II. (More) Peptic Ulcer

The ending is really neat. Don't give it away!(If you haven't read Part I, go back and do it now. There's a link at the bottom of this page.)

The next big step in improved therapy for peptic ulcers came in the late 1970s, and it was the introduction of medicine that really reduced stomach acid, long known to be a big part of the problem.

When Tagamet came on the market, patients could throw away their Probanthine and Donnatal and say goodbye to dry mouths and blurred vision. After taking Tagamet, and its later cousins Zantac, Pepcid, and Axid, patients found they no longer needed so many slurps of Maalox and Gelusil. Unfortunately, as is almost always the case, there were some side effects (for example, many men grew unwanted breasts!) and interactions with other drugs.

We got along pretty well after Tagamet et al became commonly used, and then the research chemists discovered drugs that did a better job of inhibiting acid manufacture. These agents, introduced in the '90s and called "proton pump inhibitors", shut off acid almost completely. (Some have wondered if this is a potential problem, eg, could we be making it easier for tuberculosis to occur, since TB loves a non-acid environment. So far, this hasn't proven to be a significant worry.) The first one, Prilosec, was also one of the first drugs to be marketed directly to consumers, as well as being about the most expensive drug per capsule ($3 + per each) ever invented.

It was also in the 1990s that operators became more adept at using flexible fiberoptic gastroscopes, making it simpler (although more expensive) to diagnose and follow up therapy for peptic ulcers. Biopsies, particularly of ulcers located in the stomach, where cancer is an occasional complication, could be done easily. Nothing is more fun than taking a bite out of a patient. (This has nothing to do with finances.) It was while processing all of these teeny bites of tissue that some very observant cuss noted the presence in ulcer tissue of a bacterium!

Say what, kimo sabe? A bug in the ulcer? Well, yes, there it was, and it could be made to grow on culture media, and it was given a name: Helicobacter pylori. At this point the entire gastroenterologic world was set on its collective ear, from which posture it recovered rapidly. The next step was to search tissue taken from the GI tracts of non-ulcer patients for H. pylori, and this showed there was none.

Thus, H. pylori was identified as a probable ulcer-causing agent. Following this, in countries which shall remain nameless, family members of ulcer patients were required to submit to inspection and biopsy of their stomachs. This unpleasant exercise showed a strong family concordance in the presence of H. pylori, and at least partly suggested an infectious trait.

Since most people don't relish (literally and figuratively) swallowing the gastroscope, there had to be a better test for H. pylori, and although they aren't "better", a blood test and a breath test (using bacteria "food" with a radioactive carbon atom) were developed. These are now used commonly, albeit somewhat inaccurately, in deciding who needs to be treated for H. pylori. And yes, there is treatment which for practical purposes cures ulcers.

Once the involvement of an infectious agent was proven, it was just a small step to appropriate treatment. After trying several antibiotic combinations, the experts found that they couldn't exactly recommend one as being superior. Almost all of them work, as long as they are accompanied by a bismuth compound (Pepto Bismol comes to mind!) and a strong acid inibitor like Prevacid or Prilosec. With experience and knowledge, it has become known that eliminating H. pylori also reduces the occurrence of stomach cancer.

Think back on all of those years and all of that suffering, and try to understand that now it is possible to cure peptic ulcer once and for all time with 14 days of antibiotic therapy. This is truly revolutionary. (Of course, those of you who follow this column will immediately appreciate that there is a potential for antibiotic resistance to develop among those teeny little H. pylori creatures down in your stomach. Ouch! It already has.)

Drs. Sippy, Bilroth, and Wangensteen did the best they could with the knowledge they had. They were all, truly, giants in the field at the time. They all made one big mistake, and that was that they never considered in their wildest imaginations that peptic ulcer disease was infectious.