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Once we thought ulcers were caused by stress. This belief was strong and people often did not question it. Later doctors began to think the main problem was acid. For duodenal ulcers this really seemed to be true. However, the theory didn't work as well with stomach ulcers. Stomach ulcer patients were often found to have less than average acid production.
This unexpected finding did not make scientists or doctors turn their attention away from acid. As better acid-reducing medications became available, focus on acid as the enemy increased. Treatments to reduce acid did help make ulcer patients much more comfortable. Unfortunately, over two-thirds of them suffered with episodes of recurrent symptoms.
Then in 1983, two Australian doctors made a brilliant discovery. They found bacteria in samples taken from the stomachs of patients with inflamed or ulcerated stomachs. The doctors suggested that these bacteria cause the ulcers and published their work in medical journals. It was very difficult to convince other scientists and medical people to accept their idea.
The two Australian doctors, convinced they were right, decided to test their theory. The story about their experiment indicates they swallowed a beaker full of these germs. They apparently learned three things. First, if you swallow these germs, you can get a very upset stomach. Second, this was a difficult infection to treat in 1983. Third, if you experiment on yourself and get sick, your wife will get very angry with you.
Over the next 10 years, the rest of the medical world came to realize the tremendous importance of this discovery. There was an explosion of public health and clinical research to increase scientific understanding of these bacteria.
We came to know this germ as helicobacter pylori "he-lick-oh-back-ter pie-lore-ee" or H. pylori. The bacteria have two to seven tails that allow them to move around and find a suitable spot to live. They have a spiral shape and look a lot like a piece of fusilli pasta.
The bacteria are thought to live almost exclusively in the human stomach. They prefer the end of the stomach called the antrum (see illustration). Stomach acid makes this a pretty hostile place for any living thing. In the antrum, acid levels are a bit less than in the main part of the stomach. The germ has the ability to make ammonia to neutralize acid. In this way, it is able to nestle down sandwiched between the mucous that coats the stomach and the surface of the stomach.
We now know most people who become infected with H. pylori get the infection before school age. At this young age, children are more likely to put fingers, toys and other things into their mouths. Infection is more likely when there is crowding, sharing of beds and less opportunity for careful hygiene. After infection, the bacteria live happily in the antrum for the rest of the person's life.
The infection is found in 20 to 40 per cent of Canadians depending upon the community. Generally, 29 per cent of all Canadian residents are thought to be infected. About 10 per cent of young Canadians have H. pylori. It affects sixty per cent of older Canadians, despite the fact most people become infected during childhood. Older Canadians are more likely to have H. pylori because of the nature of their living conditions when they were children. In developing countries, as many of 90 per cent of people have this infection. Experts have described it as the most common bacterial infection in the world!
Fortunately, H. pylori does not cause any health problems for more than 85 per cent of Canadians infected by the bacteria. Less than fifteen per cent of people infected will get an ulcer at some time in their adult life. H. pylori is a leading cause of duodenal ulcers and is also an important cause of stomach ulcers. In Canada, H. pylori and anti-inflammatory medications are the most common causes of stomach and duodenal ulcers. Other causes are rare.
Though all people infected by H. pylori will have some inflammation of the stomach, this does not cause any problems for most of them. If the person naturally produces high acid, the bacteria will move along from the antrum to the duodenum where an ulcer might form. In someone who produces less than the usual amount of acid, the bacteria migrate up into the main part of the stomach where they could cause a gastric ulcer.
When H. pylori lives in the stomach for many years, a cycle of changes can occur that occasionally leads to cancer of the stomach. Only a small percentage of Canadians infected by the bacteria will get cancer of the stomach. It is rare under age 50. Nearly all of the people discovered to have cancer in their stomach have one of the following alarm signals:
The answer is maybe. Testing is recommended if you have certain symptoms and agree to treat the infection if it is found. Expert doctors have been unable to find a reason to test for the bacteria in people who do not have symptoms suggesting an H. pylori-related illness.
The symptoms that suggest H. pylori are described by the general term dyspepsia. Dyspepsia is a pain or discomfort in the upper abdomen coming from the stomach or duodenum. The discomfort may include bloating, belching, fullness, burning or a sense of indigestion. Some people with dyspepsia need testing for H. pylori. Your doctor can help make this decision.
Doctors test for H. pylori in a few different ways. It can be done using a gastroscope (flexible telescope) passed into the stomach. Testing can also be done using stool, blood or breath. Most people prefer breath testing to stool testing. Breath tests are more accurate than blood tests, particularly when H. pylori is less common, as it is in Canada. This test involves drinking a special liquid. H. pylori in the stomach feed on the drink and produce a type of carbon dioxide, which can be measured in the breath half an hour later.
The treatment of H. pylori infection is as simple as one, two, three. One week of treatment, two times a day, with three carefully selected drugs is usually successful. After treatment it is very uncommon for adults to get the infection again. However, sometimes treatment does not eliminate the infection. It is only necessary to check for a cure if the dyspepsia persists or there are complications such as bleeding or perforation. If re-testing is needed, a breath test is recommended because blood tests remain positive for a long time after the bacteria is eliminated. Family members of infected patients do not need to be tested unless they have dyspepsia. Testing children is difficult and needs special care.
Simple indigestion after a feast of chili or beer is very common and does not suggest a problem with H. pylori. Persistent or recurrent symptoms not related to dietary indiscretion should be checked. Heartburn and regurgitation of bitter fluid into the mouth strongly suggests acid is flowing backwards from the stomach up to the esophagus. This is called reflux and is not caused by infection with H. pylori.
Thirty to forty per cent of Canadians have dyspepsia each year. Some have recurring symptoms from ulcers. Now we can help most of them to be comfortable. Finding and treating H. pylori infection can free many ulcer patients from a lifelong risk of symptoms and complications. Others will be helped by recognizing anti-inflammatory medication as the cause and taking action to stop discomfort and damage.
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