More than one-third of gastric and duodenal ulcers (ulcer diseases) regress spontaneously. The healing processes are apparently promoted by a change in the patient’s psycho-vegetative constellation. This assumption is also supported by scientific studies, according to which almost half of the patients are cured by placebos (placeboes without active ingredients). The efficacy of acid-binding drugs (antacids) barely exceeds the “success rate” of placebos. Consequently, uncomplicated ulcers are treated as outpatients. Bed rest is not required.
Primary goal of ulcer treatment
The goals of ulcer disease therapy are rapid pain relief, ulcer healing, and recurrence prevention. However, in the long-term course, ulcer disease is characterized by recurrent ulcer disease. Up to 80 percent of patients suffer a recurrent ulcer within a year if only acid secretion-inhibiting pharmaceuticals were used to heal the previous ulcer. The reason for this is that acid blockers do not sanitize the Helicobacter pylori infection underlying the ulcer disease. If prevention is carried out through years of continuous therapy with acid blockers without prior sanitation of the infection, the gastric inflammation may even worsen. Therefore, the be-all and end-all of any treatment is to kill the Helicobacter pylori bacteria. This therapy has been given a special name: Eradication Treatment.
Helicobacter pylori eradication
In the case of both the initial occurrence of an ulcer and recurrent ulcers, sanitation of the Helicobacter pylori infection is necessary as a primary therapeutic measure. This not only cures the current ulcer, but also provides effective prophylaxis. Conventional treatment with acid secretion inhibitors alone heals the current ulcer more slowly than combination with remediation of the Helicobacter pylori infection and offers no protection against recurrent ulcer, 60 to 80 percent of which can be expected in the stomach and duodenum within a year of the end of therapy. For remediation of Helicobacter pylori infection, the combination of a proton pump inhibitor to reduce gastric acid production with two antibiotics is now recommended. The antibiotic used is clarithromycin and either metronidazole or amoxicillin. This can achieve successful clearance of the infection in 85 to 100 percent of cases.
When is treatment successful?
Successful treatment of a peptic ulcer is possible only if the patient consistently complies with eradication treatment. Therapy should always be started with all three medications at the same time. After seven days, the treatment is finished. Normally, healing of duodenal and gastric ulcers is achieved within four and eight weeks, respectively. Eight weeks after the start of eradication therapy, another gastrointestinal tract scan is performed. At this point, 85 to 90 percent of gastric ulcers are completely healed. Biopsies are taken from the ulcer scar to confirm eneutically that the ulcer is benign, since malignant ulcers can also feign healing under acid-inhibiting therapy according to endoscopic criteria. At the same time, tissue samples are taken from different gastric mucosal regions to detect Helicobacter pylori. If a gastric ulcer has not completely healed at the time of control gastroscopy eight weeks after initiation of Helicobacter pylori infection remediation, tissue samples are taken from the edge of the ulcer and from the floor to rule out malignancy. If eradication therapy was successful and there is no malignancy, therapy is continued with a proton pump inhibitor for four weeks. This is followed by another gastrointestinal endoscopy. If the infection is not sanitized after an eradication attempt, another attempt is made with the three drugs. Four to six weeks after completion of this second therapy, the success is checked again. Encouragingly, re-infection with Helicobacter pylori is less than one percent. The sanitation of the infection is therefore permanent. Lack of compliance with therapy during Helicobacter pylori eradication can worsen the course of the disease and promote the development of severe bleeding.
Antacids
Antacids neutralize stomach acid that has already been formed.They usually contain aluminum or magnesium hydroxide or carbonate compounds. They are available on the market in large numbers as gels, suspensions or tablets. Aluminum-containing preparations tend to have a constipating effect, magnesium-containing ones a laxative effect. The preparations should be taken one to two hours after a meal and, if necessary, again after three hours. Other drugs should be taken with a safety interval of one hour, otherwise their absorption in the stomach may be impaired.
Histamine H2 antagonists
Histamine H2 antagonists take precedence in both acute ulcer therapy and recurrence prophylaxis. Unlike antacids, they decrease gastric acid production by blocking the histamine H2 receptors of the vestibular cell. The most important substances are ranitidine, famotidine, nizatidine, roxatidine and cimetidine. Advantageously, a single daily dose in the evening is usually sufficient. The main side effects of H2 blockers are allergic reactions, gastrointestinal symptoms such as diarrhea, fatigue, headache, and dizziness. Less common are increases in serum creatinine or liver enzymes and, with prolonged use in men, enlargement of the male breast and libido disturbances.
Proton Pump Inhibitors
For example, the active ingredient omeprazole is a proton pump inhibitor. They decrease acid secretion by inhibiting a key enzyme responsible for proton transport from the occupant cell of the stomach. They are particularly indicated in cases of Helicobacter pylori colonization of the stomach and small intestine, ulcer recurrence or Zoller-Ellison syndrome. The most important side effects are gastrointestinal symptoms such as diarrhea, constipation and flatulence as well as blood count changes. When given as a high-dose injection, visual disturbances and even blindness due to optic nerve damage have been described.
Protective Film Formers
Protective film formers, such as sucralfate, coat the gastric mucosa with a thin film that protects against aggressive gastric acid and adheres to the ulcer base for about six hours. The main side effect is occasional constipation. Protective film formers are taken on an empty stomach one hour before meals, if possible. Water may be drunk afterward. Antacids and H2 antagonists should not be taken at the same time as protective film formers, but should be staggered by approximately one hour because of possible impairment of effect.
Anticholinergics
Anticholinergics, but especially pirenzepine, inhibit gastric acid secretion by occupying the receptors needed by the vagus nerve transmitter to stimulate the gastric mucosal occupant cells. Anticholinergics are primarily used in combination with other ulcer therapeutics. Since they inhibit not only the main parasympathetic nerve but also the other nerves, higher doses cause unpleasant side effects for patients such as dry mouth, bladder emptying disorders, accommodation disorders, or rapid heartbeat. They should not be given to patients with elevated intraocular pressure (glaucoma) or prostate enlargement.
Bismuth Preparations
Bismuth preparations, which are now usually given in combination with antibiotics to combat Helicobacter pylori infection, are also considered ulcer therapeutics. They are taken half an hour to an hour before meals. The affected person must know that the stool will turn black and may also temporarily discolor the tongue, gums and dentures (depending on the preparation).
Antibiotics
Penicillin derivatives such as amoxicillin, as well as substances such as metronidazole, have become more important in combating Helicobacter pylori infection as part of ulcer therapy.
Preventing an ulcer
Following treatment instructions and avoiding alcohol, nicotine, and caffeine will promote the healing process. An easily digestible diet in several small meals (about 5 times a day) does not overload the stomach, and the stomach can empty at smaller intervals. This prevents excessive amounts of hydrochloric acid from remaining in the stomach for a prolonged period. In general, psychotherapeutic treatment can be recommended to all ulcer patients.
