Barry Marshall, MD. I bet you’ve never heard that name before. Well, he should be as renown as Jonas Salk, Michael DeBakey, Madame Curie, or Christian Barnard. Who is he? Dr. Marshall is an “obscure..Australian..internist” who made a discovery that changed the diagnosis and treatment of peptic ulcer disease, in both the stomach and duodenum (first part of the small intestine), forever. Peptic ulcer disease was a common affliction from which patients suffered for decades. I still remember my mother complaining frequently about her “ulcer,” and during my medical training, many patients were hospitalized for treatment of their “ulcer.”
Dr. Marshall set out to search for a specific cause of ulcer disease. He was skeptical of the knowledge of that time. With the help of a hospital pathologist, Marshall discovered a cork-screw-shaped bacteria, called Helicobacter pylori (H. pylori for short), was present in large quantities in the biopsies of ulcers and stomach cancers. He ultimately determined H. pylori to be the cause of peptic ulcer disease. Culturing the tissues enabled Dr. Marshall to identify this organism and study its characteristics and behavior.
His discovery led to the conclusion that peptic ulcers were actually an infectious disease—a bacterial infection—not a disorder of excess stomach acid. His research changed the entire focus of the diagnosis and treatment of peptic ulcers and proved they could be cured by taking readily available antibiotics.
Mainstream gastroenterologists (stomach and intestinal specialists) were dismissive of his research and held on to the idea ulcers were caused by excess stomach acid and stress. Animal studies failed to change doctor’s minds so to prove his point, Dr. Marshall ran an experiment on himself. He took H. pylori specimens from the gut of a sick patient, stirred it into a broth, and drank it. Within a few days he became ill—he developed gastritis (the precursor to an ulcer), vomited, developed bad breath, and felt exhausted. He, then, biopsied his own gut and found the tissues teeming with H.pylori bacteria proving, unequivocally, that this bacterium was the underlying cause of ulcers. From this discovery it naturally followed that combinations of antibiotics could cure ulcers and prevent stomach cancer. For his discovery, he and his colleagues received the 2005 Nobel Prize.
Prior to Dr. Marshall’s revelation, peptic ulcer disease was very common as I mentioned above. Stomach and duodenal ulcers were treated with antacids, liquid and other special diets, and nasogastric suction (sucking the acid out of the gut), because hydrochloric acid, and foods that stimulate production of it, were thought to be the cause. Patients often required hospitalization for treatment. Gastric surgical operations were devised to reduce gastric acid production and bypass the ulcerated area. H2 blockers (drugs which block hydrochloric acid production) were thought to be a cure, but actually only alleviated the symptoms.
Dr. Marshall’s proposal was to treat ulcers with combinations of antibiotics and hydrochloric acid inhibitors, instead. Patients presenting with gastric symptoms were gastroscoped, biopsied, tested for H. pylori, treated with antibiotic combinations, and cured. Over the years, the incidence of peptic ulcer disease has declined steadily to where now, it is very rare. Now, patients with ulcers have usually developed them from taking too much ibuprofen, naproxen, or other NSAID’s (non-steroidal anti-inflammatory drugs). I can’t recall seeing a true peptic ulcer patient the last 20 years.
Roughly sixty percent (60%) of the world’s adult population has Helicobacter pylori growing in their digestive tract. Most often it is acquired during childhood by putting dirty hands, or dirty objects, in your mouth. It’s spread from one person’s mouth to another. Children, or anyone, who doesn’t wash their hands, are prone to get it. Contaminated water or food are sources, too. People who live in developing countries, share housing with others who have H. pylori, live in overcrowded conditions, or don’t have access to clean water are likely to have H. pylori growing in the lining of their stomach.
Most patients with H. pylori are asymptomatic, but as the bacteria multiply in the stomach lining, gastritis develops. When gastritis worsens, H. pylori erode the surface lining and peptic ulcer formation begins. When an ulcer develops, symptoms of upper abdominal gnawing pain, especially when the stomach is empty, burping, bloating, nausea, heartburn, loss of appetite, and weight loss then appear. Only about 10% of people with H. pylori develop a peptic ulcer, however. Prior to Dr. Marshall’s discovery, peptic ulcers were very difficult to get rid of and were considered a chronic disease. The identification of H. pylori and the discovery of treatment regimens has changed all that.
The diagnosis of Helicobacter pylori infection can be made by several means. These are:
- History, physical exam, and high index of suspicion
- Serologic blood tests for antibodies against H. pylori.
- Stool sampling to check for H. pylori in your feces
- Urea breath test–ingest urea and if H. pylori is present, an enzyme is produced in the breath. A special instrument is used to detect this enzyme.
- Endoscopy—direct visualization of the stomach lining and biopsy of tissue to look for or culture H. pylori.
Treatment normally is accomplished by various combinations of antibiotics and acid suppressing drugs. “Triple therapy,” as it’s called, includes the antibiotics clarithromycin, amoxicillin, and metronidazole, and the proton-pump inhibitors, Prevacid, Nexium, Protonix, and AcipHex. Bismuth compounds are also effective. Drug companies have simplified dosing by packaging different drug combinations in bubble pack cards arranged in the order each component should be taken. Researchers at the University of Michigan Health System have recently recommended “first line bismuth quadruple therapy” instead of triple therapy concluding the addition of bismuth was essential for effective therapy.
The long term outlook after treatment of H. pylori is generally positive. Four or more weeks after treatment is completed, testing is repeated to check whether H. pylori has been eradicated.
Dr. Barry Marshall has been credited with ridding much of the world of two dread diseases. His belief in his research results and his perseverance, in spite of rejection and ridicule, testify to the certainty of his conclusions. He knew he was right and time has vindicated his work.
Dr. G’s Opinion: What a genius is Dr. Barry Marshall. He took a misunderstood, improperly treated chronic disease and completely changed everything about it resulting in its near eradication. In my mind, he belongs on the Mt. Rushmore of medical researchers.
References:
- discovermagazine.com/2010/mar/07
- healthline.com/health/Helicobacter-pylori
- mayoclinic.org/diseases-conditions/h-pylori
- CDC Fact Sheet for Health Care Providers: Helicobacter pylori
- ACG Clinical Guideline: “Treatment of Helicobacter pylori,” William Chey, MD, et al. The American Journal of Gastroenterology, Vol. 112, February 2017.
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