During my first years of medical practice, when I diagnosed peptic ulcer in a patient, the accepted culprits for stomach and duodenal ulcers were alcohol, smoking and a family history of ulcers and stress. Occasionally, ulcers were a side effect of medication.
Cimetidine, the first "acid suppressant" drug, under the brand name, had just come on the market and had completely changed the treatment of peptic ulcers. Until then, surgery was the only definitive intervention. A procedure called vagotomy, in which the nerves in the stomach that control acid release are cut, brought relief to patients, but it involved opening the abdomen and was not without side effects.
Several other acid-suppressant drugs quickly became available and treatment with these was soon the norm. While short-term cure was excellent, recurrence of ulcers remained a problem.
Doctors had firmly regarded the stomach as a sterile environment, so the hypothesis that peptic ulcers could be caused by bacterial infection was always going to be met with scepticism. It fell to two physicians based in Perth, Western Australia, Robin Warner and Barry Marshall, to face down the disbelief and even hostility that greeted their discovery of the organism Helicobacter pylori in ulcer patients.
Despite reporting the presence of Hpylori in all 13 patients with duodenal ulcers and 24 out of 28 people with proven gastric ulcers in 1983, the wider medical community was slow to embrace the concept. It was not until Marshall conducted an energetic media campaign that the message finally got through to patients.
Current medical guidelines for the treatment of both types of peptic ulcer firmly advocate the eradication of H pylori. The "Maastricht 2-2000 Consensus Report", which followed a meeting last September of European experts, outlined first- and second-line treatment regimes for the condition.
A minimum seven-day treatment with two antibiotics, as well as acid suppression with a proton pump inhibitor - the most powerful successor to cimetidine - is the recommended first-line therapy for all patients with ulcers who are also shown to have Hpylori.
But there are lots of people with symptoms similar to peptic-ulcer disease who do not have ulcers. Dyspepsia is a condition caused by an abnormality in the muscles of the gut that can lead to symptoms such as nausea, vomiting, heartburn and upper abdominal discomfort.
There is some debate about whether to treat H pylori in patients with dyspepsia. The Maastricht report advises treatment, although it acknowledges the evidence for doing so is not as strong as that for treating the bacterium in ulcer patients.
The issue of cost-effectiveness is an important one. Earlier this year, a paper in the British Medical Journal concluded that the cost of endoscopy - the use of a fibre-optic telescope to look into a patient's stomach - combined with testing for the H pylori bug, in an effort to identify those in need of treatment, was not justified. The quality of life in these patients was no better than that of those receiving acid-suppression treatment alone.
On the other hand, a study in the Lancet has just shown that eradication of H pylori reduces the relapse rate in people with acid reflux into the oesophagus, or gullet.
The treatment of ulcers, dyspepsia, acid reflux and other upper-gastrointestinal problems has come a long way in 20 years. I suspect there are more chapters in this saga yet to be written.
I was grateful for the response to my column of June 18th, which sought alternatives to the word accident to describe unintentional injury. Here are just two of the suggestions: "preventure", an amalgam of preventable, or capable of being prevented or hindered, and venture, or an undertaking of chance or danger; "actloss" or its plural, "actless", which retains the "ac" of accident, suggesting a loss of lessening of acxtion on the part of the injured, while impyling it's occurrence as a result of some action not being taken by the injured or others.
You can e-mail Dr Muiris Houston, Medical Correspondent, at mhouston@irish-times.ie or leave a message on 01-6707711, ext 8511. He regrets he cannot reply to individual medical problems