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Studies Find Ulcer Bacteria, NSAIDs a Bad Mix

Urge purging of H. pylori before long-term painkiller use

THURSDAY, Jan. 3, 2002 (HealthDayNews) -- Two new studies solidify an ongoing evolution in medical thinking about peptic ulcers: They're not caused by worry and stress but mostly by pills and bugs.

The pills are nonsteroidal anti-inflammatory drugs (NSAIDs), painkillers such as aspirin, ibuprofen, and naproxen. The bugs are bacteria called Helicobacter pylori, so named because of their helicopter shape. The new studies, appearing in the Jan. 5 issue of The Lancet, show that drug treatment to eradicate H. pylori helps heal ulcers, and that the combination of H. pylori infection and NSAID use increases the risk of ulcers substantially.

One study was done at the Prince of Wales Hospital in Hong Kong, where gastroenterologists found that giving H. pylori eradication treatment to ulcer patients who were long-term users of NSAIDs helped eliminate the ulcers. All the patients got standard ulcer treatment. After six months, only 12 percent of those getting H. pylori treatment still had ulcers, compared to 34 percent of those who were not treated for H. pylori.

The other study is a meta-analysis, which pooled data from 16 previous studies. It found that peptic ulcers are twice as common in people infected with H. pylori than in uninfected individuals, that H. pylori infection almost doubled the incidence of bleeding ulcers, that NSAID use increased the incidence almost fivefold and that the two together increased the incidence more than sixfold.

The new results should help settle an ongoing controversy about the roles of NSAIDs and H. pylori in peptic ulcers, says Dr. Richard Hunt, professor of medicine at McMaster University Medical Center in Hamilton, Ontario, leader of the group that did the meta-analysis. Some earlier studies gave conflicting results, including one saying that NSAID use might protect against ulcers, he notes.

"We carefully undertook a systematic review that explores the relationships," Hunt says. "The risks are similar if there is an H. pylori infection and an NSAID is not taken, or if an NSAID is taken and H. pylori is not present. If both are present, the risk is additive."

"This is probably the resolution of the controversy," says Dr. Roy E. Pounder, the director of the Centre for Gastroenterology at the Royal Free and University College Medical School in London, and the author of an accompanying editorial in the journal. "They both point in the same direction, that the two [studies] appear to be summative."

NSAIDS are known to damage the lining of the intestinal tract. So do some strains of H. pylori, which is believed to infect half the world's population. The stress theory of ulcers began to fade in the 1980s, when a young Australian physician, Dr. Barry Marshall, who named H. pylori, performed a dramatic self-experiment, swallowing a massive dose of the bacteria and then curing the resulting ulcer by eradicating the infection.

The new studies could affect medical practice, says Hunt. "What our study clearly emphasizes is how important it is to ask the patient if there is any history of infection. In those patients who are infected, it is obligatory to treat the infection and be sure to eradicate it," he adds.

For people who must take painkillers, Pounder says, the physician should test for an H. pylori infection and treat the patient accordingly. And some patients might be prescribed the new generation of painkillers, the cyclooxygenase-II (cox-II) inhibitors. "Maybe this could be a reason to use the more expensive cox-II inhibitors," Pounder says.

For ulcer patients who do not use NSAIDS and are free of H. pylori, the physician should look for other causes, such as cancer, tuberculosis or Crohn's disease, Pounder says. "Almost all the other causes can be detected by taking a biopsy of the ulcers," he adds.

What To Do

People who regularly take NSAIDs should be alert to the risk of ulcers, and people with the persistent abdominal pain, nausea and vomiting that are symptoms of an ulcer should see a doctor at once.

You can get a rundown on H. pylori and ulcers from the National Library of Medicine and can learn about NSAIDs by consulting the National Institute of Diabetes and Digestive and Kidney Diseases.

SOURCES: Interviews with Richard Hunt, M.D., professor of medicine, McMaster University Medical Center, Hamilton, Ontario; Roy E. Pounder, M.D., director, Centre for Gastroenterology, Royal Free and University Medical College, London; Jan. 5, 2002, The Lancet
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