Treatment of Gastric Ulcer
Gastric ulcer is a superficial or deep fissure in stomach mucosa caused by irritation, trauma or inflammation of mucosal membrane. The infection caused by H. Pylori bacteria causes inflammation of gastric mucosa followed by multiple ulcers formations during recovery. The treatment option is to treat the gastritis caused by H. Pylori with antibiotics during early stages. Gastric ulcer is observed as superficial or deep ulcer. Deep ulcer penetrates into deeper mucosa and often infiltrates through the mucosal blood vessels resulting in mild to profuse life threatening bleeding. Most of the superficial ulcer are harmless but causes mild to severe pain.
Treatment is indicated for pain as well as prevention of ulcer developing into deep seated ulcer. The treatment of pain depends on intensity and frequency of healing. Mild gastric ulcer which may rapidly heal can be treated with medications such as antacids for 2 to 4 weeks. Multiple repeated gastric ulcers often caused by hyper reaction to stomach acidity may be treated with medication which can neutralize the acidic pH of stomach digestive juice.
In few cases gastric ulcer may not respond to any conservative treatment and is treated with surgical options. Gastric ulcer resulting in bleeding is considered emergency to prevent life threatening bleeding. Bleeding ulcer is often treated as an emergency. Bleeding is stopped by cauterizing the bleeding vessels. The procedure is performed using gastroscopy. The treatment for gastric ulcer is divided in two section, conservative treatment by medications and invasive treatment by using surgery.
Conservative Treatment of Gastric Ulcer
Antibiotics to Treat Gastric Ulcer-
Antibiotics are prescribed to treat gastritis caused by H. Pylori infection. The H. Pylori infection is confirmed by blood test and bacterial culture when patient is suffering with symptoms of gastritis. Earlier initiation of antibiotics prevents severe gastric inflammation and ulcer formation. Most effective antibiotics against H. Pylori are tetracycline, amoxicillin, metronidazole (Flagyl) and levofloxacin (Levaquin).
Antacids to Treat Gastric Ulcer –
Antacids are prescribed to neutralize pH in gastric juice by reducing H+ molecule of gastric acid. Antacid prevents further enhancing the penetration of ulcer into mucosa by preventing continuous acid effects on eroded mucosa. Antacid also helps to reduce pain by reducing pH of stomach content. Antacids are taken as chewing pills or liquid. Antacids also covers the most surface of mucosa depending on quantity taken at interval. The presence of antacid neutralizes gastric mucosa and also covers most mucosal layer of stomach resulting in protection from continuous acidic effects of gastric juice over the superficial layer gastric mucosa. Large number of antacids are sold over the counter in pharmacy. The most common antacids used to treat gastric ulcer contains aluminum hydroxide, magnesium hydroxide and calcium carbonate. The product sold on shelf are Maalox, Mylanta, Tums and Rolaids. Antacids are avoided in pregnant patient and children under 12 years of age.
The cyto-protective agents protect the gastric or stomach mucosa from gastric acid. The medications are taken in liquid form. The medications cover the surface of ulcers and protects the ulcer from further effects of acid. The most common agents available as a medication are Carafate and Cytotec.
Antacids to Treat Gastric Ulcer –
Antacids medications acts on acid producing glands of stomach mucosa and reduces acid content of gastric juice. Two different types of antacids are used to reduce secretion of acid and known as H2 inhibitors and proton pump inhibitors.
- H2 receptor Inhibitors- H2 receptor inhibitors are also known as H2 antagonist. The few selective cells of gastric mucosa secrete hydrochloric acid. Hydrochloric acid is mixed with gastric juice. The acid producing mucosal cells are known as ECL cells. The ECL cell starts producing acid when H2 receptor lying on surface of RCL cell is stimulated. The stimulation of H2 receptor triggers the production of histamine, which stimulates the proton pump to secrete acid. The quantity secreted is substantially reduced when H2 receptors are blocked by H2 receptor blocker. The most common H2 receptor inhibitors used are famotidine (Pepcid), cimetidine (Tagamet HB) and nizatidine (Axid AR). The side effects are less frequent. Side effects that may be observed are nausea, diarrhea, headache and dizziness. The medication is not prescribed during first trimester in pregnant mother and children under 12 years of age.
- Proton Pump Inhibitors- Proton pump inhibitors are also known as PPI. Proton pump is an enzyme system that lies within ECL cells. Enzyme system is described as hydrogen/potassium adenosine triphophatase or AT Pase proton pump. Activation of enzyme system or proton pump triggers secretion of hydrochloric acid. Histamine activates the proton pump. Histamine is secreted following H2 receptor stimulation. Histamine triggers the proton pump to secrete hydrochloric acid. The inhibition of pump is most effective way to control or stop acid secretion. The gastric acid secretion is reduced by 99% following a one week of treatment. The long treatment is necessary to prevent relapse. There are several proton pump inhibitors available. Proton pump inhibitors are expensive and need physician prescription. The most common proton pump inhibitors used are omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium) and pantoprazole (Protonix).
Surgical Treatment for Gastric Ulcer
The indication for surgery is continuous pain not responding to conservative treatment and bleeding. Surgery is the final choice of treatment. The preference of surgical treatment depends on severity of symptoms and if gastric ulcer is also associated with duodenal ulcer known as peptic ulcer. There are five choices of surgeries to treat gastric ulcer. Endoscopy is performed mostly to cauterized bleeding ulcer. Once the bleeding is control then patient may be considered for one of the 4 remaining choice of surgeries.
- Billroth I Gastrectomy for Treating Gastric Ulcer- The procedure is performed when patient is suffering with selective recurrent gastric ulcer not responding to conservative treatment. Surgery involves removal of pylorus a distal 1/3rd of stomach and then end of remaining stomach is connected to duodenum. Surgery improves the gastric emptying time. The gastric juice with high acidic content stays for short period of time during stage of empty stomach resulting in minimum detrimental effect on stomach mucosa.
- Billroth II or Pólya Gastrectomy for Treating Gastric Ulcer- The procedure is preferred when ulcers are found in stomach as well as duodenum. The procedure involves removal of part of lesser curvature or right side of stomach and stomach antrum. The remaining stomach is connected by anastomosis to jejunum. The surgical procedure thus is also known as gastro-jejunostomy. The surgery helps to improve gastric emptying time and also prevents exposure of stomach as well as duodenal mucosal surface for gastric acid content.
- Highly Selective Vagotomy- The vegus nerve is a parasympathetic autonomic nerve. The end fibers of vagus nerve are connected to the gastric mucosal cells. The vagus nerve impulse stimulates the gastric mucosal cells to secrete histamine. Histamine then triggers proton pump to secretes acid. The surgery involves cutting the selective nerve fibers of vagus nerve that supplies the branches to stomach and duodenum. The selective removal of nerve fibers prevents activation of proton pump and thus decreases secretion of acid. Surgery involves laparotomy incision to expose stomach and vagus nerve. Vagus nerve is then transacted or cut.
- Truncal Vagotomy and Pyloroplasty to Treat Gastric Ulcer- The distal part of the stomach is known as pylorus. Pylorus contains thick muscle fibers and continuous periodic contractions of muscles of pylorus controls emptying of stomach. The food stays in stomach for few hours because of such continuous contraction of muscles of pylorus. The pyloroplasty surgery involves the horizontal incision and then longitudinal closure of pylorus muscles and mucosa. The surgery prevents the continuous closure of exit of gastric lumen so acidic gastric juice content does not stay in stomach for long time. The pyloroplasty or bypass of pyloric lumen is also performed by connecting body of stomach to jejunum. Pyloroplasty surgery is most often combined with vagotomy. Truncal vagotomy is transaction of main branch of vagus nerve, which contains nerve fibers of stomach, duodenum, jejunum, liver and celiac plexus.
- Endoscopic Cauterization of Gastric Ulcer- The gastric or stomach ulcer with conservative treatment in few cases stays asymptomatic most time with very mild on and often pain. The gastric ulcer may continue enlarging in size and depth. Occasionally in few cases ulcer starts bleeding profusely because of infiltration in mucosal artery. The mild to moderate bleeding is noticed as hemoptysis (spitting blood or blood in vomitus) or blood in stool. Severe bleeding causes profuse vomiting of blood. The loss of blood leads to severe low blood pressure. Treatment of bleeding gastric ulcer is elective or emergency. Mild bleeding is treated as elective, while severe bleeding is considered emergency. Endoscopy procedure is performed using tubular camera known as endoscope. The surgeon can see the image through eye piece at opposite end of camera or over the TV screen when eye piece is connected to TV image transmitter. The procedure is also performed as a diagnostic procedure to evaluate the position and number of ulcer.Gastric endoscopy is always extended to duodenum, jejunum and proximal part of small intestine. If the gastric ulcer is bleeding, then cautery is used to cauterized bleeding vessels. Tiny tubular cautery electrode passed through the endoscope. The advanced research in surgery indicates vagotomy and pyloroplasty can be performed using endoscopy.
Alternative Therapy for Gastric Ulcer
Several substances are used orally to treat gastric ulcer. The favorable results are often few and there are scientific data to prove the treatment is effective. The substances used are honey, garlic, cranberry, turmeric, mastic and cabbage. Probiotics and flavonoids are also often tried with some success.