By Tedler D. Depaynos, MD
It was just before the Holy Week when the patient suddenly again felt a burning pain at his epigastric area. Because he felt this before and was transiently relieved by Maalox, a drug suggested by a nurse friend to take when he had several similar pain episodes in the past, he took the same medicine and he was thankful he had some leftovers in his table drawers at home. They live in a distant barangay in Itogon where no pharmacy exists. The Maalox gave slight relief but this time he was surprised that his stools became literally blackish like “dinuguan”, the bloody meat dish that he enjoys a lot. The stools however became “normally colored” after 4 – 5 days but he was noticed by his co-workers to be pale and his complexion appeared to be suddenly fairer than his wife’s despite his constant exposure in the sun. He also felt that he is most of the time sleepy, feeling weak because the steps he climbs every day seem to be getting higher and his silent heart beats became pronounced. It was only after 3 weeks that he was able to seek consultation in the hospital where he was diagnosed to have probably a bleeding peptic ulcer with a resulting severe anemia as confirmed by a simple blood test.
Actually he wanted to go to the hospital earlier when he started feeling that his condition was worsening. Because nobody would be taking care of their less than 1 year old baby boy he simply could not do it. It was only when his mother arrived from the far away low land province to baby-sit for them that he was free to seek medical consultation and was admitted.
Because the bloody stools appeared digested, the bleeding most probably came from the upper portion of the gastrointestinal tract like the esophagus, stomach or duodenum. He may have a chronically bleeding lesion but the one episode of grossly bloody stools implies a onetime major event. Because his anemia appears to be massive as manifested by his severe paleness, weakness and sleepiness, a continuous chronic bleeding in small amounts was entertained.
To confirm the impression, an esophago-gastric-doudenoscopy was done. Actually this is now routinely done by our locally well trained young gastroenterologists. It is done under sedation. The endoscopy of our patient revealed gastritis and a bleeding ulcer at the duodenal opening. The ulcer was biopsied and the bleeding was successfully cauterized. A test for the presence of H. Pylori bacteria was also done. Most of the time an Acid Related Disorder is given by younger MDs as the initial diagnosis. It is a general term replacing the term, peptic ulcer. To be more précise one of our older textbook on surgery defines esophagitis, gastritis or doudenitis as inflammation of the inner superficial lining called the mucosa. Actually, the “itis” implies inflammation as in tonsillitis or dermatitis. When the lesion involves the deeper muscular layer, it is generally termed as an acute ulcer. When it reaches the outer lining, the serosa, it is termed chronic ulcer and since it is already too deep, the danger of perforation as a complication is present. Bleeding complication results when a blood vessel is eroded by the ulcer. This may have happened to the patient.
The chemical reactions resulting in the formation of the ulcer maybe extensive and complicated but in layman’s terms it is simply due to plain uncontrolled hyperacidity or a weakened mucosa or both. The possibility of cancer as the cause especially in the stomach which has a higher incidence cannot be discounted and is always entertained by those practicing the Hippocratic Oath. Hence, a biopsy is routinely done by gastroenterologists doing endoscopy. Fortunately, it was negative in this patient.
Ulcers are usually infected by the bacteria H. Pylori so that as a rule ulcers do not heal without eradicating the bacteria. Some textbooks theorize that it is the bacteria that weaken the mucosa leading to the formation of ulcers. Aside from drugs to control the hyperacidity, two antibiotics usually are prescribed to be taken for at least 2 weeks to eradicate the bacteria. Ulcers are just like any wound that it takes time to heal. With the intake of medicines, the pain may disappear but it does not mean that the ulcer has healed already. It takes at least 3 to 6 weeks for ulcers to heal so that medicines should not be taken less than this time. Our patient took Maalox whenever there was pain. The pain may be relieved by neutralization of the gastric acid, but the ulcer is still there. He never took it continuously that is why he developed the complication of bleeding which caused the severe anemia. To correct it, several blood transfusions were given.
Fortunately, the bleeding was stopped, the anemia corrected and the patient discharged with home medications. Of course he was advised not to take gastric irritating beverages and food like strong alcoholized water even though with ice and the favorite of Korean connoisseurs which are spicy foods. Smoking and the intake of non-steroidal strong analgesics like Aspirin, Ibuprofen and Diclofenac are taboo because they definitely contribute to the formation of this disease. Since the patient is from a mining town he must be stressed in looking for the elusive gold. There is such a thing as stressful ulcers.**
