SECOND OPINION

EXPERIENCED general practitioners dealing with a child with worms or with headlice knows that they should treat the whole family, whether or not they have any symptoms. If they fail to do this, those left untreated may act as a source of reinfection. Now some doctors in Vienna are saying that this family treatment approach may sometimes be needed in the case of stomach ulcers.

Until 10 years ago, duodenal ulcers (small, painful ulcers in the exit tube from the stomach) were thought to be due to damage to the lining of the stomach from excess acid, often formed in response to emotional stress. In one of the biggest reversals in 20th-century medicine, this explanation has been replaced by an entirely different one. Duodenal ulcers have now been shown to be associated with infection with a bacterium, Helicobacter pylori, which lives in the stomach. The chronic infection causes inflammation of the stomach lining, weakening it so that acid may penetrate it, causing ulceration.

The infective explanation still leaves some questions unanswered: some patients with ulcers do not seem to have the bacterium, and many people who have it do not have ulcers. Nevertheless, for the first time patients with recurrent duodenal ulcers can be treated with a high chance of success; a combination of antibiotics and acid-suppressing drugs will heal the ulcer in almost all cases, and the cure is usually permanent.

A few patients do, however, relapse. Research at the University of Vienna (Gut 1995; 36: 831) looked into possible explanations. A small group of 18 patients who had duodenal ulcers that had recurred at least twice were examined using an endoscope (a viewing tube passed down the throat into the stomach) and the presence of an active ulcer was confirmed. Small samples of the stomach lining were removed for tests for the Helico-bacter pylori bacterium. The patients were given two antibiotics, ampicillin and metronidazole, and an acid-suppressing drug, ranitidine. After 12 days, the ulcers were healed. The patients were examined again after four, eight, 14, 27 and 43 months. Two were found to have become reinfected, and their spouses agreed to undergo the same tests. In both cases the symptomless spouse had stomach infection with the bacterium.

Helicobacter pylori exists in many different strains; each individual patient is likely to have a bacterium with some unique features. The striking finding in the Vienna investigation was that in each case the spouse of the patient who relapsed was found to be a symptomless carrier of the same strain of the bacterium as that which had caused the reinfection. Though the evidence is preliminary it does suggest that patients with duodenal ulcers who relapse after antibiotic treatment will commonly have been reinfected by their husbands or wives. (How this infection is spread within a family is unknown, but it is probably caused by faulty personal hygiene.)

The antibiotics needed to eliminate the bacterium are unpleasant and may have side effects, so no one is suggesting they should be given to the whole family of all ulcer patients. The Viennese doctors do, however, recommend treating both husband and wife if the first treatment is followed by a relapse.