Statistics show that peptic ulcer is far more prevalent than is
supposed by the casual observer. “In the combined statistics of 59,450
autopsies of various series evidence of healed or unhealed ulcer were
observed in 4.4 per cent.” (Bassler.)
The reason for this is that peptic ulcer may present very definite
symptoms which are readily interpreted or they may be so atypical as
to make definite diagnosis impossible. Like all gastro-intestinal
diseases, many of the symptoms are easily confused with so-called
indigestion or “stomach trouble.”
=Etiology.=—One characteristic of gastric and duodenal ulcer is that it
only occurs where the mucous membrane is subject to the influence of
hydrochloric acid and pepsin; lower end of esophagus, stomach and first
part of duodenum.
Similar ulcers are often found in the sigmoid and rectum where the
feces often become acid due to bacterial action, or on account of
slow movement, hydrochloric acid and pepsin which may have escaped
neutralization in the duodenum may attack the mucosa.
For the part played by spinal and rib lesions on the glandular layer
of the stomach, the reader is referred to a previous discussion of the
lesion.
Probable secondary causes of gastric ulcer are: (1) Embolism of an
artery (gastric arteries are terminal). These emboli are supposed to be
caused by toxic and infectious agencies which enter the circulation, as
sometimes occurs in pyemia and large burns of the skin.
(2) While hydrochloric acid associated with pepsin seems to be an
important factor, it is doubtful whether it can attack the mucosa
without there being a previous abrasion or other injury. It is said
that a normal secretion of mucus is nature’s protection against self
digestion.
The swallowing of substances of a coarse or irritating nature or those
chemically corrosive or at extremely high temperature may so injure the
mucous membrane as to permit an attack by HCl and pepsin.
Certain occupations seem to predispose to gastric ulcer, such as
cobblers, or others who in their work press various objects against the
stomach.
Sharp blows over the stomach have been followed by acute ulcer. A
frequently associated condition is gastroptosis, which seems to be
explained on the basis of narrowing of the blood vessels and their
more ready occlusion. Probably sagging of the duodenum is an important
predisposing factor.
Anemia and chlorosis should not be overlooked as predisposing causes.
And tuberculosis and syphilis are possible associated disorders.
Of all the theories advanced, the lowering of vitality, due to lesions
of the splanchnics and vagus nerves remains the most logical.
=Symptoms.=—The most characteristic symptom is pain, which in a typical
case comes on at a regular time after taking food. It may be a half
hour, an hour or two hours, and in the case of duodenal ulcer may be
as late as four hours. The distance beyond the cardia at which the
ulcer is located seems to govern the time; also the time at which the
secretion of hydrochloric acid reaches its height, which varies in
different individuals.
The pain is due to free acidity (that which is not combined with the
food) irritating the raw surface of the ulcer. Pain is often increased
or lessened by posture. If turning on the left side gives relief the
ulcer is probably at the pylorus; if worse when standing than reclining
the ulcer is probably on the greater curvature.
The pain is usually localized by the patient, and pressure at the given
spot increases the pain. In many cases there is referred pain in the
region of the 9th, 10th and 11th ribs on the left side.
At the height of pain vomiting may occur, due probably to pylorospasm
resulting from high acidity. Vomiting always gives relief. The taking
of protein food or alkali will usually relieve the pain of ulcer,
(hunger pain). Ulcer patients are usually well nourished owing to the
habit of relieving themselves by eating, or they may be thin due to
their fear of food.
In acute ulcer frank blood may show in the vomit, and may be the first
indication of trouble, whereas in the chronic type it may be occult, or
occult blood may be found in the feces. The hemorrhage of ulcer, unlike
that of cancer, is not constant.
=Diagnosis.=—Diagnosis of duodenal ulcer, as distinguished from
gastric, is made by finding the tender spot to the right and below the
pylorus, the pain coming on three or four hours after taking food, and
the finding of blood in the feces (tarry stool) and not in the stomach
contents. Repeated examinations may be necessary owing to the fact that
hemorrhage is not constant.
The large percentage of stomach ulcers are near the pylorus, and of the
duodenal ulcers the ascending portion is the area almost invariably
involved.
Ulcer is differentiated from functional disorders by a history of
real pain as distinguished from the vague disturbances of sensation
often called pain by neurotic patients. Also its regular appearance in
relation to food. The pain of “gastralgia” has no regular habit and is
not influenced by food.
Referred pain from cholecystitis, chronic appendicitis, etc. has no
relation to food and is not relieved by food or alkalies.
Ulcer is to be distinguished from cancer by the age of the patient (in
cancer usually over 40) with a previously good gastric history, except
in cases where cancer has been grafted on to a chronic ulcer. In these
cases a careful inquiry will bring out a characteristic ulcer history
up to a certain time, when all symptoms change; pain becomes constant;
is not relieved by food or alkali; vomit becomes dark in color and has
a characteristic odor, appetite fails, and signs of cachexia set in.
Gastric ulcer should be suspected in all cases of persistent gastric
symptoms which are not readily relieved by treatment and regulation
of diet, and in which there is found high acidity and continuous
hypersecretion not accompanied by mucus.
The X-ray and gastric analysis should never be neglected in suspected
cases, keeping in mind the possible injury from the tube in case of
recent hemorrhage.
=Treatment.=—Osteopathic treatment of gastric ulcer will be almost
uniformly successful if we will analyze all of the factors entering
into the problem.
It is obvious that in order to heal the ulcer we must remove all
factors which interfere in any way with nutrition. Then give the
stomach as near absolute rest as possible while at the same time
building up the nutrition by a generous but well chosen diet.
When acute hemorrhage has recently occurred, complete rest in bed with
a trained nurse in attendance is the first indication. Complete rest of
the stomach, all nourishment being given by nutrient enema. An ice bag
is to be placed over the stomach, and removed every three or four hours
to allow surface circulation to react. Warm applications should not be
used while there is any marked bleeding.
During this period no effort on the part of the patient should be
permitted, and no manipulative treatment which would tend to increase
blood pressure should be given.
After all evidence of hemorrhage has ceased for ten days, or at once
in case of chronic ulcer, we may carefully correct all spinal or rib
lesions in the splanchnic area especially the 6th dorsal, or cervical
lesions affecting the pneumogastric. Pain and pylorospasm may be
relieved by steady pressure at the 4th and 5th dorsal on the right side.
After spinal lesions have been corrected without unduly irritating the
stomach, careful relaxing treatment should be given with the patient on
the back, keeping in mind that all exertion will tend to irritate the
ulcer.
If special care is observed, frequently definite relief may be given
by placing patient in knee-chest position and gently raising the lower
portion of duodenum where it lies alongside of ascending 3rd and colon,
4th lumbar.
During this period a hot water bag or a thermal pad should be kept over
the stomach night and day.
In certain cases of perforation in a few obstinate conditions, and in a
few where mechanical obstruction is marked, surgery may be indicated.
The following diet will be found best during the first week:
7 A. M. A half glass of cooked milk, with the leathery substance which
rises on the top removed, and the yolk of one egg stirred into it and
sweetened, if desired; taken luke warm or cool, but never ice cold.
This amount to be increased on the second day to three-fourths of a
glass, and on the third to a full glass, which is to be continued for
a week. If the milk produces diarrhea, add two tablespoonfuls of lime
water to each portion.
9 A. M. A saucerful of gelatine (Knox’s or Crystal Rock) with 2
tablespoonfuls of cream and a teaspoonful of sugar.