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Where have all the ulcers gone? Peptic ulcers are very common lesions in the stomach and the first portion of the small intestine called the duodenum. Why, then, do I – a gastroenterologist - rarely discover them in my patients? The answer is twofold.
First, my gastroenterology practice is now limited to
outpatients exclusively. It’s been years
since I’ve done hospital rounds. Back in
those days, one the most common reasons I was called in to consult on a
hospitalized patient was to evaluate internal bleeding. I saw hundreds of these patients and many of
them had ulcers responsible for the bleeding.
As an aside, most folks commonly believe that ulcers cause abdominal
pain, which they certainly can, although most bleeding ulcers cause no pain at
all. And, we do not believe that personal stress causes ulcers, although this myth
still survives. I rarely see bleeding ulcers in my outpatient
practice as these patients more likely proceed directly to the emergency room,
which is the proper venue for them. So,
I encounter peptic ulcers rather seldom
The second reason that accounts for the relative scarcity of
ulcers in my practice is because such a large fraction of gastro patients are
on medicines that heal ulcers. The most
common class of these medicines is proton pump inhibitors (PPIs), with
Prilosec, Nexium and Prevacid being three brand name examples. It is very typical that patients who are
referred to me with abdominal pain or nausea or an upset stomach are already on
PPI medicines prescribed by their primary care physicians. So if an ulcer was the culprit, the
medication will have likely healed it prior to the patient seeing me. As another aside, these medicines are wildly
overprescribed, an issue that might merit a future blog post.
Outpatient gastroenterology is a different job requiring a
different skill set compared with hospital gastroenterology. Truthfully, if I were asked now to see
patients in the hospital, I would be quite uncomfortable having been out of
this arena for several years. In
medicine, one needs repetition and an adequate volume of similar cases to
remain current and sharp. When one of my
patients is hospitalized with internal bleeding, I won’t be doing the
doctoring. I will be leaving it to the
professionals.
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