"Shouldn't have had that big business lunch/dinner," you think to yourself as you reach for your cigarettes. You make your way to the kitchen, trying not to wake the whole household, where a glass of milk, or even a sandwich miraculously relieves the pain. The symptoms described above are classical of a duodenal ulcer, one type of peptic ulcer.

You might not be aware of this, but smoking has been identified as a major risk factor for peptic ulcers.

"Cigarette smoking has been associated with increased duodenal ulcer frequency, decreased response to therapy, and increased duodenal ulcer mortality." That is a direct quote from Harrison's, a well known textbook of medicine. The reasons for this are unclear, but it is thought that nicotine may inhibit one of the pancreatic enzymes important in the control of acid secretion in the duodenum.

What is peptic ulcer disease?

This term refers to a group of ulcers which occur in the upper part of the gastrointestinal tract. The most commonly involved organs are the upper part of the duodenum and the stomach. Acids and pepsins (a group of enzymes) are involved in the causes of these ulcers. The two main types are duodenal (in the duodenum) and gastric (in the stomach). These are both chronic diseases.

We still don't know exactly what causes peptic ulcer disease, but it seems that there is a mismatch between the secretion of gastric acid and pepsin, the so-called aggressive factors, and the ability of the gastric wall (mucosa) to protect itself, so-called mucosal defense or resistance. The bacterium Helicobacter pylori is also definitely implicated in the development of peptic ulcer disease.

Duodenal ulcer

This is the most common of the peptic ulcers and its symptoms tend to be as described above. The severity of the symptoms is variable and there may be long periods of remission between attacks. This ulcer is most common in men, and it is thought that about 10 percent of the population may have duodenal ulcers at some stage of their lives. There seems to be a genetic predisposition to duodenal ulcer disease, as it is three times more common in first-degree relatives of duodenal ulcer patients than in the general population.

It is now recognised that the bacterium Helicobacter pylori plays a major role in causing duodenal ulcers, and antibiotics are now part of the normal treatment. Other forms of treatment are simple antacids, the H2-receptor antagonists (eg Zantac® and Tagamet®) and so-called coating agents such as Ulsanic®. Losec®, a proton pump inhibitor is also frequently used. As mentioned before, a course of antibiotics is also common now.

There is little reason for the bland diets often suggested to people with duodenal ulcers, although obviously, if there are particular foods which make the symptoms worse, avoid them! Change in diet has not been shown to have any effect on ulcer healing.

Most duodenal ulcers heal within four to six weeks of treatment with any of the above agents. Maintenance therapy is seldom recommended after only one, uncomplicated episode, but is used with frequent and severe recurrence. Most doctors suggest giving up smoking for the reasons detailed above. Surgical treatment is reserved for severe, intractable disease, with complications such as massive bleeding, and is used less and less frequently in the private sector. In the public sector where the more expensive drugs are not available, surgery is more common.

Gastric ulcers

Gastric ulcers tend to occur later in life than duodenal ulcer, usually in the 60's. They are also more common in men. The most likely cause of gastric ulcers is direct injury to the gastric mucosa due to a defect in gastric mucosal resistance. There may also be a link with regurgitated duoenal contents, particularly those containing bile.

Pain, in the upper abdomen is the most common symptom, but it is less predictable than that in duodenal ulcer. Some people find that food and antacids relieve the pain, while in others the pain is actually worsened by eating. While any bleeding associated with duodenal ulcers is usually slow and subtle, massive bleeding or haemorrahage is more common in gastric ulcers, occuring in about 25 percent of cases. There is a higher mortality associated with gastric ulcer than with duodenal ulcer. This could partly be due to the greater age of most gastric ulcer patients.

Medical treatment is much the same for gastric ulcers as for duodenal ulcers, but healing tends to be much slower. Again, surgery is reserved for intractable disease and for complications such as massive haemorrhage.

Diagnosis

For simple duodenal ulcer disease in a younger person with typical symptoms diagnosis is often made on the history of sypmtoms and the response to treatment. However, in an older person, and in someone not responding well to treatment, fiberoptic examination using an endoscope is the most effective form of diagnosis. Using this the ulcer can be directly visualised and if necessary a specimen can be taken for biopsy.

Other causes of "heartburn"

The ulcer syndromes described above are not the only cause of upper abdominal pain, and are far less common than simple heartburn, usually caused by a diet high in fat and alcohol. Smoking seems to exacerbate this as well. Many people experience heartburn after meals and find that if they cut down on fats and also the quantity eaten, that they will reduce the symptoms to the extent that they do not need to use antacids regularly.

A common symptom is burning pain which seems to spread up into the chest, often waking a person with a choking sensation which is only relieved by sitting up in bed and leaning forward. This is commonly thought to be cardiac pain, and is indeed very difficult to distinguish from this. This can also be caused by gastro-oesophageal reflux, which is literally stomach acid refluxing back into the oesophagus (swallowing tube!). These symptoms are definitely relieved by a low fat, low alcohol diet. Weight loss and stopping smoking also help. It is not a good idea to eat too soon before going to bed either, and raising the head of the bed will often help.