Doctors Slow to Attack Bug Behind Ulcers
Arlene Ozburn got an excellent medical tip from a friend at work: Maybe her ulcers were caused by a bug.
Her HMO doctor pooh-poohed the idea. Weight was the problem, he said. Or maybe stress. He put her on Tagamet, the standard acid blocker.
It took two years of pain, two years of nagging, before Ozburn’s physician gave in and had her checked for ulcer bacteria. A specialist quickly found the culprit--a germ called Helicobacter pylori--and gave her antibiotics.
“I felt better within a couple of days,†Ozburn said. “I could not believe the difference.â€
She was cured. The ulcers were gone for good.
“Why do they put people through hell when there is this treatment?†Ozburn asked.
It’s a question many ulcer sufferers are asking.
The discovery that bacteria cause stomach ulcers is one of the most amazing medical breakthroughs of this generation. Yet it is only slowly, grudgingly working its way into routine practice.
At some time in their lives, one in 10 Americans will have an ulcer. And, like Ozburn, they almost certainly will come away from a doctor’s visit with a prescription for the wrong medicine--one that may hold the disease at bay but not cure it.
Ozburn is a secretary in the veterinary department at the University of Arizona in Tucson, and she was lucky enough to know a professor who’d heard of the ulcer microbe. Like her, many others read in the newspaper or hear over coffee that there is a cure for their misery.
Digestive disease specialists say this is turning the treatment of one of humanity’s most common afflictions upside down. Over and over, ulcer patients such as Ozburn tell their disbelieving family physician the correct diagnosis and demand the right medicine.
“The thing that is most striking is that patients are more and more aware of this,†said Dr. Gary Falk, a gastroenterologist at the Cleveland Clinic. “The patients come to the clinic, say they have a history of ulcer disease and want advice on this H. pylori stuff. But their doctor has not checked them for it.â€
The reason? There are several. But probably none is more important than the revolutionary nature of the discovery itself. It has meant doctors have to forget just about everything they learned in medical school about stomach ulcers.
Stress doesn’t cause ulcers. Neither do coffee, spicy food or too much stomach acid. Most ulcers are caused by H. pylori, a spiral-shaped bacterium that burrows into the lining of the stomach and duodenum. People may bear all the stress the world can heap upon them, but unless they are infected with H. pylori, they won’t get ulcers.
Ulcers are an infectious disease, just like pneumonia or strep throat. And that means two weeks of the right pills can make them go away, probably forever.
It turns out that about half of all U.S. adults are infected with H. pylori. Most don’t get ulcers. But when ulcers do occur, the bug is probably responsible for 80% or more. The only major exception is ulcers triggered by aspirin and some other painkillers.
“One thing is very simple,†said Dr. Amnon Sonnenberg of the Veterans Affairs hospital in Albuquerque, N.M. “If you have an ulcer, then you should have antibiotic therapy. No gastroenterologist has the slightest doubt about this.â€
But most people with ulcers don’t see gastroenterologists, who specialize in digestive diseases. Instead, they take their bellyaches to a general internist or family practitioner.
Sonnenberg estimates that these primary care doctors are using antibiotics to cure about one-third of their ulcer patients these days. Instead, the front-line treatment remains the tried and true, acid-blocking drugs such as Tagamet, Zantac and Pepcid. These medicines will heal an ulcer--temporarily. But, in time, they often come back.
Even if family doctors have heard about using antibiotics for ulcers, many say they don’t know enough about diagnosing the infection and choosing the drugs to cure it.
Experts are still arguing over the right combination of medicines. Perhaps 10 or 15 different mixtures are making the rounds. Even though all of them work, no one can say which is best. Many involve three different prescriptions and require taking about 15 pills a day.
One reason doctors feel unsure about this is because the U.S. Food and Drug Administration has not yet endorsed a particular combination of antibiotics for ulcers. And until that happens, drug companies cannot advertise--or even talk to doctors--about using their medicines to cure ulcers.
“Basically, we can’t discuss it at all,†said Cathy Kernen of Astra Merck, one of the companies seeking FDA recognition.
This means a lot of doctors know little about the new treatments for ulcers--despite more than 2,000 articles in medical journals about H. pylori since 1992. Their primary source of new medical information is not journals but drug salespeople, known as detail men, who call on their offices.
“Until the drug rep appears at the general practitioner’s door with a glossy brochure and gives the doctor some samples, nothing much happens,†said Dr. Barry Marshall of the University of Virginia.
Marshall is the George Washington--or perhaps the Che Guevara--of the ulcer revolution. Working as a pathologist at Royal Perth Hospital in Australia in the early 1980s, he and Dr. Robin Warren first noticed an odd-looking bacterium in the lining of the digestive system.
Scientists still marvel at Marshall’s talk at a bacteria conference in Brussels in 1983. This unknown doctor got up, described isolating a new bug and then made the incredible announcement that he had discovered the real cause of ulcers.
“He didn’t have the demeanor of a scientist,†remembers Dr. Martin Blaser of Vanderbilt. “He was strutting around the stage. I thought this guy was nuts.â€
Demeanor wasn’t all he lacked.
Despite his contention, repeated over and over, that bacteria cause ulcers, he had no convincing proof. At one point, he tried to bring around an intensely skeptical medical profession by purposely infecting himself with H. pylori. (He got inflammation but no ulcer.)
Eventually, other scientists looked into it, but the work took time. Some say Marshall’s stridence kept the whole issue controversial longer than it needed to be.
Drug companies waited several years to get into the field in a big way. Their backing was necessary to pay for the expensive studies to prove antibiotics really work, but for some there was little incentive.
Histamine-2 receptor antagonists--Tagamet and its acid-blocking cousins--were already the most lucrative drugs on the market. In a way, they were perfect: They relieved ulcers but didn’t cure them, so people had to keep taking them.
By the early 1990s, though, the connection between bacteria and ulcers was indisputable. In February 1994, a panel of experts brought together by the National Institutes of Health wrote a strongly worded statement: Infected ulcer patients “require treatment†with antibiotics.
But on the front lines of medicine, family doctors contend that is harder than it sounds.
Some acknowledge that a lack of handouts from drug companies holds them back. “Traditionally, the only way you get any education is from the drug reps coming out to you,†said Dr. Francis T. Daly Jr. in rural Lock Haven, Pa., who only rarely sees ulcers treated with antibiotics.
Another common complaint is the difficulty of diagnosing ulcers. Perhaps one in 10 or 20 belly-pain patients actually has an ulcer. Although a simple blood test is now available to diagnose an H. pylori infection, many doctors are unfamiliar with it. And even if the test shows patients have the bug, that doesn’t mean they have ulcers. The definitive test--a tube-down-the-throat procedure called endoscopy--costs $1,000 or so.
Some specialists recommend routinely giving antibiotics to every infected person who has classic ulcer symptoms. Forget about doing an endoscopy first, they say. Getting rid of H. pylori is probably a good idea, if it hasn’t caused ulcers yet.
But many general doctors interviewed seemed reluctant to do this, in part because of uncertainty about which regimen to use, the multitude of pills necessary and the nausea and other side effects they sometimes carry. Instead, they send patients home with Zantac and see what happens.
“What most of us are doing at this point is the same approach we used for many years,†said Dr. Kenneth Evans of Oklahoma City. “Whenever someone comes in complaining of what sounds like an ulcer, we treat it with standard H-2 blockers. If they don’t get well, we begin a work up and do tests that can diagnose the disease.â€
If they don’t get better on the H-2 drugs--and many of those with ulcers will, if only temporarily--there is a chance that they eventually will end up on antibiotics. But several gastroenterologists estimated that it is still less than 50-50.
FDA endorsement of two antibiotic regimens, expected soon, will improve the chances, as will approval of a breath test to make diagnosis of the infection even easier.
“Once the therapies and tools and toys that are needed are available, it’s going to be done. In fact, if it’s not done, it will be malpractice, and doctors are very sensitive to that,†said Dr. David Graham of Baylor College of Medicine.
For Arlene Ozburn and millions of others, this should mean freedom at last from the gnawing and burning of ulcers. Few, though, are likely to be more thankful than John E. Newman Jr., 66, a retired management consultant in Houston.
Newman came down with ulcers in 1952 on his way to the Korean War. The Navy blamed stress, as did all the doctors he saw for the next 40 years.
He took the standard medicines, but nothing helped much. Every three months or so, his ulcers flared up painfully. Twice, he suffered serious bleeding attacks, losing five pints of blood each time.
Finally, three years ago, he read a newspaper article about H. pylori and called Graham, one of the doctors mentioned. A few weeks later, he was cured.
That’s when he realized that all those years, even between attacks, he had been in pain, a dull pressure in his stomach that he didn’t notice until it went away.
“Forty years of pain gone, my life completely changed, my temperament, my patience, my ability to concentrate,†he said. “It has made a profound difference. Profound is not too strong a word.â€
