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A consumer education brochure
If you are occasionally slowed down by an upset stomach, indigestion,
heartburn or even an ulcer, you certainly are not alone. Over 95
million people in the U.S. experience some kind of digestive problem.
Over 10 million people are hospitalized each year for care of gastrointestinal
problems and the total health care costs exceed $40 billion annually.
While many digestive problems are more common as people get older,
they can occur at any age, even in children. All people are susceptible
to digestive problems, regardless of gender, ethnic or socioeconomic
background.
Table of Contents
The gastrointestinal
tract
The gastrointestinal (GI) tract permits food to be made into
nutrients that provide energy, and then allows the unused matter
to be removed from the body. The GI tract starts with the mouth,
where food is eaten, and follows through the digestive system
to the esophagus, the stomach, the small intestine, the large
intestine (colon) and the rectum. Other organs associated with
the GI system include the liver, pancreas and gallbladder.
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GI bleeding: What it
is and what it isn't
When your physician speaks about GI bleeding, he/she is usually
not talking about an external wound that results in visible bleeding
from one or more GI organs, but rather means something more specific.
Bleeding in the gastrointestinal tract means that some part of
the body represented in the diagram above is bleeding internally,
either slightly (which may or may not be very serious) or heavily
(which may have serious health consequences).
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How do you recognize
the symptoms of GI bleeding?
Because GI bleeding is internal, it is possible for a person
to have GI bleeding without having pain, literally without knowing
you are bleeding. That's why it is important to recognize those
symptoms which may accompany GI bleeding. Basically, the symptoms
of possible GI bleeding vary, depending upon whether the source
of the bleeding is in the upper part of the digestive tract (the
esophagus, stomach or the beginning of the small intestine) or
in the lower part (small intestine, colon or rectum).
- Symptoms of Upper GI Bleeding:
- vomiting bright red blood
- vomiting dark clots, or coffee ground-like material
- passing black, tar like stool
-
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- Symptoms of Lower GI Bleeding:
- passing pure blood or blood mixed in stool
- bright red or maroon colored blood in the stool
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What are the different
types of GI bleeding?
GI bleeding may come from various parts of the GI tract, and
may be caused by various things.
| Esophagus |
Vomiting bright red (blood) or
coffee ground material, Black stools |
Ulcer, varices Liver disease |
| Stomach |
Vomiting bright red (blood) or
coffee ground material, Black stools |
Ulcer, gastritis, varices |
| Small Intestine |
Bright red/maroon bleeding |
Ulcer, AVMS, Tumor |
| Large Intestine (Colon) |
Blood in the stool |
Colon cancer, polyps, colitis,
AVMS, diverticulas |
| Rectum |
Bright red bleeding |
Hemorrhoids, Diverticulosis, Tumor
|
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Ulcers
About 20 million Americans will suffer from an ulcer in their
lifetime. Duodenal (beginning of the small intestine) ulcers often
occur between the ages of 30 and 50, and are twice as common among
men. Stomach ulcers occur more often after the age of 60 and are
more commonly seen in women.
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What is an ulcer?
Most GI bleeding comes from ulcers. An ulcer is an area of the
lining of the stomach or duodenum that has been destroyed by digestive
juices and stomach acid. Most ulcers are no larger than a pencil
eraser, but they can cause tremendous discomfort and pain.
What are the symptoms of ulcers?
The most common symptom of an ulcer is a gnawing or burning
pain in the abdomen located between the navel and the bottom
of the breastbone. The pain often occurs between meals and sometimes
awakens people from sleep. Pain may last minutes to hours and
is often relieved by eating, taking antacids or acid blockers.
Less common symptoms of an ulcer include nausea, vomiting and
loss of appetite and weight, and bleeding.
What causes ulcers?
In the past, ulcers were incorrectly thought to be caused
by stress. Doctors now know that there are two major causes
of ulcers. Most duodenal and gastric ulcer patients are infected
with the bacterium Helicobacter pylori (H. pylori). Others who
develop ulcers are regular users of pain medications called
non-steroidal anti-inflammatory drugs (NSAIDs), which include
common products like aspirin, ibuprofen, naproxen sodium and
ketoprofen.
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What should I know about
Helicobacter pylori (H. pylori)?
The largest number of ulcers arise because of the presence of
H. pylori. Because H. pylori exists in the stomachs
of some people who do not develop ulcers, most scientists now
believe that ulcers occur in persons who have a combination of
an hereditary/family predisposition, plus the presence of the
bacterium, H. pylori.
The use of antibiotics to fight the H. pylori infection
is a major scientific advance. Studies now show that antibiotics
can permanently cure 80-90 percent of peptic ulcers. Blocking
stomach acid remains very important in the initial healing of
an ulcer.
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What should I know about
Non-Steroidal Anti-Inflammatory Drugs?
The second major cause for ulcers is irritation of the stomach
arising from regular use of non-steroidal anti-inflammatory drugs,
or NSAIDs. NSAIDs are available over-the-counter (OTC) and by
prescription.
If you are taking over-the-counter pain medications on a regular
basis, you will want to talk with your physician about the potential
for ulcers and other GI side effects. NSAID- induced gastrointestinal
side effects can be reduced by using alternative therapy. Your
doctor may recommend that you change the medication you are using;
or add some other medication in conjunction with your pain medication.
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What are the complications
of ulcers?
Bleeding – Internal bleeding in the stomach or the duodenum.
Perforation – When ulcers are left untreated, digestive juices
and stomach acid can literally eat a hole in the intestinal lining,
a serious medical problem that requires hospitalization, and often
surgery.
Obstruction – Swelling and scarring from an ulcer may close
the outlet of the stomach, preventing passage of food and causing
vomiting and weight loss.
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How are ulcers diagnosed?
The two tests most commonly used to evaluate for ulcer are a
procedure called an Endoscopy or EGD, and an X-ray known as an
Upper GI Series or UGI.
- Endoscopy
- This test involves insertion of a small lighted flexible tube
through the mouth into the esophagus, stomach, and small intestine
(duodenum) to examine for abnormalities and remove small tissue
samples (biopsy). The test is usually performed using medicines
to temporarily sedate you.
- Upper GI Series
- Alternately, there is an X-ray test where you are given a
chalky material (barium) to drink while X-rays are taken to
outline the anatomy of the upper digestive tract.
Tests for Helicobacter pylori
There are several tests available to your doctor to evaluate
for the presence of the bacterium, H. pylori. Samples of
blood can be examined for evidence of antibodies to the bacteria;
a breath test can be examined for by-products from the bacteria;
or biopsies from the stomach can be examined.
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How are ulcers treated?
In contrast to past beliefs, diet has little to do with ulcer
healing. Doctors now recommend that patients with ulcers only
avoid foods that worsen their symptoms. Patients who smoke cigarettes
should stop. Smoking has been shown to inhibit ulcer healing and
is linked to ulcer recurrence. In general, ulcer patients should
not take NSAIDs unless instructed to do so by their physician.
Numerous medications which inhibit acid production can rapidly
heal ulcers. Antibiotic therapy for H. pylori can accelerate healing
and prevent recurrence. When an ulcer fails to heal or if complications
of bleeding, perforation or obstruction develop, surgery may be
necessary.
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NSAIDS — Issues that
may arise with regular use of NSAIDS
At one time aspirin was virtually the only non-prescription
pain reliever available. It has always had excellent pain relief
benefits, but it was also recognized that, when used regularly,
it could cause digestive problems for some patients. Some modified
versions of aspirin came onto the market in an effort to achieve
the benefits of aspirin while "buffering" the prospect for stomach
discomfort. Acetaminophen, which is not an NSAID, achieves similar
benefits of pain relief with minimal, if any, impact on the stomach
lining.
New NSAID medications became available in prescription form
that also offered excellent pain relief, but like aspirin, these
new prescription medications also had the potential to promote
the development of ulcers and bleeding in the GI tract. Since
they were being administered under a doctor's prescription, any
such effects could be monitored.
NSAIDs became more popular as prescription remedies, and soon
they were cleared for OTC marketing by the FDA. A partial list
of NSAIDs that are available over-the-counter and recommended
maximum daily doses appears on the last page.
Some health benefits associated with aspirin and NSAIDS
As was noted above, the main benefit recognized early on for
aspirin was the relief of pain and the reduction in fever. Other
important health benefits from aspirin have also come to be recognized.
One of the more important of these is the use of aspirin in helping
to prevent heart attack and perhaps stoke. The benefit stems from
aspirin's role as a platelet inhibitor. Studies have shown that
these benefits can be obtained with a small daily dose of aspirin.
NSAIDs were found to have an additional benefit of reducing
inflammation, (dependent on dose), and so helped alleviate not
only the symptom of pain, but also served to reduce the actual
cause of the pain, e.g., reducing joint inflammation in rheumatoid
arthritis.
Balancing pain releif and concerns with side effects
Adverse side effects can accompany the benefits in a portion
of patients taking any medication. No drugs escape the need for
this kind of risk-benefit evaluation. It has become necessary
to balance the benefits of analgesia, platelet inhibition, and
anti- inflammatory effect from NSAIDs and aspirin against potential
adverse effects on the stomach and digestive system. For patients
who are dependent on regular use of pain relievers, this can mean
determining whether there are alternate ways to achieve pain relief,
without risking ulcers or GI bleeding which may accompany regular
use of aspirin and NSAIDs.
In this regard, aspirin and NSAIDs have been found to cause
damage to the lining (or mucosa) of the digestive tract primarily
in the stomach and upper intestine. This damage can result in
an ulcer or intestinal bleeding. Although this can happen to an
individual who is an infrequent user of aspirin or NSAIDs, it
is of a much greater concern in frequent users, and those consuming
higher dosages of these medications.
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Personal medical history
is important
As with any other risk-benefit analysis, the determination of
the risk associated with a particular patient's use of NSAIDs
requires a careful look at the patient's medical history. Here
are some key issues:
- Age
- Has been identified as a risk factor in several studies. Older
patients also often require pain medications more often or in
larger doses, further increasing their risk.
- Previous Ulcer
- A history of an ulcer or an ulcer complication have been identified
in several studies as risk factors for complications due to
aspirin or NSAID use.
- Alcohol
- Alcohol, taken alone can cause irritation of the GI tract.
There have been some indications that patients who consume alcohol
at the same time they are taking aspirin or NSAIDs have an increased
risk of damage to the intestinal lining, including ulcers and
GI bleeding. There have been some reports that chronic heavy
alcohol users may be at increased risk of liver toxicity from
excessive acetaminophen use. Individuals who consume large amounts
of alcohol should not exceed recommended doses of acetaminophen.
In 1993, FDA Advisory Committees recommended that all OTC pain
relievers contain an alcohol warning to date, some, but not
all OTC pain relief products have complied with that recommendation.
Chronic heavy alcohol users should consult their physician for
advice on when and how to take pain relievers.
- Steroids
- Patients taking NSAIDs who also are taking a prescription
corticosteroid, medications like prednisone (in doses over 10
mg), have been found to have a seven fold increased risk of
having GI bleeding.
- Anticoagulants
- Similarly, patients who are taking NSAIDs at the same time
they are taking oral prescription anti-coagulants (for example,
medications like coumadin) have been found to have a 12-fold
increased risk of bleeding.
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Magnitude of NSAID Use
Adverse effects associated with NSAIDs become more likely as
the cumulative amount of NSAID increases, relating both to the
size of each dose you take, as well as how frequently how many
times a day, how many days a week you consume NSAIDs.
The most important ground rule, however, is to follow the instructions
on your medication. No medication whether a prescription or over-the-counter
drug should be taken more frequently than is directed in the labeling.
Most NSAID ulcers heal easily if the NSAIDs are stopped. If
the medication cannot be stopped, the dose may often be reduced.
Even if your physician determines that continued administration
of NSAIDS is needed, healing can still occur.
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Asymptomatic patients —
Patients can have an ulcer or GI bleeding without any obvious symptoms
An individual can develop damage to the intestinal lining without
being aware of it significant GI bleeding occurs frequently without
any symptoms being present.
Of particular concern are patients with arthritic conditions.
More than 14 million such patients consume NSAIDs regularly. Up
to 60% will have gastrointestinal side effects related to these
drugs and more than 10% will cease recommended medications because
of troublesome gastrointestinal symptoms.
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Medications that can be
taken to inhibit or reverse the NSAIDs-induced injury to the intestinal
lining and GI bleeding
Conventional treatments for ulcers (classes of prescription
ulcer drugs called H2 blockers and proton pump inhibitors), have
been found to have a beneficial effect in treating NSAID-induced
ulcers and in preventing GI bleeding. These treatments often will
be effective, particularly if NSAID use is stopped or reduced,
although healing can occur in many cases where a patient receives
these anti-ulcer medications, even when NSAID use continues.
Another medication, misoprostol, has been used effectively to
prevent gastric and duodenal ulcers and has been shown to reduce
the risk of bleeding in those that must continue using NSAIDs.
As with all instances where patients are taking more than one
prescription or over-the-counter medication, patients and their
physicians need to evaluate any side effects, potential drug interactions,
or other factors, e.g., limitations on use during pregnancy.
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What can you do if you
are concerned about avoiding GI bleeding?
If you are taking over-the-counter NSAIDs on a regular basis,
you will want to talk with your physician about the potential
for ulcers and other GI side effects. Most patients contact their
family doctor, or primary care physician, when they experience
GI problems. Many of these disorders, including Helicobacter pylori,
can be treated readily by your primary care doctor.
In the case of recurring or more serious problems, you may need
to see a gastroenterologist, a physician who specializes in disorders
and conditions of the gastrointestinal tract. After completing
the same training as all other physicians, gastroenterologists
study for an additional 2-3 years to train specifically in conditions
of the gastrointestinal tract.
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Conclusion
GI bleeding is an important, and potentially serious condition.
It can arise initially with few if any symptoms. Ulcers, i.e.
damage to the intestinal lining that may result in GI bleeding,
can be promoted by the use of non-steroidal anti-inflammatory
drugs, or NSAIDs. While some damage may occur with modest, short-term
doses, problems are more likely to arise in regular NSAID users,
and increase with the magnitude of use more frequent use and/or
higher dosages.
NSAIDs and aspirin have some very positive health benefits.
Like all medications, care must be taken with their use. For example,
they should not be taken with alcohol, as the combination can
increase the risk of GI bleeding. Patients who need to use NSAIDs
regularly should consult regularly with their physician to be
alert for any potential GI effects. Since problems may arise with
few, if any, symptoms, ongoing monitoring with your physician
is important. If problems do arise, and are recognized early,
there are a variety of ways to minimize or reverse any adverse
effects, either by using alternatives to NSAIDs, or through your
physician prescribing medications that can reduce any adverse
effects.
Over-the-Counter NSAIDs
| Actron ® |
ketoprofen |
1-6 pills/day (up to 75 mg/day) |
| Advil® |
ibuprofen |
1-6 pills/day (up to 1,200 mg/day) |
| Aleve® |
naproxen sodium |
1-3 pills/day* (up to 660 mg/day) |
| Bayer® |
aspirin |
1-12 pills/day (up to 4,000 mg/day) |
| Ecotrin® |
aspirin |
1-12 pills/day (up to 4,000 mg/day) |
| Excedrin® |
aspirin, acetaminophen, and caffeine
|
2-8 pills/day (up to 2,000 mg/day
aspirin, 2,000 mg/day acetaminophen, and 520 mg/day caffeine) |
| Motrin IB® |
ibuprofen |
1-6 pills/day (up to 1,200 mg/day) |
| Nuprin® |
ibuprofen |
1-6 pills/day (up to 1,200 mg/day) |
| Orudis KT® |
ketoprofen |
1-6 pills/day (up to 75 mg/day) |
* 2-pill limit for patients over age 65
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