“Dr. B, its my indigestion. It is getting worse. Could it be an ulcer?” asks Susan as I enter the examination room.

Well Susan, what do you mean by indigestion?

“Dr. B, its my stomach!”

O.K. Susan, indigestion means different things to different people. Doctors describe indigestion as dyspepsia. Both terms are pretty vague. Medical text books describe this as a chronic (usually over 3 months), recurrent, often meal-related upper abdominal discomfort, pain or fullness.

Dyspepsia occurs in about 10 percent of the population. Most people carry on with off- the-counter medications. One-third of the people, who do seek help, will have no ulcer on investigations. This is called non-ulcer dyspepsia.

“Dr. B, what is an ulcer?” An ulcer is a break in the lining of an organ. The body responds to this with tissue reaction which may heal the ulcer or produce local tissue destruction with a crater formation.

There are 3 conditions to think about when a patient presents with indigestion: 1) ulcer of the stomach or duodenum (first part of small intestine), 2) cancer of the stomach and 3) non-ulcer dyspepsia.

Symptoms from gall bladder and pancreatic disease may mimic above conditions but they are more acute in nature with intervals where everything may be fine.

Clinically, I do not think Susan has cancer of the stomach as she is 38, has a good appetite and has not lost weight. Abdominal examination does not reveal any lumps.

Complicated ulcers can present with bleeding, weight loss, or vomiting and may mimic symptoms of cancer. Patients who are on non-steroidal anti-inflammatory drugs are prone to ulcers. In Susan’s case, there was no such history.

“Dr. B, what next? I have already tried off-the-counter medications. Is there a way to find the cause and treat it?”

Sure, Susan, let’s investigate with an ultrasound and gastroscopy. Ultrasound will check the gall bladder, liver and pancreas. Gastroscopy will examine the lining of the esophagus, stomach and duodenum.

Most of the ulcers in the stomach and duodenum are caused by Helicobacter pylori organisms (bugs). Biopsies taken during gastroscopy will identify whether these bugs are present. Gastroscopy will check for ulcer and cancer as well.

“Dr. B, you lost me! Gastroscopy? Helicobacter pylori………bugs? Scary stuff!

Susan, gastroscopy is not a difficult procedure. A flexible instrument with light and camera at the tip is swallowed under mild sedation. The magnified lining of the esophagus, stomach and duodenum are seen on a TV screen.

It allows us to do biopsies, remove polyps, dilate narrow areas, can often control bleeding and allows us to take photographs and video of the procedure.

Helicobacter pylori (H. pylori) is a bacteria found beneath the mucus layer of the stomach. In Canada, 10 to 20 percent of the population is infected with this organism. In developing countries, most people are infected before the age of 10 years.

It is estimated that 1 in 5 individuals with H. pylori will develop gastric or duodenal ulcer. A very small percentage may develop cancer of the stomach.

Susan’s ultrasound is normal. Gastroscopy reveals a duodenal ulcer with presence of H. pylori infection. Susan is treated for seven days with “triple therapy” – two antibiotics and an acid reducing agent.

Response rate to this therapy is over 90 percent for healing the ulcer and eradicating the bugs. The risk of recurrent infection is 1 to 3 percent over 5 years, usually from the immediate environment.

Susan feels great and is happy that we are able to identify the cause and treat it. A classic example of modern technology at work!

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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