January 27, 2025
dr kalu

By Dr. ANUMA KALU ULU

In medical terms, an ulcer is a wound so a skin ulcer will mean a skin wound and in the same vein, a stomach ulcer would mean a wound in the stomach. However, ‘stomach’ ulcers as known in Nigeria are actually medically called peptic ulcers and comprise stomach ulcers and duodenal ulcers. Duodenum here stands for the C-shaped first part of the small intestine into which the stomach opens. These ulcers are called peptic ulcers as derived from pepsin, the acidic enzyme secreted by the stomach to aid in digestion of foods, mostly proteins. In excess amount or in the absence of food or other substrates in the stomach, this enzyne can eat into the stomach lining, causing ulcers. Stomach ulcers are also called gastric ulcers.
Although we are talking about peptic ulcers today, i shall not fail to mention other maladies that mimic peptic ulcers and which form a spectrum from the most benign to the most sinister, with similar treatment to peptic ulcers. They include dyspepsia (indigestion), esophagitis, gastritis and gastro-esophageal reflux (GERD). Their causes are similar and include peptic acid, alcohol, cigarettes, medications, some foods, invasive procedures causing direct injury to the lining of their walls and infections with organisms like Helicobacter pylori. I shall define each of these separately because although their symptoms are similar, they also have a few individual subtleties and I shall proffer their remedies subsequently.

Dyspepsia simply means indigestion and can present with bloating, a sense of abdominal fullness with early satiety as well as upper abdominal and chest pain. It is caused by poor digestion of foods with resulting prolonged accumulation of the food in the stomach and its sequelae.

Esophagitis means irritation of the esophagus (called oesophagus in Nigeria) which is the part of the alimentary canal between the mouth and the stomach, and mostly caused by peptic acid. There are other causes like medications including bisphosphonates useful in calcium metabolism, like alendronate. The pain here is described as heartburn

Gastritis is irritation of the stomach wall and is caused mostly by alcohol and cigarettes and to a lesser extent by other things like medications including many pain killers such as cataflam, brufen (ibuprofen), naproxen, etc; H.pylori infection, invasive surgical procedures, etc. It usually presents with vomiting which could be bloody, coffee-grounds, bilious or just watery.

GERD is usually caused by a weak gastro-esophageal sphincter (the valve in the lower end of the esophagus at its junction with the stomach which normally prevents stomach contents from flowing back into the esophagus) with resulting flow back or reflux of gastric acid from the stomach into the lower esophagus. The stomach lining is thick (remember the meat delicacy called ‘towel’ which is actually the stomach wall) and can withstand the gastric acid to a large extent with no resulting injuries but when this same gastric acid flows back into this lower esophagus with relatively thinner and more fragile wall (remember your meat delicacy called round-about which includes this part of the alimentary canal), it eats away at this exposed esophagus resulting in the irritation and injury known as GERD.

I shall take peptic ulcers (stomach ulcers and duodenal ulcers) together since they are mostly differentiated by location as their causes and general presentation are similar. A typical Nigerian thinks ulcers are only caused by not eating in time and this is so far from the truth. All the causative factors for the spectra of diseases listed above are also implicated in ulcers but the final common pathway is via increased activity of peptic acid secreted by the stomach. It could be by hypersecretion of the acid overwhelming and eating into an intact stomach wall resulting in the ulcer and this type is not significantly modulated by timing of meals, as in a syndrome called Multiple Endocrine Neoplasia-1 ( MEN-1) This hypersecretion can also be elicited by eating a large amount of food with resulting distension of the abdominal wall, setting off a reflex that induces the stomach to secrete copious amount of acid, since the distension senses the presence of food. This increased acid can also eat into the stomach lining causing ulcers. At regular intervals, there is a basal acid secretion from the stomach which is unrelated to the presence of food and are usually not deleterious, but when people do not eat with set frequency but in a haphazard fashion, the basal acid not encountering any substrates in the stomach can accumulate and start eating into the stomach lining. This is the type we know much of in Nigeria
For duodenal ulcers, the cause is chiefly overflow of gastric acid from the adjoining stomach especially in hypersecretory states. Usually, the duodenum receives the liver secretion (bile) and pancreatic secretion and these 2 secretions are alkaline so they neutralize the acidic contents from the stomach once they reach the duodenum. In situations of decreased secretion of above alkaline fluids or blockage of their outflow or in situations of excessive stomach acid secretion and invariably an astronomical overflow into the duodenum, then the acid can eat into the duodenal wall causing ulcers. As a rule of thumb, people with stomach ulcers try to avoid eating because the churning of such foods in the stomach physically scrapes at the ulcer causing increased pain and discomfort, and as such they tend to be thin. On the other hand, those with duodenal ulcers eat a lot because their pain is worse when hungry, because there is no food in the stomach for the basally-secreted acid to work on, so more free acid flows into the duodenum causing injury and pain. These people usually look buxom because they eat a lot and their pain is usually worse in the early mornings like say 4am, 5am etc because there has not been any food in the stomach since dinner.

SYMPTOMS: Apart from already enumerated symptoms of peptic ulcer, sufferers could present with their abdomen feeling hot and making loud noises, also with burning abdominal and chest pain, or squeezing upper abdominal or chest pain or even throat pain, like somebody having a heart attack. They can also present with back pain or a sharp pain to the sides as if hooked by something. This is because the stomach moves around and can float to any of these places though still anchored, carrying its symptoms to these destinations. In fact, most of the cases termed worm infestations in Nigeria are actually peptic ulcers.

DIAGNOSTIC TESTS:
The gold standard here is endoscopy, which is passage of a camera mounted on a slender instrument down the mouth into the stomach to physically visualize the lesions, but this is not readily available everywhere in Nigeria, so what do we do? The next best thing is barium swallow, where somebody drinks an opaque substance and plain x-rays are taken to show a filling defect. This too requires some preparation and wont be available everywhere, like in the villages. The rampant practice in Nigeria of sending people for occult blood in stool and diagnosing them with peptic ulcer just because of the presence of blood in their stools is totally asinine and defies all reasonable postulation. This abracadabra presupposes either that all peptic ulcers cause bleeding or that the only causes of gastrointestinal bleeding are peptic ulcers, both postulations being so far divorced from reality!! For starters, there are more frequent causes of gastrointestinal bleeding than peptic ulcers including hemorrhoids ( which we call piles in Nigeria), rectal prolapse, colonic polyps, diverticulosis, colon cancers, rectal fistulae, anal fissures and anal tears. On the hand , the incidence of bleeding ulcers is so low compared to the total incidence of ulcers, and occurs only when the ulcer physically erodes a blood vessel, just like skin ulcers will bleed if a blood vessel is compromised.
So how do I diagnose peptic ulcers in my village Obiene Ututu in Abia State or my medical mission sojourns to Obinofia in Ezeagu and Akpugo both in Enugu state devoid of other ancillary services. Simply, clinically by asking about symptoms and eliciting pain when I press down on the epigastric region, being the first part of the stomach just immediately below the sternum ( breast bone). At this point it does not matter if it is dyspepsia, esophagitis, gastritis, GERD, stomach or duodenal ulcer since all are treated similarly and give same epigastric pain when palpated. You do not need to give your stool to anybody for diagnosis of peptic ulcer!! Some gastritis can be caused by infection with Helicobacter pylori and this organism can be obtained from biopsy taken during endoscopy or from stool sample ( the only time stool is needed!) or less reliably from the blood, and in specialized centers only.

TREATMENT:
Avoiding the causative factors like alcohol, cigarettes, etc is the key but in cases where an established disease exists, remedies exist:
Sleeping with head raised on say at least 2 stacked pillows helps to reduce the severity of GERD, since it can help to prevent the acud reflux from the stomach into the esophagus.
Eating in between meals or even nibbling at biscuits etc in between breakfast, lunch and dinner ensures that there is always food in your stomach for the continually-produced stomach acid to act on but you should not eat a large quantity at one time to avoid reflex increased acid production from stretched abdominal wall. Avoid eating uncooked raw peppery food because the pepper can cause burning and stinging in the ulcer resulting in increased discomfort, akin to putting pepper into a skin wound. Same goes for very hot food, as it can burn the ulcer and lead to more discomfort.

Medications will include coating agents that physically cover the ulcer, preventing further damage from foods, stomach acid, etc and include Mistmag trisilicate and Gestid in Nigeria as well as TUMS, Rolaids and Maalox here in the USA. Underneath these, the protected ulcer can heal at its pace.
In the past, Histamine-2 blockers like Ranitidine (Zantac) at 150mg 2x/day or 300mg once daily or Famotidine (Pepcid)20mg once daily or Cimetidine (Tagamet) 400mg 2x/day was used to decrease acid production. Though some still use the medications above especially in the rural areas in Nigeria, proton-pump inhibitors (PPI) like omeprazole 20mg once daily, lansoprazole 30mg once daily, pantoprazole 40mg once daily, esomeprazole 40mg once daily, etc, have revolutionized ulcer treatment. Taken for initial 4 to 8weeks they have good result in healing the ulcers, and occasional flare ups can be quelled with a burst of same medications at intervals. The coating agents above also help. In confirmed H.pylori infection, a combination of 2 antibiotics and a PPI taken for 2 weeks is usually eradicative. This could include Metronidazole (Flagyl) 500mg 2x/day with Clarithromycin (Biaxin) 500mg 2x/day or Amoxicillin 1000mg 2x/day with flagyl 500mg 2x/day. There are other combinations too.
Finally, bleeding ulcers are very rare but when they occur will require surgical evaluation. I hope this will be helpful to the the reader.

23 thoughts on “The Medical Iconoclastic Series: Management of ‘stomach’ ulcers in Nigeria”

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    What is AML?

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  9. Anti-money laundering (AML)
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    What is AML?

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    USDT, as the widely regarded as the well-known stablecoin, is commonly used in various exchanges worldwide. However, using USDT can carry several hazards, especially if your monies may tie to opaque or unlawful operations. To mitigate these threats, it’s imperative to take advantage of offerings that check USDT for sanctions.

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  10. 鉅城娛樂城
    鉅城娛樂城作為亞太區知名線上娛樂平台，以豐富多元的遊戲內容及優質服務贏得玩家信賴。平台通過TST技術測試及GLI系統認證，確保遊戲公平性。目前推出首存1000送1000優惠活動，最高回饋可達20萬，並提供日日續儲10%的回饋金。平台提供真人百家、棋牌、老虎機、體育電競及彩票等多樣化遊戲選擇，讓玩家享受如臨現場的娛樂體驗。

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    鉅城娛樂城作為亞太區最受歡迎的線上娛樂平台之一，以其豐富多元的遊戲內容和卓越的服務品質贏得了廣大玩家的信賴。該平台不僅擁有一系列令人 excited 的遊戲，還致力於為玩家提供公平、公正的遊戲環境。

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    目前，鉅城娛樂城推出了首存1000送1000的優惠活動，這讓新玩家能夠在註冊後，迅速享受雙倍的存款金額，提升遊戲體驗。此外，平台最高回饋可達20萬，讓玩家在參與遊戲時享受到更多的利潤。值得注意的是，鉅城娛樂城還提供日日續儲10%的回饋金，進一步增強了玩家的參與熱情。

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    總結

    總而言之，鉅城娛樂城憑藉其卓越的遊戲內容和專業的客戶服務，已成為亞太區線上娛樂的不二之選。公正的遊戲環境、誘人的優惠活動及多樣的遊戲選擇，吸引了無數玩家的目光。無論你是新手還是老玩家，鉅城娛樂城都能帶給你一段難忘的遊戲旅程。

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  12. TU娛樂城
    TU娛樂城擁有國際級的SGS服務認證，是首家獲得7星級認證的娛樂平台。每日提供近千場體育賽事直播，並設有真人、彩票、電子遊戲等多元娛樂選項。平台採用128位加密技術，打造安全可靠的服務環境。多端支援包含Web、H5及iOS、Android原生App，讓會員能隨時享受專業服務體驗。

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    Đá gà online cho phép người chơi tham gia vào các trận đấu bất cứ lúc nào và ở bất kỳ đâu, chỉ cần có kết nối internet. Điều này mang đến một sự thuận tiện vượt trội so với hình thức đá gà truyền thống, nơi người chơi thường phải đến sân đấu để có thể tham gia. Nhờ vào công nghệ livestream, người chơi có thể theo dõi trực tiếp các trận đấu từ xa, cảm nhận được không khí kịch tính và hồi hộp như đang ở sân đấu thực sự.

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    Trong bối cảnh đó, để đá gà online phát triển bền vững, cần có các quy định hợp pháp và minh bạch nhằm bảo vệ quyền lợi của cả người chơi và động vật. Đồng thời, việc nâng cao nhận thức của cộng đồng về đạo đức trong việc tham gia các trò chơi giải trí này cũng là rất quan trọng.

    Tóm lại, đá gà online là một hình thức giải trí mới mẻ, mang đến nhiều trải nghiệm thú vị cho người chơi. Tuy nhiên, đi kèm với nó là trách nhiệm trong việc bảo vệ quyền lợi động vật và đảm bảo tính hợp pháp của các hoạt động cá cược. Chỉ khi có sự cân bằng giữa giải trí và đạo đức, đá gà online mới có thể trở thành một phần hấp dẫn và bền vững trong đời sống giải trí hiện đại.

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  15. Dive into the World of GTA 5 RP: Join Our Unique Roleplay Server

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  18. Equilibrado
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    Las áreas de uso de los sistemas de balanceo cubren múltiples industrias, desde la producción de vehículos de dos ruedas hasta el seguimiento ambiental. No importa si se refiere de extensas producciones manufactureras o reducidos establecimientos de uso personal, los dispositivos de ajuste son necesarios para garantizar un operación eficiente y sin riesgo de fallos.

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  22. Adventure roleplay
    Plunge into the Realm of GTA 5 RP: Become a part of Our Unique Roleplay Server

    Salutations to the thrilling world of GTA 5 RP, where all player can craft their distinct tale in a dynamic gaming environment. Our roleplay server is ideal for those desiring an captivating and enveloping experience. Engage with a active community of GTA RP enthusiasts and enter into this thrilling world!

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