EsophagitisPepic Ulcersheart
Esophagitis, Peptic Ulcers, Gastritis Esophagitis (Heartburn)
The apparent function of the esophagus seems simple: convey the food from the mouth to the stomach. Yet there are other aspects to consider. For example, the stomach contents are highly acid at times; whereas the stomach lining is protective against this acid, this is not the case with the esophagus. Thus, there must be some way to let the food pass while stopping the acid from splashing back into the esophagus.
In health, this is accomplished with a ring of muscle surrounding the junction of the two organs, commonly known as the lower sphincter. As food passes, it “relaxes” to admit the food to the stomach. Once this has occurred, it promptly shuts again. Unfortunately, in some cases the sphincter is incompetent. This may be related to totally unknown factors, but certain factors are known to contribute to this. The commonest are nicotine, caffeine, alcohol, aspirin, and stress, among others. If the mechanical factors of overeating, tight clothing, and assuming the lying -down position are added, it is clear why acid will be able to enter the esophagus in certain individuals.
Conditions related to this phenomenon include simple heartburn and esophagitis. They represent different places on a spectrum of acid irritation of the lining of the esophagus.
Symptoms
A burning sensation anywhere from the middle of the abdomen extending upward under the breastbone, all the way to the throat is typical; all or any part of the above areas may be involved. Sometimes the pain may extend to the back, left arm, or jaw. Differentiation from the pain of heart disease can be impossible in some cases.
Occasionally, there may be regurgitation of sour liquid in the back of the throat.
Typically certain factors bring on the pain–large meals, the factors discussed above, and emotional stress. If exertion plays a role it is usually inconsistent. In simple heartburn, the symptoms are infrequent, moderate, and readily relieved by simple antacids, or even by food or water. This is not necessarily a disease state. When symptoms become severe, frequent, or are associated with interference in daily activities, or when regular antacids are required for relief, further investigation may be indicated. True esophagitis occurs when the lining of the esophagus becomes red and inflamed.
Diagnosis
The symptoms noted above are highly suggestive of the diagnosis, but do not necessarily distinguish esophagitis from ulcers, gastritis, and heart disease, or several other diagnoses.
How much diagnostic evaluation is necessary is judgmental; the patient’s age, life habits, risk factors for other diseases, and other factors must be considered. For example, a young patient with classical symptoms, no cardiac risk factors, and a normal history and physical may only require a diagnostic trial of treatment. Others may require further tests.
Upper gastrointestinal x- rays (upper g.i.) will rule out most ulcers, and is commonly done. Only through endoscopy (a viewing instrument passed down the throat) can the actual red, irritated lining of the esophagus be seen. Fortunately, this is often not necessary once other diseases are ruled out. To this extent, esophagitis is a diagnosis of exclusion.
Treatment
Avoidance of precipitating factors is of paramount importance, particularly nicotine, caffeine, and drugs. Patients should stop all food intake at least three hours prior to retiring.
The first line of therapy is the use of antacids. Large doses are taken after meals, at bedtime, and for pain in between. This should be followed on a regular basis, even without symptoms, for four to six weeks so that the esophagus can heal. Elevating the head of the bed six inches is helpful in avoiding nighttime “splashback” of acid.
When this regimen is inadequate, additional medications such as cimetidine or ranitidine may be useful. Drugs which cause constriction of the sphincter are occasionally used, including bethanechol. The most refractory of cases may require surgical procedures which act to prevent sphincter incompetence, but need for this is uncommon.
Complications
After long exposure to acid reflux, the esophagus may form a scar which narrows its diameter, forming a stricture which blocks the passage of food. Swallowing difficulty may ensue, and dilating procedures become necessary. Severe esophagitis may cause bleeding from the surface of the mucous lining, which can at times be life- threatening.
A very common disease, esophagitis can usually be quickly diagnosed, promptly and safely treated, and largely prevented or reduced by a combination of the above actions. Because of its similarity to other diseases which can be more serious, the diagnosis requires a physician evaluation.
Peptic Ulcers
Part of the normal digestive function of the stomach is to secrete hydrochloric acid and an enzyme called pepsin, both of which are essential to the preliminary digestive process. The stomach lining itself is really no different from many foods, and would be subject to self-digestion, were it not for a coating of mucus which protects the wall from the actions of these chemicals.
A number of factors regulate how much acid the stomach puts out–the presence or even the sight of food, histamine, anger, and certain hormones are examples. Caffeine and nicotine are additional factors. Aspirin and other drugs can reduce the protective mucus barrier mentioned above. Alcohol, though possibly predisposing to gastritis, probably does not cause ulcers in most people (it may retard healing of an existing ulcer).
When any combination of factors overwhelms the protective factors, the acids and pepsin eat away at the stomach lining, causing a crater -like sore which can be very painful, and become very swollen and tender. If it penetrates through a nearby artery, profuse bleeding may occur; if it penetrates the wall entirely, the entire contents of the abdominal cavity may become involved with infection, acid burning and “peritonitis”– inflammation of the lining tissue of the abdominal cavity. Penetration into the pancreas causes pancreatitis, discussed elsewhere. These can be very serious or even fatal, and any of the complications can occur with none of the typical warning symptoms noted below
Most ulcers occur in the duodenum, where the stomach enters the small intestine; this is where the acid seems to affect the mucosa most intensively. Ulcers higher in the stomach itself are less common, and require more careful evaluation for underlying related disease, including stomach cancer which can ulcerate.
Gastritis is a similar disease in which the same types of factors cause symptoms almost identical to ulcers, including the potential for bleeding. However, no actual ulcer is seen on exam, but rather the lining appears red friable, and inflamed. It may be considered a pre-ulcer state in some ways.
The prevalence of ulcers has decreased in recent decades, from a high of about 10% of the population being affected at some time in their life in the 1940’s. It is most common in the middle years, though children are not immune. Males are affected twice as often as females, and there is a definite, if inconsistent, familial tendency.
Symptoms
The classical symptom complex of an ulcer consists of a burning, intense pain in the mid – upper abdomen, awakening the patient in the early morning, often with a sensation of abnormal hunger 1 or 2 hours after meals. Lasting about half an hour, the pain is relieved by most foods, but coffee and juices may worsen it. It may occur several times daily. Without complications, some variation of this complex is usually present; with complications, additional symptoms may occur (see below).
Diagnosis
The history is the most important clue to the diagnosis. There may be tenderness on examination of the abdomen, but other findings are unusual. Lab findings are generally normal.
If the symptoms are suggestive, the physician may order an upper gastrointestinal x-ray (upper g.i.). This is a stomach x-ray taken after ingestion of barium. In up to 80% of cases, the ulcer will be visible. Alternatively, a diagnostic/therapeutic trial of therapy as discussed below may be the only necessary step. The x-ray becomes more important if there is a history of ulcers in the past.
In cases where the symptoms fail to improve, recur, or where x-ray healing does not occur, a test called endoscopy may be helpful. A viewing instrument is passed down the esophagus, and the stomach visualized directly. Virtually painless biopsies may be obtained at the same time. Since ulcers in certain parts of the stomach are more likely to be related to stomach cancer, these ulcers also warrant endoscopy. The decision of whether to perform endoscopy depends on a variety of factors, but its routine use is not considered necessary in many cases. X-rays are used more routinely, but physician discretion is the most important element, taking into account all of the factors pertinent to a given patient.
Of great importance is ruling out stomach cancer and other serious diseases which can mimic ulcers. For this reason, whatever series of tests is chosen, follow-up becomes crucial.
Treatment
DIET
Years ago, patients with ulcers were routinely placed on milk-cream diets which were quite restrictive. Modern research has shown that such diets are not only useless, but may be harmful, since they stimulate acid output an hour after being taken. The only dietary advice given to most sufferers today is to avoid caffeine and any other foods which worsen symptoms, eat frequently when possible, and possibly to increase dietary fiber intake.
MEDICATIONS
Antacids remain the mainstay of therapy, despite recently introduced newer medications. By their ability to neutralize the acid produced by the stomach, they allow the ulcer to heal spontaneously. Since most acid is produced within an hour of eating or after retiring at night, a typical regiment consists of doses one hour after meals, at bedtime, and whenever pain occurs.
Typical antacids include Mylanta, Maalox, Tums, Gaviscon, and Titralac. Those containing magnesium may produce diarrhea, and others may cause other side effects; however, they are generally very safe and effective, causing ulcer healing in most patients within a month.
Recent years have seen the introduction of Tagamet, Zantac, and other so-called histamine blockers. Though originally felt to be revolutionary in their ability to decrease acid production and promote ulcer healing, it is now known that they are usually no more effective than antacids, have many more side effects, and are quite expensive. They have been overused for vague abdominal symptoms, and generally should be reserved for refractory or recurrent cases, and for special situations of great rarity. Nonetheless, Tagamet (cimetidine) has become one of, if not the, most widely prescribed drugs in America.
An additional type of drug, anticholinergics, work by decreasing acid output. They are occasionally useful, but have not been employed routinely because of unpleasant side- effects. Finally, a relatively new drug called sucralfate which acts by coating and protecting the ulcerated area, has received some attention. It seems to be as effective as cimetidine, has almost no side effects, and is probably very valuable as an adjunct to antacids. Ironically, this agent has received less widespread use than it merits, in the opinion of some.
With appropriate use of the above medications, almost all ulcers can be easily and safely managed. Patient compliance is critical, as are the reduction or elimination of precipitating factors, and careful follow-up.
Complications
BLEEDING
If an ulcer involves an artery, sudden and severe bleeding may occur, often without preceding pain. This may be noticed as black tarry stools due to digested blood products, vomiting of blood, or sudden collapse, lightheadedness, or fainting. If it is more gradual, anemia may be the first symptom. Sometimes, pallor or fatigue may be the tipoff. Aggressive treatment which may include transfusions as well as some of the measures mentioned before are indicated. All of the above require physician evaluation without delay.
OBSTRUCTION
If the area around the ulcer gets very swollen, it can block the passage of food through the duodenum. This manifests as vomiting after eating, sometimes with cramping pain, and subsequent dehydration. Treatment requires passage of a tube to relieve the pressure, and intensive anti-ulcer treatment as outlined.
PERFORATION
If an ulcer penetrates all the way through the wall of the stomach or duodenum, it can cause an acute inflammation and contamination of the abdominal cavity (peritonitis), a true surgical emergency. If untreated, shock and death may occur, though occasionally the opening seals itself off. If the penetration is through the rear wall into the pancreas, pancreatitis will occur, causing another type of very painful emergency (see article).
SURGERY
In the most resistant or recurrent cases, or in those in which the possibility of cancer cannot be ruled out by less drastic means, surgery is necessary. This can range from total removal of the stomach to selective removal or severing of the nerves which stimulate acid secretion in the stomach. Fortunately, few cases require surgery with the modern regimens used today.
Summary
Contemporary management of peptic ulcers results in excellent cure rates, diagnostic accuracy, and prognosis for the vast majority of patients. A combination of prudent medical management and excellent patient compliance are the prerequisites for such results.