CHAPTER 20
Peptic Disorders
Peptic disorders include gastritis, peptic ulcer, and gastroesophageal reflux. They involve damage to the lining of the esophagus, stomach, or duodenum (the first segment of the small intestine). These disorders are usually caused by stomach acids (especially hydrochloric acid), digestive enzymes (especially pepsin), infection with the bacterium Helicobacter pylori, and use of certain drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs).
Gastritis
Gastritis is inflammation of the stomach lining.
The inflammation can be caused by many factors, including infection, injury, certain drugs, and disorders of the immune system.
When symptoms do occur, they include abdominal pain or discomfort and sometimes nausea or vomiting.
Doctors often base the diagnosis on the person’s symptoms, but sometime they need to examine the stomach by using a flexible viewing tube (endoscopy).
Treatment is with drugs that reduce stomach acid.
The stomach lining resists irritation and can usually withstand very strong acid. Nevertheless, in gastritis, the stomach lining becomes irritated and inflamed.
Causes
Gastritis can be caused by many factors, including infection, injury, certain drugs, and disorders of the immune system.
Infections with bacteria, viruses, or fungi can cause gastritis. Worldwide, the most common cause of gastritis is infection with Helicobacter pylori bacteria. Viral or fungal gastritis may develop in people who have had a prolonged illness or an impaired immune system, such as those who have AIDS or cancer or those who take immunosuppressant drugs.
Erosive gastritis involves both inflammation and wearing away of the stomach lining. Erosive gastritis results from irritants such as drugs, especially aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs—see page 644); Crohn’s disease; bacterial and viral infections; and the ingestion of corrosive substances. In some people, even a baby aspirin taken daily can injure the stomach lining. Erosive gastritis can develop suddenly but more commonly develops slowly, usually in people who are otherwise healthy.
Acute stress gastritis, actually a form of erosive gastritis, is caused by a sudden illness or injury. The injury may not even be to the stomach. For example, extensive skin burns and injuries involving major bleeding are typical causes. Exactly why serious illness can lead to gastritis is not known but may be related to decreased blood flow to the stomach or to impairment of the stomach lining’s ability to protect and renew itself.
Radiation gastritis can occur if radiation is delivered to the lower left side of the chest or upper abdomen, where it can irritate the stomach lining.
Postgastrectomy gastritis occurs in people who have had part of their stomach surgically removed (a procedure called partial gastrectomy). The inflammation usually occurs where tissue has been sewn back together. Postgastrectomy gastritis is thought to result when surgery impairs blood flow to the stomach lining or exposes the stomach lining to an excessive amount of bile (the greenish yellow digestive fluid produced by the liver).
Atrophic gastritis causes the stomach lining to become very thin and to lose many or all of the cells that produce acid and enzymes. This condition can occur when antibodies (see page 1124) attack the stomach lining (termed autoimmune metaplastic atrophic gastritis). Atrophic gastritis can also occur in people who are chronically infected with Helicobacter pylori bacteria. It also tends to occur in those who have had part of their stomach removed.
Eosinophilic gastritis may result from an allergic reaction to an infestation with roundworms. In other cases, the cause is unknown. In this type of gastritis, eosinophils (a type of white blood cell) accumulate in the stomach wall.
Ménétrier’s disease, whose cause is unknown, is a type of gastritis in which the stomach wall develops thick, large folds; enlarged glands; and fluid-filled cysts. The disease may be due to an abnormal immune reaction and has also been associated with Helicobacter pylori infection.
In lymphocytic gastritis, lymphocytes (another type of white blood cell) accumulate in the stomach wall and other organs. This lymphocyte accumulation also occurs in celiac sprue (a malabsorptive disorder), but the cause is frequently unknown.
Symptoms and Complications
Gastritis usually causes no symptoms. When symptoms do occur, they vary depending on the cause and may include pain or discomfort (dyspepsia) or nausea or vomiting, problems that are often simply referred to as indigestion. Gastritis can lead to ulcers, which may cause the symptoms to get worse.
Nausea and intermittent vomiting can result from erosive gastritis, radiation gastritis, Ménétrier’s disease, and lymphocytic gastritis. Dyspepsia can occur, especially with erosive gastritis, radiation gastritis, postgastrectomy gastritis, and atrophic gastritis. Very mild dyspepsia also occurs with acute stress gastritis.
Ulcers can develop with several types of gastritis, especially acute stress gastritis, erosive gastritis, and radiation gastritis. Ulcers may bleed, causing a person to vomit blood (hematemesis) or pass tarry black stools (melena). Acute stress gastritis may lead to bleeding from ulcers within a few days after an illness or injury, whereas bleeding tends to develop more slowly in the case of erosive gastritis or radiation gastritis. Persistent bleeding can lead to symptoms of anemia, including fatigue, weakness, and light-headedness. If an ulcer goes through (perforates) the stomach wall, stomach contents may spill into the abdominal cavity, resulting in inflammation and usually infection of the lining of the abdominal cavity (peritonitis) and sudden worsening of pain.
Some complications of gastritis are slow to develop. The scarring and narrowing of the stomach outlet that can result from gastritis, especially from radiation gastritis and eosinophilic gastritis, can cause severe nausea and frequent vomiting. In Ménétrier’s disease, fluid retention and swelling of the tissues (edema) may occur because of loss of protein from the inflamed stomach lining. About 10% of people with Ménétrier’s disease develop stomach cancer some years later. Postgastrectomy gastritis and atrophic gastritis may cause symptoms of anemia, such as fatigue and weakness, because of decreased production of intrinsic factor (a protein that binds vitamin B12, allowing the B12 to be absorbed and used in the production of red blood cells). A small percentage of people with atrophic gastritis develop a condition called metaplasia, in which cells lining the stomach change and become precancerous. In an even smaller percentage of people, metaplasia leads to stomach cancer.
Diagnosis
A doctor suspects gastritis when a person has upper abdominal discomfort or pain or nausea. Tests usually are not needed. However, if the doctor is uncertain of the diagnosis, or if symptoms do not resolve with treatment, an examination of the stomach using an endoscope (a flexible viewing tube—see page 129) may be needed. If necessary, the doctor can perform a biopsy (removal of a tissue sample for examination under a microscope) of the stomach lining.
Treatment
Regardless of the cause of gastritis, symptoms can be relieved by taking drugs that neutralize or reduce the production of stomach acid and by discontinuing drugs that cause symptoms (see page 145). For mild symptoms, taking antacids, which neutralize acid that has already been produced and released in the stomach, is often sufficient. However, antacids have to be taken several times a day and often produce diarrhea or constipation. Drugs that reduce acid production include histamine-2 (H2) blockers and proton pump inhibitors. H2 blockers are usually more effective than antacids in relieving symptoms, and many people find them far more convenient. Proton pump inhibitors are prescribed when the strongest treatment is needed. When infection is a part of gastritis, antibiotics are also prescribed. Doctors may prescribe sucralfate, which
When the Stomach Is Infected
Infection with Helicobacter pylori, a type of bacteria, is the most common cause of gastritis and peptic ulcer worldwide. Infection is very common and increases with age; by age 60, about 50% of people are infected. Long-term infection increases the risk of stomach cancer.
H. pylori bacteria grow in the protective mucus layer of the stomach lining, where they are less exposed to the highly acidic juices produced by the stomach. Virtually all people who have H. pylori infection have gastritis, which may affect the entire stomach or only the lower part (antrum). Infection can sometimes lead to erosive gastritis. H. pylori contributes to ulcer formation by increasing acid production, interfering with the normal defenses against stomach acid, and producing toxins.
Most people with gastritis from H. pylori infection do not develop symptoms, but people who do develop symptoms experience those typical of gastritis, such as indigestion and pain or discomfort in the upper abdomen. Ulcers caused by H. pylori infection produce symptoms similar to ulcers caused by other disorders, including pain in the upper abdomen.
H. pylori can be detected with tests that use blood, breath, or stool samples. However, because blood tests can remain positive for years after the H. pylori infection has been eliminated, the breath test is often used to confirm treatment success.
H. pylori infection must be treated with antibiotics. The most popular treatment for H. pylori infection includes a proton pump inhibitor to reduce acid production combined with two antibiotics, such as amoxicillin and clarithromycin given twice daily for 7 to 14 days. The combination of bismuth subsalicylate (a drug similar to sucralfate), tetracycline (an antibiotic), metronidazole (an antibiotic), and a proton pump inhibitor is another popular option. However, this treatment requires people to take a total of four drugs up to 4 times a day for 7 to 14 days.
The likelihood that a peptic ulcer will recur during the course of 1 year is about 60 to 80% in people who have not been treated with antibiotics. This percentage decreases to less than 20% in people who have been treated with antibiotics. In addition, treatment of H. pylori infection may heal ulcers that have resisted previous treatment.
helps to prevent irritation. When gastritis leads to ulceration that perforates the stomach wall, immediate surgery is usually needed.
People with erosive gastritis must avoid taking drugs that irritate the stomach lining (such as NSAIDs). Some doctors prescribe proton pump inhibitors or misoprostol to help protect the stomach lining. The coxibs (COX-2 inhibitors such as celecoxib) are less likely to irritate the stomach lining than the older NSAIDs, but studies have shown that coxibs appear to increase the risk of heart attack and stroke with long-term use. Therefore, caution should be taken with use of coxibs.
Most people with acute stress gastritis recover fully when the underlying illness, injury, or bleeding is controlled. However, 2% of people in intensive care units have heavy bleeding from acute stress gastritis, which is often fatal. Therefore, doctors try to prevent acute stress gastritis after a major illness, major injury, or severe burn. Drugs that reduce acid production are commonly given after surgery and to people in most intensive care units to prevent acute stress gastritis. These drugs are also used to treat any ulcers that form. For people with heavy bleeding from acute stress gastritis, a wide variety of treatments have been used. Few of these treatments, however, improve the outcome. Blood transfusions may actually make bleeding worse. Bleeding points can be temporarily heat-sealed (cauterized) during an endoscopy, but bleeding often starts again if the underlying illness persists. If bleeding continues, the entire stomach may have to be removed as a lifesaving measure.
There is no cure for postgastrectomy gastritis or atrophic gastritis. People with anemia resulting from decreased absorption of vitamin B12 that occurs with atrophic gastritis must take supplemental injections of the vitamin for the rest of their lives.
Corticosteroids or surgery may be needed to relieve a blocked stomach outlet caused by eosinophilic gastritis. Removing part or all of the stomach may cure Ménétrier’s disease. There is no effective drug treatment.
Peptic Ulcer
A peptic ulcer is a round or oval sore where the lining of the stomach or duodenum has been eaten away by stomach acid and digestive juices.
Peptic ulcers can result from an infection with Helicobacter pylori or from drugs that weaken the lining of the stomach or duodenum.
Discomfort caused by ulcers tends to come and go.
The diagnosis is based on symptoms of stomach pain and on the results of an examination of the stomach by using a flexible viewing tube (endoscopy).
Antacids and other drugs are given to reduce acid in the stomach, and antibiotics are given to eliminate Helicobacter pylori.
Ulcers penetrate into the lining of the stomach or duodenum (the first part of the small intestine). Gastritis may develop into ulcers.
The names given to specific ulcers identify their anatomic locations or the circumstances under which they developed. Duodenal ulcers, the most common type of peptic ulcer, occur in the first few inches of the duodenum. Gastric ulcers, which are less common, usually occur along the upper curve of the stomach. Marginal ulcers can develop when part of the stomach has been removed surgically, at the point where the remaining stomach has been reconnected to the intestine. Stress ulcers, like acute stress gastritis, can occur as a result of the stress of severe illness, skin burns, or trauma. Stress ulcers occur in the stomach and the duodenum.
Causes
Ulcers develop when the normal defense and repair mechanisms of the lining of the stomach or duodenum are weakened, making the lining more likely to be damaged by stomach acid.
By far, the two most common causes of peptic ulcer are infection of the stomach with Helicobacter pylori bacteria and use of certain drugs.
Before current treatments for Helicobacter pylori infection were used, these bacteria were present in nearly 90% of people with duodenal ulcers and in 75% of people with stomach ulcers. Currently, the percentage is lower, about 50 to 75%.
Many drugs, especially aspirin, other nonsteroidal anti-inflammatory drugs (NSAIDs), and corticoste-roids, irritate the stomach lining and can cause ulcers. However, most people who take NSAIDs or corticosteroids do not develop peptic ulcers. Regardless, some experts suggest that people at high risk of developing peptic ulcers should use a type of NSAID called a coxib (COX-2 inhibitor), rather than one of the older types of NSAIDs, because coxibs are less likely to irritate the stomach (see page 646). However, studies have shown that coxibs appear to increase the risk of heart attack and stroke with long-term use and, therefore, caution should be taken with their use. Because of these complications, most doctors now use a standard NSAID plus a strong acid inhibitor (such as a proton pump inhibitor) for people at high risk of developing peptic ulcers.
People who smoke are more likely to develop a peptic ulcer than people who do not smoke, and their ulcers heal more slowly. Although psychologic stress can increase acid production, no link has been found between psychologic stress and peptic ulcers.
A rare cause of peptic ulcers is a type of cancer that causes excess acid production (Zollinger-Ellison syndrome—see box on page 142). The symptoms of cancerous ulcers are very similar to those of noncancerous ulcers. However, cancerous ulcers usually do not respond to the treatments used for noncancerous ulcers.
Symptoms
The typical ulcer tends to heal and recur. Thus, pain may occur for days or weeks and then wane or disappear. Symptoms can vary with the location of the ulcer and the person’s age. For example, children and older people may not have the usual symptoms or may have no symptoms at all. In these instances, ulcers are discovered only when complications develop.
Only about half of the people with duodenal ulcers have the typical symptoms of gnawing, burning, aching, soreness, an empty feeling, and hunger. The pain is steady and mild or moderately severe and usually located just below the breastbone. For many people with a duodenal ulcer, pain is usually absent on awakening but appears by midmorning. Drinking milk or eating (which buffers stomach acid) or taking antacids generally relieves the pain, but it usually returns 2 or 3 hours later. Pain that awakens the person during the night is common. Frequently, the pain erupts once or more a day over a period of one to several weeks and then may disappear without treatment. However, pain usually recurs, often within the first 2 years and occasionally after several years. People generally develop patterns and often learn by experience when a recurrence is likely (commonly in spring and fall and during periods of stress).
The symptoms of gastric, marginal, and stress ulcers, unlike those of duodenal ulcers, do not follow any pattern. Eating may relieve pain temporarily or may cause pain rather than relieve it. Gastric ulcers sometimes cause swelling of the tissues (edema) that lead into the small intestine, which may prevent food from easily passing out of the stomach. This blockage may cause bloating, nausea, or vomiting after eating.
Complications of peptic ulcers, such as bleeding or rupture, are accompanied by symptoms of low blood pressure, such as dizziness and fainting.
Diagnosis
A doctor suspects an ulcer when a person has characteristic stomach pain. Sometimes the doctor simply treats the person for an ulcer to see whether the symptoms resolve, which suggests that the person had an ulcer that has healed.
Tests may be needed to confirm the diagnosis, especially when symptoms do not resolve after a few weeks of treatment, or when they first appear in a person who is over age 45 or who has other symptoms such as weight loss, because stomach cancer can cause similar symptoms. Also, when severe ulcers
What Are the Complications of Peptic Ulcers?
Most ulcers can be cured without complications. However, in some cases, peptic ulcers can develop potentially life-threatening complications, such as penetration, perforation, bleeding (hemorrhage), obstruction, and cancer.
Penetration
An ulcer can go through (penetrate) the muscular wall of the stomach or duodenum (the first segment of the small intestine) and continue into an adjacent organ, such as the liver or pancreas. This penetration causes intense, piercing, persistent pain, which may be felt outside of the area involved—for example, the back may hurt when a duodenal ulcer penetrates the pancreas. The pain may intensify when the person changes position. If drugs do not heal the ulcer, surgery may be needed.
Perforation
Ulcers on the front surface of the duodenum, or less commonly the stomach, can go through the wall, creating an opening (perforation) to the free space in the abdominal cavity. The resulting pain is sudden, intense, and steady. The pain rapidly spreads throughout the abdomen. The person may feel pain in one or both shoulders, which may intensify with deep breathing. Changing position worsens the pain, so the person often tries to lie very still. The abdomen is tender when touched, and the tenderness worsens if a doctor presses deeply and then suddenly releases the pressure. (Doctors call this rebound tenderness.) Symptoms may be less intense in older people, in people taking corticosteroids, or in very ill people. A fever indicates an infection in the abdominal cavity. If the condition is not treated, shock may develop. This emergency situation requires immediate surgery and intravenous antibiotics.
Bleeding
Bleeding (hemorrhage) is a common complication of ulcers even when they are not painful. Vomiting bright red blood or reddish brown clumps of partially digested blood that look like coffee grounds and passing black or obviously bloody stools can be symptoms of a bleeding ulcer. However, small amounts of blood in the stool may not be noticeable but, if persistent, can still lead to anemia. Bleeding may result from other digestive conditions as well, but doctors begin their investigation by looking for the source of bleeding in the stomach and duodenum. Unless bleeding is massive, a doctor performs an endoscopy (an examination using a flexible viewing tube). If a bleeding ulcer is seen, the endoscope can be used to cauterize it (that is, destroy it with heat). A doctor may also use the endoscope to inject a material that causes a bleeding ulcer to clot. If the source cannot be found and the bleeding is not severe, treatments include taking ulcer drugs, such as his-tamine-2 (H2) blockers or proton pump inhibitors. The person also receives intravenous fluids and takes nothing by mouth, so the digestive tract can rest. If these measures fail, surgery is needed.
Obstruction
Swelling of inflamed tissues around an ulcer or scarring from previous ulcer flare-ups can narrow the outlet from the stomach or narrow the duodenum. A person with this type of obstruction may vomit repeatedly—often regurgitating large volumes of food eaten hours earlier. A feeling of being unusually full after eating, bloating, and a lack of appetite are symptoms of obstruction. Over time, vomiting can cause weight loss, dehydration, and an imbalance in body chemicals (electrolytes). Treating the ulcers relieves the obstruction in most cases, but severe obstructions may require endoscopy or surgery.
Cancer
People with ulcers caused by Helicobacter pylori have 3 to 6 times the chance of developing stomach cancer later in life. There is no increased risk of developing cancer from ulcers that have other causes.
resist treatment, particularly if a person has several ulcers or the ulcers are in unusual places, a doctor may suspect an underlying condition that causes the stomach to overproduce acid.
To help diagnose ulcers and determine their cause, the doctor may use endoscopy (a procedure performed using a flexible viewing tube) or barium contrast x-rays (x-rays taken after a substance that outlines the digestive tract has been swallowed).
Endoscopy is usually the first diagnostic procedure ordered by a doctor. Endoscopy is more reliable than barium contrast x-rays for detecting ulcers in the duodenum and on the back wall of the stomach; endoscopy is also more reliable if the person has had stomach surgery. However, even a highly skilled endoscopist may miss a small number of gastric and duodenal ulcers. With an endoscope, a doctor can perform a biopsy (removal of a tissue sample for examination under a microscope) to determine if a gastric ulcer is cancerous and to help identify the presence of Helicobacter pylori bacteria. An endoscope also can be used to stop active bleeding and decrease the likelihood of recurring bleeding from an ulcer.
Barium contrast x-rays of the stomach and duodenum (also called a barium swallow or an upper gastrointestinal series) can help determine the severity and size of an ulcer, which sometimes cannot be
Zollinger-Ellison Syndrome: An Acid-Stimulating Cancer
Zollinger-Ellison syndrome causes the stomach to produce too much acid. In this syndrome, a tumor, usually in the duodenum, pancreas, or adjacent structures, produces gastrin. Gastrin is a hormone that stimulates the stomach to produce large amounts of acid. About half of the tumors are cancerous (malignant). People with Zollinger-Ellison syndrome frequently develop many ulcers that recur despite treatment to control ulcer disease. They may also develop diarrhea that is difficult to control.
People with this disease typically have an elevated level of gastrin in their blood, which can be measured to make the diagnosis. Sometimes, testing involves giving the person a hormone called secretin. In people with Zollinger-Ellison syndrome, gastrin levels in the bloodstream greatly increase when secretin is injected into a vein. In addition, testing can reveal increased production of stomach acid. A number of tests can be performed in an attempt to find the tumor’s location, including computed tomography (CT) scanning, endoscopic ultrasound, and radionuclide scanning.
Proton pump inhibitors help control the excess production of stomach acid. Surgery to remove the tumor can be curative. Even when not curative, surgery can reduce the tumor size, which in turn reduces the amount of acid produced by the stomach and prevents local complications, such as blockage of the intestine. Radiation and chemotherapy are not helpful. Although chemotherapy may reduce tumor size, it is not curative.
completely seen during an endoscopy because it is further down the duodenum or hidden by a fold.
Treatment
Because infection with Helicobacter pylori bacteria is a major cause of ulcers, antibiotics are often used. Sometimes bismuth subsalicylate is used in combination with antibiotics. Neutralizing or reducing stomach acid by taking drugs that directly inhibit the stomach’s production of acid promotes healing of peptic ulcers regardless of the cause. In most people, treatment is continued for 4 to 8 weeks. Although bland diets may help reduce acid, no evidence supports the belief that such diets speed healing or keep ulcers from recurring. Nevertheless, it makes sense for people to avoid foods that seem to make pain and bloating worse. Eliminating possible stomach irritants, such as NSAIDs, alcohol, and nicotine, is also important.
Antacids: Antacids do not effectively heal ulcers but they do relieve symptoms of ulcers by neutralizing stomach acid and thereby raising the pH level in the stomach. Their effectiveness varies with the amount of antacid taken and the amount of acid a person produces. Almost all antacids can be purchased without a doctor’s prescription and are available in tablet or liquid form. However, antacids can interact with many different prescription drugs, so a pharmacist should be consulted about possible drug-drug interactions before antacids are taken.
Sodium bicarbonate (baking soda) and calcium carbonate, the strongest antacids, may be taken occasionally for fast, short-term relief. However, because they are absorbed by the bloodstream, continual use of these drugs may make the blood too alkaline (alkalosis—see page 974), resulting in nausea, headache, and weakness. Therefore, these antacids generally should not be used in large amounts for more than a few days. These products also contain a lot of salt and should not be used by people who need to follow a low-sodium diet or who have heart failure or high blood pressure.
Aluminum hydroxide is a relatively safe, commonly used antacid. However, aluminum may bind with phosphate in the digestive tract, thereby depleting the body of calcium, reducing phosphate levels in the blood, and causing weakness and a loss of appetite. The risk of these side effects is greater in people with alcoholism and in people with kidney disease, including those receiving dialysis. Aluminum hydroxide may also cause constipation.
Magnesium hydroxide is a more effective antacid than aluminum hydroxide. This antacid acts fast and neutralizes acids effectively. Bowel movements usually remain regular if only a few tablespoons a day are taken; more than four doses a day may cause diarrhea. Because small amounts of magnesium are absorbed into the bloodstream, people with kidney damage should take magnesium hydroxide only in small doses. Many antacids contain both magnesium hydroxide and aluminum hydroxide.
Anyone who has heart disease, high blood pressure, or a kidney disorder should consult a doctor before selecting an antacid.
Acid-reducing Drugs: Proton pump inhibitors are the most potent of the drugs that reduce acid production. Proton pump inhibitors promote healing of ulcers in a greater percentage of people in a shorter period of time than do histamine-2 (H2) blockers. They are also very useful in treating conditions that cause excessive stomach acid secretion, such as Zollinger-Ellison syndrome.
Histamine-2 (H2) blockers, such as cimetidine, famotidine, nizatidine, and ranitidine, relieve symptoms and promote ulcer healing by reducing the production of stomach acid. These highly effective drugs are taken once or twice a day. H2 blockers usually do not cause serious side effects. However, cimetidine is more likely to cause side effects, particularly in older people, in whom the drug may cause confusion. In addition, cimetidine may interfere with the body’s elimination of certain drugs—such as theophylline for asthma, warfarin for excessive blood clotting, and phenytoin for seizures.
Miscellaneous Drugs: Sucralfate may work by forming a protective coating in the base of an ulcer to promote healing. It works well on peptic ulcers and is a reasonable alternative to antacids. Sucralfate is taken 2 to 4 times a day and is not absorbed into the bloodstream, so it causes few side effects. It may, however, cause constipation, and in some cases it reduces the effectiveness of other drugs.
Misoprostol may be used to reduce the likelihood of developing stomach and duodenal ulcers caused by NSAIDs. Misoprostol may work by reducing production of stomach acid and by making the stomach lining more resistant to acid. Older people, people taking corticosteroids, and people who have a history of ulcers are at higher risk of developing an ulcer when they take NSAIDs and may also be potential candidates for misoprostol. However, misoprostol causes diarrhea and other digestive problems in more than 30% of people who take it. In addition, this drug can cause spontaneous abortions in pregnant women. Alternatives to misoprostol are available for people taking aspirin, NSAIDs, or corticosteroids. These alternatives, such as proton pump inhibitors, are just as effective for reducing the likelihood of developing an ulcer and cause fewer side effects.
DRUGS USED TO TREAT PEPTIC DISORDERS
| DRUG | SOME SIDE EFFECTS | COMMENTS |
| Antacids | ||
| Aluminum hydroxide Calcium carbonate Magnesium hydroxide Sodium bicarbonate |
Nausea, headache, weakness, loss of appetite, and constipation (aluminum hydroxide) or diarrhea (magnesium hydroxide) | These drugs are used mainly to relieve symptoms, not as a cure. |
| Histamine-2 blockers | ||
| Cimetidine Famotidine Nizatidine Ranitidine |
Rash, fever, muscle pains, and confusion (cimetidine or ranitidine) May cause breast enlargement and erectile dysfunction in men May interfere with elimination of certain drugs (cimetidine) |
The once-daily dose is taken in the evening or at bedtime. Doses taken in the morning are less effective. |
| Proton pump inhibitors | ||
| Lansoprazole Omeprazole Pantoprazole Rabeprazole Esomeprazole |
Diarrhea, constipation, and headache | These drugs are usually well tolerated and are most effective means of reducing stomach acid. |
| Antibiotics | ||
| Amoxicillin Clarithromycin Metronidazole Tetracycline |
Diarrhea (amoxicillin, clarithromycin, or tetracycline), altered taste, and nausea | These drugs are effective for treating peptic ulcers caused by Helicobacter pylori infection. |
| Miscellaneous | ||
| Bismuth subsalicylate Misoprostol Sucralfate |
Diarrhea (bismuth subsalicylate, misoprostol), darkening of the tongue and stool (bismuth subsalicylate), spontaneous abortion (misoprostol), and constipation (bismuth subsalicylate) May reduce effectiveness of other drugs (sucralfate) |
Bismuth subsalicylate is used in combination with antibiotics to cure Helicobacter pylori infection. |
Surgery: Surgery for ulcers is now seldom needed because drugs so effectively heal peptic ulcers and endoscopy so effectively stops active bleeding. Surgery is used primarily to deal with complications of a peptic ulcer, such as a perforation, an obstruction that fails to respond to drug therapy or that recurs, two or more major episodes of bleeding ulcers, a gastric ulcer suspected of being cancerous, or severe and frequent recurrences of peptic ulcers. A number of different surgical procedures may be performed to treat these complications. However, ulcers may recur after surgery, and each procedure may cause problems of its own, such as weight loss, poor digestion, and anemia.
Gastroesophageal Reflux
In gastroesophageal reflux (gastroesophageal reflux disease [GERD]), stomach acid and enzymes flow backward from the stomach into the esophagus, causing inflammation and pain in the esophagus.
Reflux occurs when the ring-shaped muscle that normally prevents the contents of the stomach from flowing back into the esophagus (lower esophageal sphincter) does not function properly.
The most typical symptom is heartburn (a burning pain behind the breastbone).
The diagnosis is based on symptoms.
Treatment is avoiding trigger substances (such as alcohol and fatty foods) and taking drugs that reduce stomach acid.
The stomach lining protects the stomach from the effects of its own acid. Because the esophagus lacks a similar protective lining, stomach acid and enzymes that flow backward (reflux) into the esophagus routinely cause symptoms and in some cases damage.
Acid and enzymes reflux when the lower esophageal sphincter, the ring-shaped muscle that normally prevents the contents of the stomach from flowing back into the esophagus, is not functioning properly. When a person is standing or sitting, gravity helps to prevent the reflux of stomach contents into the esophagus, which explains why reflux can worsen when a person is lying down. Reflux is also more likely to occur soon after meals, when the volume and acidity of contents in the stomach are higher and the sphincter is less likely to work properly. Factors contributing to reflux include weight gain, fatty foods, chocolate, caffeinated and carbonated beverages, alcohol, tobacco smoking, and certain drugs. Types of drugs that interfere with lower esophageal sphincter function include those that have anticholinergic effects (such as many antihistamines and some antidepressants), calcium channel blockers, progesterone, and nitrates. Alcohol and coffee also contribute by stimulating acid production. Delayed emptying of the stomach (for example, due to diabetes or use of opioids) can also worsen reflux.
Symptoms and Complications
Heartburn (a burning pain behind the breastbone) is the most obvious symptom of gastroesophageal reflux. Sometimes the pain even extends to the neck, throat, and face. Heartburn may be accompanied by regurgitation, in which the stomach contents reach the mouth.
Inflammation of the esophagus (esophagitis) may cause bleeding that is usually slight but can be massive. The blood may be vomited up or may pass through the digestive tract, resulting in the passage of dark, tarry stools (melena) or bright red blood, if the bleeding is heavy enough.
Esophageal ulcers, which are open sores on the lining of the esophagus, can result from repeated reflux. They can cause pain that is usually located behind the breastbone or just below it, similar to the location of heartburn.
Narrowing (stricture) of the esophagus caused by reflux makes swallowing solid foods increasingly more difficult. Narrowing of the airways can cause shortness of breath and wheezing. Other symptoms of gastroesophageal reflux include chest pain, sore throat, hoarseness, excessive salivation (water brash), a sensation of a lump in the throat (globus sensation), and inflammation of the sinuses (sinusitis).
With prolonged irritation of the lower part of the esophagus caused by repeated reflux, the cells lining the esophagus may change (resulting in a condition called Barrett’s esophagus). Changes may occur even without symptoms. These abnormal cells are precancerous and progress to cancer in some people.
Diagnosis
The symptoms point to the diagnosis, and treatment can be started without detailed diagnostic testing. Specific testing is usually reserved for situations in which the diagnosis is not clear or treatment has not controlled symptoms. Examination of the esophagus using an endoscope (a flexible viewing tube), x-ray studies, pressure measurements (manometry) of the lower esophageal sphincter, and esophageal pH (acidity) tests are sometimes needed to help confirm the diagnosis and check for complications.
Endoscopy may confirm the diagnosis if the doctor finds that the person has esophagitis or Barrett’s esophagus. Endoscopy also helps to exclude the presence of esophageal cancer. X-rays taken after a person drinks a barium solution (a substance that outlines the digestive tract) and then lies on an incline with the head lower than the feet may show reflux of the barium from the stomach into the esophagus. A doctor may press on the abdomen to increase the likelihood of reflux. The x-rays taken after the barium is swallowed also can reveal esophageal ulcers or a narrowed esophagus.
Pressure measurements at the lower esophageal sphincter indicate the strength of the sphincter and can distinguish a normal sphincter from a poorly functioning one. The information gained from this test helps the doctor decide whether surgery is an appropriate treatment.
Some doctors believe that the best test for gastroesophageal reflux is esophageal pH testing. In this test, a thin, flexible tube with a sensor probe on the tip is placed through the nose and into the lower esophagus. The other end of this tube is attached to a monitor that the person wears on a belt. The monitor records the acid levels in the esophagus, usually for 24 hours. Besides determining how much reflux is occurring, this test identifies the relationship between symptoms and reflux and is particularly helpful for people who have symptoms that are not typical of reflux. The esophageal pH test is needed for all people being considered for surgery to correct gastroesophageal reflux. A new device (using a small implanted pH electrode that transmits a signal) is available for people who cannot tolerate a tube in their nose.
Prevention and Treatment
Several measures may be taken to relieve gastroesophageal reflux. Raising the head of the bed about 6 inches (about 15 centimeters) can prevent acid from flowing into the esophagus as a person sleeps. Causative foods and drugs should be avoided, as should smoking. A doctor may prescribe a drug (for example, bethanechol or metoclopramide) to make the lower sphincter close more tightly. Coffee, alcohol, acid-containing beverages such as orange juice, cola drinks, and vinegar-based salad dressings, and other substances that strongly stimulate the stomach to produce acid or that delay stomach emptying should be avoided as well.
Many of the drugs used to treat gastritis and peptic ulcers also help prevent and treat gastroesophageal reflux (see table on page 142). Antacids taken at bedtime, for example, are often helpful. Antacids can usually relieve the pain of esophageal ulcers by reducing the amount of acid that reaches the esophagus. However, proton pump inhibitors, the most powerful drugs for reducing acid production, are usually the most effective treatment for gastroesophageal reflux, because even a small amount of acid can cause significant symptoms. Healing requires drugs that reduce stomach acid over a 4- to 12-week period. The ulcers heal slowly, tend to recur, and, when chronic and severe, can leave a narrowed esophagus after healing.
Esophageal narrowing is treated with drugs and repeated dilation, which may be performed using balloons or progressively larger dilators (bougies). If dilation is successful, narrowing does not seriously limit what a person can eat.
Barrett’s esophagus does not disappear when treatment relieves symptoms. Therefore, people with Barrett’s esophagus are asked to undergo an endoscopic examination every 2 to 3 years to ensure that the condition is not progressing to cancer.
Surgery is an option for people whose symptoms are unresponsive to drugs or for people who have esophagitis that persists even after symptoms are relieved. In addition, surgery may be the preferred treatment for people who do not like the prospect of having to take drugs for many years. A minimally invasive procedure performed through a laparoscope is available. However, 20 to 30% of people who undergo this procedure experience side effects, most commonly difficulty swallowing and a feeling of bloating or abdominal discomfort after eating.