In 1983, something happened in Australia that revolutionized the understanding of what causes peptic ulcers. A number of Australian doctors discovered modern medicine was wrong when it criticized those who claimed peptic ulcers in humans were caused by an infection.
By ingesting a pure culture of the curved bacillus Heliobacter pylori, Dr. Marshall and his associates became ill themselves with peptic ulcers. They all developed acute gastritis – inflammation of the stomach. They then allowed other doctors to look into their stomachs with a tube (endoscopy.) This did confirm stomach ulcers but the proverbial cherry on top was the actual isolation of Heliobacter from the stomach lining by doing a biopsy there (taking a piece of stomach tissue and then studying it further in the laboratory.)
Interestingly enough, they were not the first physicians to deliberately infect themselves to prove their point. The German physician Koch, founder of the organism that causes tuberculosis, was one of the first to ingest the organism that supposedly was the reason for the infection – tuberculosis bacillus – in order to make himself sick and thus prove a theory that today is widely known among scientists as “Koch’s Postulate.”
While few doctors today will deliberately infect themselves to make a point, we owe Dr. Marshall and his colleagues a great debt for changing the way we think about peptic ulcers. Prior to the discovery that peptic ulcers are often associated with an infection by Heliobacter pylori, the dictum was ‘no acid, no ulcer’ and God helped those who had the audacity to differ with the experts. Dr. Gabe Mirkin, radio host and a practitioner in Washington D.C., was threatened by other doctors when he treated ulcers with antibiotics prior to 1983. ‘Malpractice,’ they claimed. ‘He should be sued,’ others argued, and in fact they encouraged patients to sue Dr. Mirkin.
Today we know better but there are still a number of unanswered questions, especially in the paediatric population. Heliobacter pylori, also referred to as H. pylori, may be the most common
bacterial infection in humans, according to a famous paediatric textbook edited by Dr. Feigin from Baylor College of Medicine in Houston. Dr. Mark A Gilger wrote the chapter on H. pylori infections in children and its role in causing ulcers and other abdominal symptoms. While doing some training at Baylor recently, I had the privilege to ask Dr. Gilger more about this common bacterial infection – one which some doctors want to ignore completely while others argue treatment is best, especially when there may be a connection later in life to stomach cancer.
H. pylori appears to be acquired in childhood. It is spread from person-to-person and the mode of transmission is via fecies to the mouth and from mouth-to-mouth. Therefore, children under age five appear to be most important in the transmission of this organism – especially in situations where there is crowding and poor hygiene. In fact, Dr. Gilger and his group at the Texas Children’s Hospital were able to show two years ago that socio-economic status, not ethnic group, was the more important risk factor for acquisition of H. pylori infection during childhood.
It is estimated that at least one billion people in the world are infected with H. pylori. The incidence in developing countries is about ten times higher than that in developed countries. Socio-economic factors, hygiene and the number of household contacts seem to be relevant.
There are no specific symptoms for H. pylori infections in children and that leads to the heart of the confusion and debate. Pain in the upper and central part of the stomach, being awakened by pain at night, vomiting blood and recurrent vomiting are only suggestive, but in no way predictive of infection. Recurrent abdominal pain in children – one of the most common diagnosed problems in paediatric medicine – was once thought to be related to H. pylori by some; now it appears to be untrue. Few paediatricians will search for H. pylori in a child with only recurrent abdominal pain.
How do we search for H. pylori then? The gold standard is to look down the intestinal tract with a tube and to take a biopsy, thereby hopefully isolating the organism. However, this is rather invasive and at the moment the waiting time to see an expert in endoscopy is ridiculously long. Breath testing is another accurate, simple and non-invasive way to diagnose H. pylori, but it is extremely difficult to get a child in for this test at the average children’s hospital in Canada. Blood tests are very non-specific. The hope of the future lies in doing a commercial stool test, one that is not yet widely available, but according to Dr. Gilger may make the task of the average practitioner much easier in making a diagnosis.
The treatment is one of the most controversial debates currently among experts. Many agree if the symptoms are there and a biopsy backs up the presence of H. pylori, one should treat. Treatment consist of ‘triple therapy’ – usually two antibiotics and a proton pump inhibitor (acid reduction medication.)
A recent article in the New England Medical Journal raised the concern of long term outcomes when H. pylori is left untreated. Stomach ulcers top the list.
There is even some talk of vaccination against H. pylori, but this may be difficult due to the fact that the natural immune response fails to clear the organism in most cases.
The discovery of H. pylori illustrates how traditional thinking in medicine was dramatically reappraised and previous notions had to be reviewed – it even took a brave doctor to infect himself deliberately to make the point!
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