Peptic Ulcer (cont.)

What treatments are available for peptic ulcers?

The goal of ulcer treatment is to relieve pain and to prevent ulcer complications, such as bleeding, obstruction, and perforation. The first step in treatment involves the reduction of risk factors (NSAIDs and cigarettes). The next step is medications.

Antacids neutralize existing acid in the stomach. Antacids such as Maalox, Mylanta, and Amphojel are safe and effective treatments. However, the neutralizing action of these agents is short-lived, and frequent dosages are required. Magnesium containing antacids, such as Maalox and Mylanta, can cause diarrhea, while aluminum agents like Amphojel can cause constipation. Ulcers frequently return when antacids are discontinued.

Studies have shown that a protein in the stomach called histamine stimulates gastric acid secretion. Histamine antagonists (H2 blockers) are drugs designed to block the action of histamine on gastric cells, hence reducing acid output. Examples of H2 blockers are cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine (Pepcid). While H2 blockers are effective in ulcer healing, they have limited role in eradicating H. pylori without antibiotics. Therefore, ulcers frequently return when H2 blockers are stopped. Generally, these drugs are well tolerated and have few side effects even with long term use. In rare instances, patients report headache, confusion, lethargy, or hallucinations. Chronic use of cimetidine may rarely cause impotence or breast swelling. Both cimetidine and ranitidine can interfere with body's ability to handle alcohol. Patients on these drugs who drink alcohol may have elevated blood alcohol levels. These drugs may also interfere with the liver's handling of other medications like Dilantin, Coumadin, and theophylline. Frequent monitoring and adjustments of the dosages of these medications may be needed.

Proton-pump inhibitors such as omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), esomeprazole (Nexium), and rabeprazole (Aciphex) are more potent than H2 blockers in suppressing acid secretion. Different proton-pump inhibitors are very similar in action and there is no evidence that one is more effective than another in healing ulcers. While proton-pump inhibitors are comparable to H2 blockers in effectiveness in treating gastric and duodenal ulcers, it is superior to H2 blockers in treating esophageal ulcers. Esophageal ulcers are more sensitive than gastric and duodenal ulcers to minute amounts of acid. Therefore, more complete acid suppression accomplished by proton-pump inhibitors are important for esophageal ulcer healing. Proton-pump inhibitors are well tolerated. Side effects are uncommon; they include headache, diarrhea, constipation, nausea and rash. Interestingly, proton-pump inhibitors do not have any effect on a person's ability to digest and absorb nutrients. Proton-pump inhibitors have also been found to be safe when used long term, without serious adverse health effects reported.

Sucralfate (Carafate) and misoprostol (Cytotec) are agents that strengthen the gut lining against attacks by acid digestive juices. Carafate coats the ulcer surface and promotes healing. The medication has very few side effects. The most common side effect is constipation and the interference with the absorption of other medications. Cytotec is a prostaglandin-like substance commonly used to counteract the ulcer effects of NSAIDs. Studies suggest that Cytotec may protect the stomach from ulceration in those who take NSAIDs on a chronic basis. Diarrhea is a common side effect. Cytotec can cause miscarriages when given to pregnant women, and should be avoided by women of childbearing age.

Many people harbor H. pylori in their stomachs without ever having pain or ulcers. It is not completely clear whether these patients should be treated with antibiotics. More studies are needed to answer this question. Patients with documented ulcer disease and H. pylori infection should be treated with antibiotic combinations. H. pylori can be very difficult to completely eradicate. Treatment requires a combination of several antibiotics, sometimes in combination with a proton-pump inhibitor, H2 blockers or Pepto-Bismol. Commonly used antibiotics are tetracycline, amoxicillin, metronidazole (Flagyl), clarithromycin (Biaxin), and levofloxacin (Levaquin). Eradication of H. pylori prevents the return of ulcers (a major problem with all other ulcer treatment options). Elimination of this bacteria may also decrease the risk of developing gastric cancer in the future. Treatment with antibiotics carries the risk of allergic reactions, diarrhea, and sometimes severe antibiotic-induced colitis (inflammation of the colon).

There is no conclusive evidence that dietary restrictions and bland diets play a role in ulcer healing. No proven relationship exists between peptic ulcer disease and the intake of coffee and alcohol. However, since coffee stimulates gastric acid secretion, and alcohol can cause gastritis, moderation in alcohol and coffee consumption is often recommended.

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