The H. Pylori Nobel - A Gut Clenching Path to Glory?

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2005 Nobel Prize in Medicine

Australian physiologists Robin Warren and Barry Marshall were awarded the 2005 Nobel Prize in medicine for their research in the early 1980's showing that peptic ulcers were primarily caused by bacteria not stress. The story has been told many times, since Marshall has always been vociferous about his discovery and the reluctance of the medical community to change their thinking on the disease, nevertheless its an interesting tale of scientific progress.

Marshall, a medical intern at the time, and Warren, a pathologist, began their collaboration in Perth, Australia in 1981 when they decided to look more closely at a bacteria that appeared to be involved with ulcers in the stomach linings of patients. They initially isolated the gram-negative bacteria from a few patients in 1982. Marshall announced that the bacteria caused the ulcers at an international microbiology meeting in Brussels in 1983. He cultured "Pyloric Campylobacter" in 1983 and 1984 and published his findings in the British medical journal Lancet in an 1984 article titled: "Unidentified Curved Bacillus on Gastric Epithelium in the Stomach of Patients with Gastritis and Peptic Ulceration." June 16:1(8390).

Marshall apparently became distraught that scientists continued to disregard his findings in favor of their own ideas about stress causing ulcers. When he failed to infect lab rats with the bacteria to show infection, he famously swilled down some bacterial broth himself to prove his case. He reported his resulting illness in an Australian medical journal in 1985. (Marshall BJ, Armstrong JA, McGechie DB, Glancy RJ. "Attempt to Fullfill Koch's Postulates For Pyloric Campylobacter" Med J. Aust. (142) (He fullfilled 3 of 4).

In 1989, the organism was reclassified as Helicobacter, distinct from Campylobacter, based on its functional and enzymatic properties. Despite apparent progress though, especially in Germany and Switzerland where doctors produced dozens of studies that replicated the initial results, the medical and drug communities took decades to accept the research and change treatment patterns.

The New York Times published an article in 1992 titled "New Study Backs Ulcer-Cure Theory" about research published at Baylor College. Framed more as a new theory rather than as research that had been around for a ten years, the New York Times at least acknowledged that the US research "lent more support to the belief that a common bacterium lies behind most ulcers."

Still, doctors were not convinced and according to the article, a doctor at the University of California in Los Angeles said that not only was he concerned about the side effects of antibiotics but "there were not sufficient data on the long-term effectiveness of the treatment". The NYT article also substantiated ideas that drug companies opposed the research by reporting an interview with Dr. James H. Lewis, vice president of medical development at Glaxo Pharmaceuticals, maker of Zantac, the leading ulcer drug, who said:

"[I]t is still too early to say that this is the best approach to treating ulcers"..."nobody really knows" whether bacteria cause ulcers, that were caused by numerous factors including diet, stress and genetics.

That was in 1992. In 1994 a medical panel of the National Institutes of Health (NIH) recommended that antibiotics be used for the treatment of gastic and duodenal ulcers, and gastritis. Yet four years later, physicians were still following their own instincts on the treatment of such ailments. Breuer et al reported in a study called "How Do Clinicians Practicing in the U.S. Manage Helicobacter Pylori-related Gastrointestinal Diseases? A Comparison of Primary Care and Specialist Physicians." (Am J Gastroenterol.) 1998; 93(4) that:

"Anti-H. pylori therapies judged ineffective were reported as the first choice regimen by 5% of gastroenterologists and 18% of primary care physicians. Gastroenterologists appear to implement the latest scientific developments in the field rapidly whereas PCPs [primary care physicians] manifest a delayed response, due to either insufficient knowledge or to other factors influencing their approach to treatment."

In April, 1996 the FDA approved the first antibiotic (clarithromycin) in combination with an antacid (Prilosec) to treat ulcers. According to the New York Times article Dr. Robert J. Temple, an FDA official, suggested that the reason so many doctors were refusing to treat ulcers with antibiotics could be attributed to:

"[a] reluctance of doctors to adopt new therapies, fierce conservatism of academic medicine, the sluggish nature of Government agencies and the vested financial interests of large drug companies."

The FDA also noted that the drug companies effectively convinced doctors of their treatments through advertising.

Now, decades after these scientists discovered it in stomachs, Helicobacter pylori has come up in the world. It has it's own journal and website (that is frankly most interesting for the amusing bacteria that swim beguilingly across the homepage). H. pylori are now also associated with stomach cancer, so early intervention is increasingly recognized as critical. Yet although it is widely accepted as the cause of 90% of ulcers there are still some people who remain unconvinced and prescribe incomplete or ineffective therapy. Hopefully, as the Australians get the prize they deserve, patients will get the treatment they deserve.

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