up clearly on X-ray.

During endoscopy, you may be given a sedative and a local anaesthetic may be applied to the back of your mouth to numb the throat area. The endoscope is then inserted into your stomach or duodenum so the lining can be closely inspected. Tiny samples may also be removed for laboratory examination.

About a third of ulcers heal within a month using self-help measures, such as eating regular meals, giving up smoking and drinking less alcohol.

When the ulcer persists, dietary regimes, once the mainstay of treatment, have been superseded by new types of drugs that help prevent the stomach secreting acid, allowing the ulcer to heal.

Other drugs can help to encourage healing of the ulcer because they form a protective coating over the ulcer crater.

SPEEDY RECOVERY
To wipe out the h. pylori infection, you may be given antibiotics, thereby reducing the chances of the ulcer recurring. Two-thirds of the people who undergo drug treatments are well on the road to recovery within six weeks.

Antacids that neutralize excess acid may also be prescribed. They are not suitable for long-term use because the stomach may then respond by pumping out even more acid.

SURGICAL SOLUTIONS
If drug therapy fails, the doctor may recommend surgery. The most common operation used to treat ulcers is called a vagotomy. This involves cutting the tiny branches of the vagus nerve that controls digestive acid production. It is often combined with a pyloroplasty, a procedure to widen the outlet from the stomach to the duodenum.

Another procedure, known as a highly selective vagotomy, involves dividing only the tiny branches of the vagus nerve. It can be carried out without opening the stomach. Occasionally, a partial gastrectomy, which involves removing a portion of the stomach, may be recommended to reduce acid production.

SIDE-EFFECTS
Ulcer complications are rare but can be serious. Internal bleeding is one of the most important, and may lead to severe blood loss and shock.

Symptoms will usually include vomiting blood, which comes out as small, dark brown lumps called 'coffee ground' vomit, feeling faint and passing black, tarry motions.

Treating for shock and a blood transfusion might be necessary. Bed rest will usually settle the bleeding. However, if it does not, an operation may be needed to stop the blood flow.

An ulcer can perforate (break through), causing inflammation and infection of the stomach lining. This potentially life-threatening condition is known as peritonitis. The signs are collapse and severe abdominal pain.

If this does happen, emergency surgery is usually performed, but sometimes draining off the gastric juices allows the perforation to heal. This is done by passing a suction tube into the stomach via the nose.

THE CANCER RISK
The inflammation surrounding a peptic ulcer may also cause problems by constricting the part of the stomach that drains into the duodenum, resulting in a blockage. This complication - called pylori stenosis - may need surgery, too.

There's a small risk that gastric ulcers may become cancerous, so an endoscopy is usually performed to check for malignancy. There is virtually no risk of duodenal ulcers developing into cancer.

     
     

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