CAT | Gastrointestinal
Q. What about other forms of medication? Over the years we have heard about a great many. Are these still in use?
A. In some cases, yes, and on other cases, not altogether. For some time a drug called carbenoxolone sodium appeared to have a beneficial effect on gastric ulcers. It seemed to relieve ulcers in the stomach more than duodenal ones where it was rapidly destroyed. A time-release capsule was developed, but never became popular. What is more, it produced side effects which many doctors thought made the risks of use, as the first-line attack drug, not really worthwhile.
Although modestly effective, it produced fluid retention (called oedema), elevated blood pressure, and sometimes it caused the body to retain potassium to seriously high levels. Although it was possible to give other drugs to counteract these adverse effects, it was soon overtaken by the development of newer, more effective drugs. So today, whilst it is available, it is not used very often, in contrast to the newer drugs which act more rapidly and have fewer adverse side effects.
Q. What about the so-called anti-cholinergics? These once held pride of place in the prescribing habits of many doctors.
A. Certainly they did; for several years they were extremely popular. They probably reduced acid production and so relieved pain. Some believe that in cases resistant to the histamine H2-receptor antagonists, the added use of the anticholinergics may be useful.
The drugs were removed from the general prescribing list in Australia in 1976, the same year as cimetidine became available in Britain for general prescribing. ‘Tagamet’ became available in Australia soon after, so that as one drug vanished, another better one rose to fill its place.
Q. What about belladonna preparations? These seemed to be pre-eminent once.
A. They had their day also. Belladonna was often used as an additive to ulcer therapy. But, like the anticholinergics, it gradually lost out to the newcomers. Some doctors may still use it but in the main it has almost become lost in antiquity! Zinc, in small amounts in capsule form, was also used by a small number of doctors. This appeared to have some healing quality and improve healing rate but it has never taken off in a big way and it does not seem likely to.
Q. What is the current view on simple, old fashioned rest for an ulcer patient?
A. It is well known that a certain number of ulcers will heal irrespective of what line of treatment is involved. Rest has long been known to be part of this. At present many doctors still recommend it. In fact, sending an ulcer patient to hospital, whether he rests there or not, is also believed to be effective treatment.
It may be the ‘placebo’ effect — the belief that as something active is being done, this gives a high chance of a good result. One might call it mind over matter but doctors believe the placebo effect is significant, especially if the individual has faith in his treatment and believes a cure is forthcoming. For centuries the scriptures have been saying ‘as a man thinketh in his mind, so is he.’ It is salutary food for thought.
Q. What about the use of vitamins and minerals?
A. Although many western doctors have a disparaging attitude towards vitamin supplements and minerals, claiming that a good all round general diet will supply all the necessary ones, many others, specially those researching in American centres, have different views. They believe that the body, specially in the depleted state (common with ulcer patients), benefits substantially from additional vitamins and minerals. These should be tailor made for the individual, but in general will include increased daily doses of the vitamin B complex and vitamin C. Some advocate up to 100 mg of the main components of the vitamin B complex, and anywhere from 1,000 to 3,000 mg a day of vitamin C, preferably in the readily absorbable calcium ascorbate form. Added minerals covering zinc, magnesium, chromium, molybdenum, calcium, manganese and others are often suggested. These minerals are often in the orotate or chelate form which makes them more readily absorbed by the blood stream from the intestinal system. Various commercial compounds are available which contain these ingredients in suitable amounts.
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Q. What about side effects? We seem to read about adverse conditions occurring from time to time. Are these serious?
A. I suppose every known drug has an adverse side effect on somebody somewhere. It is a fact of life. Why, even most foods can be found to disagree with somebody. Considering that by 1984 around 30 million patients are said to have been treated with cimetidine, the number of adverse side effects is surprisingly small. Certainly researchers will dig up a wide range of symptoms which are claimed to have been produced by cimetidine, but in the total picture, these are very small and probably of little consequence.
The same doctors will also point out that simple, old fashioned aspirin, which has been around for nearly 100 years, may cause allergy reactions, asthma, bleeding from the stomach and bowel, nausea and vomiting, diarrhoea, and many other symptoms. But this does not preclude it from being one of the most valuable and widely prescribed drugs of all time.
If adverse side effects occur, then appropriate steps can be taken at once. On the other hand, if they are minimal, then the benefits of treatment will often outweigh any problems.
Q. Are other drugs in this family available, or is cimetidine the only one?
A. In 1982, another drug called ranitidine became available in Australia. Like cimetidine, it is a product of original research in Britain. It is marginally different, works in a similar manner, is claimed to have certain benefits, as all new drugs claim. Time, however, will show if this is really the case. Some major British trials have indicated that it may be of special benefit in the few cases in which cimetidine therapy fails to work. No drug will be effective 100% of times and a related drug may prove effective, this appears to be the case with ranitidine. Another preparation is a drug called oxmetidine, which is also similar in activity. Yet another named omeprazole has also been developed. How these will compare to the others, time will tell. It has all been succinctly put by a Sydney gastro-enterologist who recently wrote in an Australian medical magazine: “It is difficult to envisage that these drugs will be any safer or more effective than cimetidine in equipotent dosage.”
Q. Can the patient still take other medication with cimetidine if necessary?
A. The most likely medication will be antacids, and this is often taken in the early days along with cimetidine. It does little more than reduce pain. As pain disappears, most will cease using antacids, but they may be taken if desired. Often the decision is left with the patient.
It is pointed out that the doctor will be careful in prescribing other non-ulcer type drugs in the event of high dosage levels being required. Sometimes, in severely ill patients, cimetidine is given by injection, either directly into the blood stream (intravenous) or the muscle (intramuscular injection). This helps it work more rapidly.
In ageing patients, when the liver and kidney are not working as efficiently as in younger days, the drug may further reduce their working efficiency, and drugs such as warfarin, phenytoin, theophylline, which go to the liver also, must be taken with care. Nevertheless, this is the doctor’s concern. He is well aware of these special circumstances in certain patients and will offer the appropriate advice.
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Q. Suppose that when everything possible has been tried the patient still does not recover from his ulcer. Or, as we have just mentioned, complications take place. Does surgery hold the final and ultimate answer for these patients?
A. True. About 90 per cent of ulcers are cured by medical treatment and good nursing but about 10 per cent require surgery. The chief reasons which indicate the need for surgery are that the ulcer persists despite thorough and conscientious medical treatment, it may haemorrhage, perforation may have
occurred, there may be an obstruction or there may be signs of
malignancy (cancer) especially in stomach ulcers.
Over the years various forms of surgery have been tried and
these are constantly varying. There is no doubt as to the value of
surgery in difficult cases, especially where there are serious
complications.
Q. What operations are currently performed?
A. An operation called the vagotomy and drainage procedure is used for persisting duodenal ulcers. This cuts the nerve to the acid secreting glands so that further acid production is prohibited.
Q. What about stomach ulcers that don’t heal?
A. Another operation called the Bilroth 1 gastrectomy is carried out. This also is very successful, for it removes a large part of the acid producing wall of the stomach.
Q. Does that summarise the current status of peptic ulcers?
A. I think it does. But in concluding this section, let me quote from a leading professor of medicine in Sydney who specialises in ulcers. He recently wrote: ‘No patient in any society should be allowed to experience the morbidity, economic and social loss and mortality associated with an unhealed chronic ulcer.’ That sums up the situation in the 1980s. I agree with his sentiments entirely and I am sure nearly every Australian doctor will concur.
Q. Now that we have handled in detail this very common problem, why don’t we go on to examine some of the other relatively frequent and quite important disorders of other parts of the G.I. system?
A. Yes. I think we should tackle them in order of merit from this point on. Some are extremely important and their early diagnosis and treatment are vital. Others whilst probably annoying are not life endangering.
As we said earlier, this small booklet is not an encyclopaedia, so that the disorders will be mentioned fairly briefly from now on. But it will serve as a guide of what disorders may take place, how they may be recognised, when to see the doctor and a guide to the type of treatment you may be offered. It is designed to be informative and, ideally, supplement the advice of your own physician. It is not meant to replace his care. Treatment is always a very personal matter and is always tailor-made to suit the individual needs of each patient. It is important to remember this.
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Q. We often hear of the disastrous complications that may occur in patients with peptic ulcers. What are these and how serious?
A. Complications may certainly take place and can be serious, and in certain cases life-endangering. Fortunately, according to recently published reports, there seems to be a fairly large reduction in these complications over the past decade and hopefully this trend will continue. With today’s quick and accurate methods of early diagnosis and excellent methods for treatment it is highly likely complications may gradually become unusual.
Q. Are the complications usually serious?
A. In most cases they are and often represent a surgical emergency. It is generally obvious the person is acutely ill and needs urgent hospital care.
Q. Let’s consider the complications. Which one comes first?
A. Let’s start with haemorrhage or haematemesis as the doctors say. This may present as acute vomiting of bright red blood, or vomitus with the appearance of ‘coffee grounds’ (the more common). There is often the passage of loose, black, ‘tarry’ stools (‘melaena’), or even bright red blood via the back passage. There is a sudden onset of weakness, faintness and dizziness, chilliness, thirst, cold moist skin and a desire to have a bowel action. This may be in a person with a dyspeptic history or even in those with no such history. It indicates the ulcer has increased in size. It has eroded a large artery or vein in the wall of the duodenum.
Q. If this happens what does the patient or those who are with him do?
A. This is a surgical emergency and demands urgent medical assistance. Do not delay. Get the patient to a doctor or hospital as promptly as possible. Often a blood transfusion is required and full investigation necessary. Promptness is essential.
Q. What is next on the list of complications?
A. Perforation. This usually occurs in males between 25 and 40 years. It indicates the ulcer has ruptured through its wall and contents are spilling into the abdominal cavity. There is usually an acute onset of pain in the epigastric region (just below the breast-bone). It often radiates to the right shoulder or right lower abdomen. There may be nausea or vomiting. This may be followed by a temporary reduction in pain. This could last a few hours. This is followed by a sudden board-like rigidity of the abdominal wall; there is a fever, rebound tenderness (when the area is pressed), an increased heart rate and often signs of prostration.
Q. What treatment is carried out?
A. Acute cases require urgent medical assistance. Any symptoms that come in this category must be treated as a surgical emergency. Although these cases are often ‘acute’, milder ‘sub-acute’ or ‘chronic’ ones occur, in which the perforation in a milder form occurs over a period of time.
Q. What comes next?
A. Penetration. Sometimes the ulcer penetrates into adjoining structures rather than rupturing into the abdominal space. It may involve adjacent organs such as the pancreas, liver, bile ducts or the omentum. This may be indicated by radiation of the pain into the back, nocturnal distress, inadequate or no relief from food or medication. Symptoms such as this in a person who has suffered ‘ulcers’ or ‘dyspepsia’ indicate an immediate need for expert medical attention and investigation.
Q. Earlier on you talked about ulcers forming near the pylorus, the narrow canal leading from the stomach to the duodenum. How does this fit into the picture?
A. It may cause obstruction. About 30 per cent of patients with a duodenal ulcer suffer obstruction of the pylorus, the canal joining the stomach to the duodenum. There may be no symptoms. Alternatively, it may produce fullness in the epigastric region, and vomiting may occur soon after a meal. This will contain much undigested, recently eaten food. This also needs proper medical investigation.
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Q. What is the current view on diet as it relates to ulcers? At one time diet was the most important part of treatment and we all recall the awful sloppy foods that were served to grumbling ulcer victims. Is diet still important?
A. The answer is ‘No’. Today most doctors believe diet plays no part in therapy. Ideally, the patient is allowed to eat whatever he desires. The concept of small, frequent feeds of non-irritating foods with an emphasis on milk, cream custards, gruel, strained foods and in between meal snacks is no longer regarded as important. Also, the concept that rough, raw vegetables and fruits were harmful is also not generally considered important. Tea, coffee, alcohol, condiments, pips, coarse salad vegetables, fried foods, spices and spicy fare and meat extracts were all incriminated as being bad news and prolonging the healing process.
Today the ulcer patient is allowed to eat virtually whatever he pleases.
Q. What about smoking and alcohol intake?
A. Opinions seem to vary on this. Some experts claim that ulcers heal more slowly if the patient continues to smoke. Others say it doesn’t matter. Personally, I think that the irritation of acids from swallowed cigarette smoke may cause harm and it’s better not to smoke. Furthermore, smoking is definitely harmful to other systems of the body, notably the respiratory and heart-blood vessel systems. Anyone who continues to smoke is foolish. Smoking is definitely harmful to general health. Some experts also believe the intake of alcohol may be adverse to healing. Once more, others dispute it. I think that the more effort that is made to remove known irritants like alcohol from the ulcer which is trying to heal, the better.
Q. What is the attitude about arthritic drugs and aspirin?
A. Aspirin and other widely used drugs for arthritis are well known for their ability to irritate the lining of the stomach and duodenum. These come under the heading of “non-steroidal antiinflammatory” drugs and ideally in the early stages of ulcer treatment it is usually recommended they be stopped. Most arthritics are able to put up with their pains for a short time, or alternative drugs (usually not as effective) are available as a stop gap. Also, cortisone-like drugs are usually stopped during early active treatment, for it seems that oral forms may inhibit, or delay, healing. However, once more, special instructions and alternative treatment will be given by your own physician or gastro-enterologist. Be guided by him and stick firmly to his advice.
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Q. Let us spend a few moments in summing up the various forms of investigation and treatment currently available and see how it works out.
A. Why not. Symptoms lead to medical investigation. This may include a medical examination and history taking, then probably either a barium meal x-ray examination of the stomach and duodenum, an endoscopic examination of the same areas. A diagnosis of chronic peptic ulcer is made, being either in the stomach or duodenum. If in the stomach, a biopsy will indicate if it is only an ulcer or an ulcer plus cancer. Provided the diagnosis of an ulcer is confirmed there are four most likely courses available. The patient may be given antacids in large doses, or cimetidine, or colloidal bismuth or he or she may be admitted to hospital. Antacids may give symptomatic relief and hospital care may cause the ulcer to heal. With cimetidine and colloidal bismuth healing usually occurs rapidly. In 3 weeks, about 50% improvement; in 6 weeks, about 75%; in 9 weeks, about 90%.
Q. What if healing does not occur?
A. If healing is slow or absent (and the experts say that this occurs in about 10% of cases), then the diagnosis must be re-checked. Hopefully, the gastric ulcer will not turn out to be a cancer after all — but it is always a possibility which certainly warrants verification. Or it may be due to the patient surreptitiously taking some other form of medication, such as analgesics which are notorious for creating gastric bleeding and ulcers. If a peptic ulcer is still in evidence a variant to cimetidine may be tried, such as ranitidine, or the patient may be hospitalised for treatment there.
This is the current routine often recommended by gastroenterologists. Today, diagnosis and treatment of peptic ulcers have never been better. There is no reason why anyone with an ulcer should put up with the pain and discomfort that it entails. Adequate investigation and therapy are readily, and fairly cheaply, available to everybody in this country.
Q. Do some people complain of costs?
A. Some misguided individuals complain that medication is costly. These people are misguided in the extreme. At present the government in this country picks up the bulk of the tab for most of the forms of ulcer treatment. However, even if the patient had to pay the entire drug cost himself, this is minimal when the alternatives are considered.
In the bad old days a severe ulcer required up to three months’ absence from work plus, in many cases, the financial hardship that this entailed, plus the costs of hospitalisation, drugs, medical attention, etc. The economics were often mind-blowing and bank-busting.
But today, within a few days, with a relatively small drug bill, the patient may be back to work again, with symptoms gone and the ulcer well on the way to healing. The economics have taken a dramatic change for the better. I always tell my patients never to begrudge the small price they are paying for their medication. The very same persons who complain will think nothing of going out to dinner for the evening with friends and blowing twice the sum as it costs, for example, for the retail price for six weeks’ cimetidine treatment. If you are tempted to complain of costs, please remember the alternatives which in the past used to be dramatically expensive.
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