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The logic of dyspeptic ulcer ML Kothari, Jyoti M KothariDepartment of Anatomy, Seth G.S.Medical College, Parel, Bombay 400012, India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 614415
The cause and cure of a peptic ulcer are where medicine is least likely to look for-in medicine's irreverence for the vitally evolved acid, stomach and the pylorus, and in man's indifference towards their irrepressible urges, and needs. The so-called peptic ulcer is the dispensable tip of a dyspeptic iceberg, the dyspepsia, with or without duodenitis, giving rise to a symptom-complex that bears little correlation with what the physician can observe, investigate or measure. Medicine's unabashed ignorance. of dyspepsial duodenitis/ulcer allows one to fall back on the patient for setting himself right. The best thing about the dyspeptic complex is its readiness to disappear. Dyspepsia, duodenitis, ulcer therefore represent a state of ill-being, and not of pathology, visceral or psychic.
A recent article [32] in the BMJ drove home the point that modern medicine': strongpoint is its unmitigated ignorance about all the major problems it contend: to be researching upon and solving. Such holy ignorance allows medical men to do all that they fancy, for a la Albert Camus no one is wrong when no one is right Peptic ulcer has been one such problem, the illogic of which was presented earlier. [31] We now present incontrovertible scientific data to emphasize that what has been plaguing human stomachs and duodena is not peptic ulcer, but a symptom-complex that can only be labelled a dyspepsia, [10],[24],[39],[51] a culmination of which can be an ulcer. Also underscored is the fact that an appreciation of the marvels of human GI tract can empower medical men to rely more on their patient's gut-feelings and the resilience of their gut to set their dyspeptic problems right. Since the field to be covered is vast, it is imperative to present only the points on the various aspects. Phylogeny 1. Stomach, pylorus, pepsin, and HCL -targets of an ulcer-therapist-are the most consistent vertebrate features from fishes to ferrets, mouse to man. [16],[46] Even the J-shape of the gastrum is a common feature "in forms as far apart phylogenetically as sharks and man." [46] 2. Stomach, through its pylorus is the guardian-angel of the sanctum sanctorum formed by the small intestine beyond, taking care to see that the latter gets just the right thyme, right in every conceivable way. [7],[12],[21],[28],[46] 3. The fact that the so-called peptic ulcer is only a man's privilege acquits the alleged culprits, on strength of the experimentalistic assumption that man and mouse are no different. 4. It is therefore likely that man's ulcer is a manifestation of his avoidable quarrel with his integral phylogeny, the quarrel springing from his being "civilized" [17] and thus hurried, harried, and a little too rational to be natural. JBS Haldane has remarked somewhere that a man is too careful about what he puts in his car, and not one-tenth as careful about what he puts into himself, and how. 5. Man with his exaggerated orificial pleasures is an animal that is ever ready to transgress the "Pray, do not eat/drink now" call from within. The socialization of the orificial instinct in man has robbed him of the life-giving/bliss-giving role of food. With the intrinsic rhythm and urges connived at, he has made dyspepsia into a virtue that supports an entire industry manufacturing digestants. Anatomy The enormous vascularity, innervation -"a unique vagal dowry" [13] -musculature and the presence of the only definative [46] sphincter of the gut viz., pylorus, bespeak Nature's rule that all these are there as they are needed. So is true of the chief and the parietal cell mass. Stomach, pylorus and duodenum behave as unit [12],[28] -the gastroduodenal pump. "The exact mechanism of control of the transfer of stomach contents through the pylorus into the duodenum is still not fully clarified." [19] Physiology 1. "0! it is excellent/To have a giant's strength, but it is tyrannous/To use it like a giant." A la Shakespeare, stomach foes not use its powerful musculature for bushing things into the delicate duodeium. "By far the greater part of the work s utilized in mechanical digestion, serving .o macerate the food particles and break :hem up into small fragments." [12] Stomach, as it were, gizzards the food (and wishes that man's teeth could ease its task). 2. Pyloric antrum, canal, and sphincter are ultrasensitive mechanisms that know food from a fly, gruel from gravel, high pH from low pH, osmolar variations, chemical composition and so on. A primitive response is to shut down the sphincter whenever it is felt that the contents cannot be passed on into the small intestine. May be, it is this that prevents too rapid a loading of the circulation by fat. 3. Notwithstanding the above, patency of the pylorus [7],[12],[21],[50] is a rule, allowing whatever acid is produced in the stomach to be passed on into and quickly neutralized by the first part of duodeium. [7],[15],[19],[21] "Recent investigations of the disposal of acid by the human duodenum indicate that there is a marked capacity of the duodenal mucosa to dispose off acid by the combined mechanisms of neutralization, dilution, and insorption directly through the duodenal mucosa." [49] 4. Modern medicine knows everything about HC1 secretion except why it is there --like the sentry in Quiller-Couch's Zarina's Violet. HCl secretion-the hunchback of Gastre Dame-obliges the body with a quick input, molecule for molecule, of bicarbonate into the blood which then is secreted by the pancreatico-biliary-intestinal system. [33] HCl secretion gives a net gain of alkali when (a) amphoteric foods (protein) neutralize the gastric HCl, and (b) gastric HCl is thrown out by vomiting. HC1 secretion is a good indicator of the state of acidosis/alkalosis: In the former [27] as may be induced by HC1 infusion, the rate of HCl secretion goes up; in the latter, as may be induced by NaHCO 3 ; infusion, the rate goes down. [33] The increased secretion of HCI in states of burns, stress, pulmonary insufficiency etc. is 4. The pyloric-duodenal interrelationship is such that acid in that area acts as an antacid by inhibiting gastric secretion of HCL .[4] (Here lies one cause of the failure of medicinal antacids). Even the rate of gastric emptying is controlled by the duodenal receptors, which are supposed to be working less effectively in duodenal ulcer cases, as compared to normal people. [48] 5. The GI tract is "the principal endocrine organ of the body" [43] there being more endocrine cells in the stomach, in number and types, than in the pituitary. The increasingly recognized gut hormones control everything that the gut does-peristalsis, sphincteric action, secretion, digestion, absorption, and more. Some of the hormones find way into the general circulation to possibly produce such symptoms as migraine and headache associated with GI-upsets and stress. Many a psychosomatic problem associated with a visceral (peptic) ulcer is a function of hormonemia. The hormones probably account for Palmer's observation that "All visceral lesions cause the same symptoms." [41] backed by the fact that "The trouble with the gastrointestinal tract is that it is so repetitious, both anatomically and physiologically." [41] Etiology 1. In incriminating [26],[27],[40],[44] acid-pepsin for ulceration, medicine tells only hall the truth (!). "A biopsy taken through the gastroscope heals as quickly when the acidity is high and continuous as in cases of hypochlorhydria." [5] Wide surgical incisions and mucosectomized gastric areas heal rapidly. [17] The other half of the truth; then, that medicine fails to tell is the realization that peptic ulcers have "a remarkable tendency to heal," [35] in the teeth of the very acid-pepsin that allegedly caused them. May be, acid-pepsin helps healing of peptic ulcers. 2. Virchow raised the problem: If acid-pepsin are responsible, why not the 360 o and the length and breadth of stomach and duodenum? Why should an ulcer be localized [5],[16],[38] to a single small, punched out area? Why is acute perforation of an ulcer not seen in more than 2 per cent of patients [26] ? And why does the perforation-hole itself remain so small despite the alleged peptic onslaught? And having occurred, why does even a perforated ulcer heal, [26] a la Hermon Taylor, without a thing being done to the culprits? Dear Aunt Acid, [2] doesn't after all seem to be as unkind as portrayed ulcerologically. 3. Granting that acid-pepsin are etiologic, de-etiologizing the patient medically or surgically makes the matter worse. The illogic peptic dogma "no acid, no ulcer" perpetuates "yes acid, yes ulcer," a notion fed by such elegant ads-"In few minutes his antacid will stop working. What Then?" [1] What use is an antacid, if it stops working in a few minutes? Normality of Distribution 1. Like in all other fields of modern medicine, ulcerologists know (and treat) hyperchlorhydria/hypochlorhydria without knowing/defining the missing middle -euchlorhydria. 2. Average acid output is in no way normal acid output. "The range and not the average is the reality." [6] 3. HCl secretion is a biologic trait that is, like most other traits, normally distributed, [11] in its intensity. Cases of ulcer/ hyperacidity fall equally on either side of the midpoint of the bell-shaped curve. "It is clear that among men and women with duodenal ulcer the lower levels of gastric secretion are equally common." [11] 4. The same individual has "hyperacidity" at 1.0 p.m. say, and no acidity 15 minutes after, on its own. What truly he has had, and may have again, is acidity -the consciousness of having acid within. Once and forever, the term hyperacidity [40] can be logically replaced by the level-non-committal acidity. 5. The normality of distribution extends to the age incidence of the onset of gastroduodenal ulceration, as well the age incidence of ulcers found at autopsy. "The peak of age incidence of gastroduodenal ulcer is the same as the period of arterio-sclerosis and other serious diseases of old age." [54] Just as the tails of the Gaussian curve stretch to infinity, [45] "new" cases of ulcer occur in the youngest to the oldest. [54] As far as HCl secretion and its alleged by-product ulcer go, we are dealing with a biologic phenomenon about which, like cancer or coronary, no one seems to know anything. 6. Point 5 above could drive home the point that not heredity but polygenic inheritance [45] mediates the so-called susceptibility to acidity and ulceration. The other side of the coin is that these are the people who need to be a bit extra careful about their gastroduodenal physiology. Pathology 1. With all the symptoms, the so-called ulcer is so often absent. [10],[39],[51] 2. The much-prized ulcer has turned out to be the dispensable tip of the dyspeptic iceberg; it is a late event[10],[39],[51] in the history of an individual's dyspepsia, a final evidence that he and his physician have failed the patient's complexer-than-a-computer gastroduodenal region. 3. "The most important lesson has been that a great deal of organic gastrointestinal diseases-ulcers, tumours, gall stones, etc.-never cause symptoms or cause symptoms only very late in the course of things. The most seasoned clinician must continuously wonder how organic lesions of the same location, size and nature can produce symptoms of such differing intensities and apparent importance in different patients." [41] The Boy-dian [5] stock-title The Relation of Symptoms of Lesions is of little help in gastroduodenology. 4. The most natural tendency of an ulcer is to burn itself out. John Fry, [18] M.D., F.R.C.S., from a wide experience with peptic ulcer found in his general practice, gave a profile of the disease to conclude that, apart from the natural remissions uninfluenced by medical treatment, there was "a very definite likelihood, in both duodenal and gastric ulcers, for the condition ultimately to 'burn itself out' naturally and spontaneously." This natural burning out cures the ulcers in doctors without any operation, [31] but the medicos have no such patience [44] for their patients' ulcers. Such authoritarian-ism was long enunciated by Mayo. [37] "Unfortunately, only a small number of patients with peptic ulcer are financially able to make a pet of an ulcer"-a teaching that is yet to burn itself out in surgical training. Clinical Features 1. Ulcerology has not escaped medicine's text-bookish [26],[27],[35],[44] attempts at typicalizing what is, ulcer or no ulcer, so atypical [41],[51] at an individual level. 2. The atypicality arises from the ability of the disturbed gut-dyspepsia-to promote symptoms, visceral/psychic/ somatic, ranging from heaviness to harriedness, distension to depression, vomiting to vanity, nausea to nervousness, and flatulence to flushes. 3. Dyspepsia is the most compelling feature; the overall symptomatology is varied, each symptom fleeting in character from hour to hour, with very little correlatable pathophysiology to account for the presence or the absence of a symptom or a sign. 4. Dyspepsia defies definition. In more general terms, it is the absence of instinctive friendliness with food and drinks the welcome to food is reluctant, the afterfood feeling is one of unease. There is an inability, a la Harris, [22] of the person and his GI tract to declare, "I'm OK, You're OK." 5. Much against Hurstian concept of diatheses, [40] ulcer/dyspepsia is every human's privilege: "As far as we know, the disease is available to all, at any moment. This means that it must be due to a physiologic deficiency or excess-some abnormal activity that is quickly available among the physiologic functions of everyone, to throw some built-in protective device out of balance." [41] More about it anon, but it could be suggested right here that the protection lies in pyloric patency that allows no damming back of acid. Should it occur, and should the stomach with its might force the acidic contents as a jet directed towards the duodenum, duodenitis/dyspepsia/ulcer could occur. Restoration of pyloric patency cuts down the onslaught permitting relief/ healing to occur. 6. The symptomatogenesis at the gastropyloroduodenal level is more functional than structural. The finer individual nuances of muscle tension, hormonal release, acid/alkali secretion, receptorfunction, etc., create a situation that can be hellish for the patient without the clinician realizing why. The one consistent thing that produces pain is the stretching of gut. [41] It is a part of the common, nonmedical teaching to keep one's stomach filled much below its brim. The unease of an overfilled stomach could be ascribed (a) to the tightly shut pylorus on one hand, and (b) the stomach musculature kneading and chyming its contents, against high intraluminal tension, on the other. Hormoneria may also be responsible. 7. Increasing recognition is now being accorded to the fact that dyspepsia [16],[24],[39],[51] is far more common than duodenitis, which probably is commoner than and precedes the clinically dispensable manifestation of an ulcer. The most important wage of dyspepsia is not an ulcer, which occurs late in a dyspeptic's life, but the gnawing absence of joie de vivre. 8. "Dyspepsy and cheerfulnes do not go together." [25] A dyspeptic is incapable of meeting the world in bouyant spirits, declaring, a la Kalidas: Look to this day, this wonderful day. Dyspeptic gut, through a primitive mechanism that may be important for our survival in the biologic past, grips the mind viciously through the vagal dowry, creating an odd affective mixture of irritation, depression, fear, listlessness, and above all, a sense of ill-being. While our intellect functions in the newest and the most highly developed part of the brain, our emotions continue to be dominated by a relatively crude and primitive cerebral system . [36] "This situation provides a clue to understand the difference between what we `feel' and what we `know'." [36] A dyspeptic, with or without an ulcer, knows he shouldn't be irritated, but he can't help his feelings . He is in a dyspeptic vice. Investigations 1. With the irrelevance" of acid estimation, the right place for the nasogastric tube and the suction-pump is in the museum. 2. Histamine-stimulated MAO [30] is highly academic, but hardly useful. 3. The "time-honoured method" of radiologic investigations is blighted by as many as 30 per cent false-negatives and 37 per cent false-positives. [47] To wit, listen to a physician-patient: "The pain was ripping me apart while they were working on me in the X-ray department, but the pictures failed to show the crater. So I was dicharged cured." [20] 4. Endoscopy [39],[51] can help only if it can , detect a lesion, which may still be irrelevant. 5. Investigations on how effective the surgeon's knife has been in destroying [23],[31] the patient's physiology helps neither the patient nor the physician, as far as the patient's well-being goes. Therapy 1. The glorious failures of therapy are iterated here to stress that a patient must treat himself. 2. Drugs, a la Sir Colenso Ridgeon in Shaw's The Doctor's Dilemma, are a dyspeptizing delusion. How could the consistently unpalatable-nauseating-antacids do any good to the gastroduodenum that is in no mood ever to welcome the insipid pulp of mentholated AI(OH) 3 ? 3. Unpalatability is a peremptory inner judgment on the inacceptability of a thing. So for any diet fad-Sippy's or Bippy's. The evanescent relief afforded by antacids springs from the temporary elevation of pH that eases the task of pyloroduodenal region, possible reduction of muscle spasm, and thus, of pain. 4. Gastric irradiation, [42] supercooling etc., deserve to be mentioned only to be condemned for the barbarity. 5. Surgery [14] cures, by complicating [3],[23],[26],[31],[44] the problem. 6. An ulcer often heals despite the patient and his physician. 7. "The warmth of clinical art rather than cold science is still required to manage the patient with a peptic ulcer." [18] Epistemology 1. "But nature gives her observer cause only for admiration at the simplicity with which she works, and for astonishment at the proneness of the human wit to explain any phenomenon which appears remarkable by means of infinitely greater and more incomprehensible wonders." [8] 2. Simplicity of approach, even when compelled by logic and/or biorealism, is not a particular weakness of modern medicine, thriving as it does on the Bombay-to-Calcutta-via-Rome approach-a gimmickry that makes the medical men look very learned, the patient's problems insolubly complex, and the remedial measures expensive and intricate. [9] As a starting point, a 6-worded aphorism can help ulcerology a great deal: If ulcers could heal, ulcers can. 3. As a historian of science once put it., "Isn't it amazing how many things there are that aren't so?" Quoting thus, Alan Watts [53] cajoles us further: "The world becomes intelligible through amazing reversals of common sense, and, as Whitehead saw, the notions most worth questioning are just those which are most taken for granted. Science, too, is the game of hide-and-seek, for the scientist most skilful in basic research has the peculiar flair for realizing that the best hiding places are those where no one would think of looking: they are usually right out in the open. How often an important discovery floors us with its simplicity, with the feeling of, "Well, why didn't I see that; it was right under my nose!" 4. The solution to the dyspeptic/ulcerous problem is truly under our nose-in the area it occurs, /afflicts. Some of the needed ingredients of the solution comprise (a) teleologism that compels us to realize that HCl, pylorus, and vagal dowry are no mistakes of our maker, (b) corrected causalism that clears acid-pepsin of any guilt, (c) humility that what is not thought of/done upon doctors' GI tract will not be exercised [31] on the patients, and (d) the Hippocratic invocation of Primum non nocere-the treatment of ulcer should not exceed, in mental, physical, visceral and material cost the problems it allegedly gives rise to. 5. The 9 times greater projection of the gastroduodenum on the human brain rather than the other way round should drive home the point that the CNS is not the cause [26],[27],[44] of dyspepsia; ulcer, but its helpable victim. 6. Medicine had better diagnosed the pillars of unwisdom [29] upon which its impressive edifice rests. A principal monumental superstition, a la Koestler, [29] is medicine's measurementism parameterism-"that the only scientific method worth that name is quantitative measurement; and, consequently, that complex phenomena must be reduced to simple elements accessible to such treatment, without undue worry whether the specific characteristics of a complex phenomenon, for instance man, may be lost in the process." The solution to the problems under discussion does not lie in our measuring MAO or urinary enterogastrone, but in knowing the ease, disease of a patient. This would entail a greater reliance on what a patient feels, and not on what a gadget shows, and a greater respect for the "intangibles and unapproachables" [29] of a patient's symptomatology. 7. The philosophism inherent in such an approach is ulcer-realistically defended by Palmer: [41] "The time has come in ulcer therapy for more philosophy and less technology."
Phylogenic 1. The gastric production of HCl as "the universal acidifying agent" [16] is a design in acid-base-regulation. [33] 2. In absence of food, the natural pyloric patency permits the acid secreted to be totally and immediately neutralized in the duodenum. For a while that the pylorus closes, the body gains in alkali because of the HCl secreted and retained in the stomach. 3. Nature's master-stroke, in fortifying body's alkali reserves through HCI secretion, lies in making stomach the rendezvous for the powerful HCI and the ingested, usually-alkaline life, called food. The alkali-gain is so much as to spill over the rigorously-conserving kidney, seen as the post-prandial alkaline tide in the urine. Man has a penchant for working against this scheme by consuming fermented/denaturalized foods that are poor in their alkali content. 4. The man-made alkalies-the so-called antacids-are no substitutes for the alkaline foods for the simple reason that the highly sensible pyloroduodenal region has evolved in the company of amphoteric foods, and not through the courtesy of Aluminium Hydroxide gel. 5. Since acid-base-regulation affects every cell in the body, gastric HCl secretion is a target of all the systems of the body including the endocrines. [30] Physiologic 1. The GI tract is a neuromusculohormonal ensemble whose spokesman is the gastroduodenal region whose message, I'm OK, is conveyed by a code called appetite-Life's lust for life. 2. Equally, this inner voice is as unreserved and irrepressible in declaring I'm NOT OK by coding for the lack of appetite, a feeling that is beyond words but always accompanied by a sense of ill-being. 3. The enormous vagal dowry, apart from performing the medically-despised release of gastrin to promote acid secretion, is there to mediate visceropsychic bliss, or the absence thereof. Such bliss is every vertebrate's right. 4. The stomach could be looked upon as the Import House of a city called an individual. The sensitive but obstinate pylorus is the arch-angel that takes care of not only the gut beyond, but such processes as fat/carbohydrate metabolism, as also, say, the distantly placed bone marrow. The uniformly cold response that stomach accords to most wonder-drugs is, may be, one way of pylorus and Nature telling medicine that, any day, the error of omission is preferable to that of commission. 5. Although the stomach can accommodate to a oral orgy by distending to the point of resting its greater curvature on the urinary bladder, it best functions in the optimally-stretched state. The optimality is individual-specific-a state that should not encroach on the consciousness. Overeating is now recognized as a definitive form of Selyean stress. 6. Fasting-an empty stomach-is the most physiologic way of resting the gut and curing dyspepsia/ulcer. "At the same time I decided to break another rule of orthodox medicine, the one that says that the stomach of an ulcer patient should never be empty, I had an appetite of a horse, so I decided to suppress it. In other words I was going to do the very opposite to what I had been doing until then." [20] This confession by a medical man [20] who cured himself of a bad ulcer could be paraphrased for public use: Always have the appetite of a horse, but never hog. Let that sense of ease and comfort that accompanies unsatiated appetite prevail. Eupeptic 1. Teeth, time and temperateness are indispensable tools for being kind to one's stomach. 2. Despite hitherto denial by modern medicine, eupepsia is a physiologic state, held as the starting-point of all health, by non-allopathic medical sciences. 3. In matters of oral import, the best guide is WIDD: When In Doubt, Don't. 4. Like the Pascalian heart, the stomach has its own secret reasons for likes and dislikes about food. When in difficulty, the wisdom of the stomach is superior to the rationalization by the intellect. 5. As socializing elements, food and . ' or drinks are eupeptic only to the degree that they do not overstrain the enterostatic (alimentostatic) mechanisms. Dyspeptic 1. Man is not born dyspeptic; he trains himself to be so. Children rarely show off the dyspeptic demeanor. 2. Dyspepsia is dis-ease, not disease; disappearance is its cardinal quality. 3. Dyspepsia is a long-protracted, recurrent warning that eventually paves way for gastroduodenitis which long-continued can end up in an ulcer. 4. The symptomatology of dyspepsia is a manifestation of a number of interacting influences-muscle spasm, mucosal irritation, hormonal overaction and so on. The symptomatology is incapable of being analyzed by modern medicine. 5. Dyspepsia is an agent that makes hell out of an inherent heaven. Milton (and Lord Krishna in Gita) could be paraphrased to state that not so much the mind, but it is one's gut that makes heaven or hell. Ulcer: Causative/Curative 1. An ulcer is a medal honouring long, dyspeptic service. 2. Yet, each ulcer, like Mr. Dolittle in My Faid Lady [34] , is willing, wanting, waiting to heal. 3. It is neither acid-pepsin (for DU) nor bile (for GU) that causes ulceration, but the way they are delivered. 4. The gastric-might, the pyloric-tight and the duodenal target account for DU. Whenever the situation is such as forces the stomach to push against pyloric resistance, acid-pepsin is delivered as a jet on to a point in the duodenum. It is possible that gastric distension alters the direction of pyloric canal so that the jet, instead of jumping into the duodenal lumen, hits on the duodenal wall. 5. The ability of fasting to restore eupepsia may be exploited towards ulcerhealing-a thing practised successfully in the past. [31] 6. The complications of an ulcer are mere consequences of the continuation of factors that produce an ulcer. The Greek invocation-Gnothi seauton -Know thyself could be practically paraphrased as a Gnothi gastroduodenumKnow (thy) stomach and duodenum. The acceptance of ignorance is the beginning of one's knowledge. Medicine's such acceptance, vis-a-vis dyspepsia/ulcer can mean ushering in an era of the realization that some of these problems are so highly individualistic that they are best managed by the patient himself. The patient may fail, but the physician will always. Such a concept hits directly at physicianly omnipotence. It is time we had hit more widely.
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