Peptic ulcer

Introduction:

Peptic ulcers are open sores or erosions in the lining of either the duodenum (duodenal ulcers) or the stomach (gastric ulcers). The duodenum is the first part of the small intestine. About 10% of all Americans get ulcers, and they can recur. Contrary to popular belief, ulcers are not caused by spicy food or stress but instead are most commonly due to either an infection or long-term use of certain medications.

Signs and Symptoms:

• Abdominal pain with a burning or gnawing sensation
• Pain 2 - 3 hours after eating
• Pain is often aggravated by an empty stomach; for example, nighttime pain is common
• Pain may be relieved by antacids or milk
• Heartburn
• Indigestion (dyspepsia)
• Belching
• Nausea
• Vomiting
• Poor appetite
• Weight loss

If you experience any of the following symptoms, this is considered an emergency and you should call your doctor immediately:

• Sudden increase in the abdominal pain or sharpness in the quality of the pain
• Vomiting blood or material that looks like coffee grounds
• Blood in your stool or black, tarry stools

Causes:

When the stomach's natural protections from the damaging effects of digestive juices (including acid and pepsin, an enzyme that helps breakdown protein) stop working or the acid production is too overwhelming for these protective defenses to work properly, you can get an ulcer. There are a few different ways this happens.

• Helicobacter pylori (H. pylori) -- H. Pylori, a bacterial organism, is responsible for most ulcers. This organism weakens the protective coating of the stomach and duodenum and allows the damaging digestive juices to irritate the sensitive lining below. Interestingly, as many as 20% of Americans over age 40 have this organism living in their digestive tract, but not all of these people develop ulcers -- most do not.

• Non-steroidal anti-inflammatory drugs (NSAIDs) -- ongoing use of this class of medications is the second most common cause of ulcers. These drugs (which include aspirin, ibuprofen, naproxen, diclofenac, tolmetin, piroxicam, fenoprofen, indomethacin, oxaprozin, ketoprofen, sulindac, nabumetone, etodolac, and salsalate) are acidic. They block prostaglandins, substances in the stomach that help maintain blood flow and protect the area from injury. Some of the specific drugs listed are more likely to produce ulcers than others. Therefore, if you must use long-term pain medications, talk to your doctor about which ones are safest.

• Zollinger-Ellison syndrome -- people with this uncommon condition have tumors in the pancreas and duodenum that produce gastrin, a hormone that stimulates gastric acid production. Diarrhea may precede ulcer formation.

• Other causes of ulcers are conditions that can result in direct damage to the wall of the stomach or duodenum, such as heavy use of alcohol, radiation therapy, burns, and physical injury.

Risk Factors:

• Genetic factors may predispose you to developing an ulcer
• Increasing age
• Chronic pain, from any cause such as arthritis, fibromyalgia, repetitive stress injuries (like carpal tunnel syndrome), or persistent back pain, leading to ongoing use of aspirin or NSAIDs
• Alcohol abuse
• Diabetes may increase your risk of having H. pylori
• Living in crowded, unsanitary conditions increases the risk of H. pylori infection
• Immune abnormalities may, in theory, make it more likely for H. pylori or other factors to cause damage to the lining of the stomach or duodenum
• Lifestyle factors, including chronic stress, coffee drinking (even decaf), and smoking, may make you more susceptible to damage from NSAIDs or H. pylori if you are a carrier of this organism. Again, however, these factors do not cause an ulcer on their own.

Diagnosis:

First, your doctor will take a detailed history of your symptoms and risk factors, including how long indigestion and pain have been present, how strong these sensations are, if you have lost weight recently, what medications (over the counter and prescription) you have been taking, your smoking and drinking habits, and if anyone in your family has had ulcers.

As part of the physical exam, your doctor will do a thorough check of your abdomen and chest as well as a rectal exam to look for, in part, any sign of bleeding. A blood test will be drawn to check to see if you are anemic. These types of tests are done to make sure that you have not had any bleeding about which you have been unaware (called occult bleeding).

If there are no signs of bleeding and your symptoms are mild and not serious or life-threatening, your doctor may have you try medications that suppress the amount of acid in your stomach. This is done to see if you feel better, before pursuing expensive and uncomfortable testing. If your symptoms persist or get worse despite the medication, further testing is necessary.

One of two tests will be performed to try to identify an ulcer:

• Upper gastrointestinal (GI) series
• Endoscopy

For an upper GI series, you will drink a chalky liquid called barium and then undergo a series of x-rays to check for an ulcer.

Endoscopy, amore accurate test, involves the careful insertion of a thin tube with a tiny camera at the end (called an endoscope) into your mouth, down your throat, through the esophagus to the stomach and duodenum. This allows both direct visualization of these organs for an ulcer or other problems and sampling of tissue from the walls (called biopsies) of the stomach and small intestines to test for H. pylori. You are lightly sedated for this procedure.

Other tests that may be performed to look for H. pylori include a blood test checking for antibodies to this organism, a breath test after drinking a substance called urea, and a stool test looking for the organism in the feces. The breath test, which is the least invasive, is proving to be at least 95% accurate.

Prevention:

Preventing NSAID-related ulcers involves finding different medications or alternative approaches to relieve your pain. Talk to your doctor about your options. If you have to take NSAIDs for a long time, your doctor may consider prescribing another medication to try to prevent the development of ulcers. This medicine may include an H2 blocker (such as cimetidine, famotidine, nizatidine, or ranitidine) or a proton pump inhibitor (such as omeprazole, lansoprazole, or rabeprazole).

You can also make lifestyle changes that make you less prone to get an ulcer from either NSAIDs or H. pylori.

Treatment:

The main goals for treating a peptic ulcer include eliminating the underlying cause (particularly H. pylori infection or use of NSAIDs), preventing further damage and complications, and reducing the risk of recurrence. Medication is almost always needed to alleviate symptoms and must be used to eradicate H. pylori. Surgery is required for certain serious or life-threatening complications of peptic ulcers and may be considered if medications are not working. Even with medications, many lifestyle factors, including making changes in your diet, are important. Plus, certain herbs, acupuncture, or homeopathy may prove to be a useful addition to usual medical care, especially to help relieve symptoms or prevent recurrence.

Lifestyle

Doctors used to recommend eating bland foods with milk and only small amounts of food with each meal. We now know that these eating habits are not necessary for the treatment of ulcers. Dietary and other lifestyle measures that should help, however, include:

• Eat a diet rich in fiber, especially from fruits and vegetables. This may reduce your risk of developing an ulcer in the first place and may speed your recovery if you already have one. The vitamin A may be an added benefit from these foods.
• Foods containing flavonoids, like apples, celery, cranberries (including cranberry juice), onions, garlic, and tea may inhibit the growth of H. pylori.
• Quit smoking.
• Receive treatment for alcohol abuse; your doctor can help get you appropriate care.
• Cut down on coffee, including decaffeinated coffee, as well as carbonated beverages all of which can increase stomach acid.
• Reduce stress with regular use of relaxation techniques, such as yoga, tai chi, qi gong, or meditation. These practices may also help lessen pain and reduce your need for the damaging NSAIDs discussed. To incorporate any one of these techniques into your daily activities, consider taking a class; some early information suggests that, if you have an ulcer, a formal stress reducing program may be more beneficial than listening to tapes on your own at home.

Medications

• If you have H. pylori, you will probably be prescribed three different medications. "Triple therapy" (including a proton pump inhibitor, such as omeprazole or Prilosec, to reduce acid production and two antibiotics to get rid of the organism) is commonly used to treat H. pylori -related ulcers. A medicine called bismuth salicylate may be recommended in place of one antibiotic. This drug, available over the counter, coats and soothes the stomach, protecting it from the damaging effects of acid. Two drug regimens are currently being developed.

Some of the same drugs are used for non-H. pylori ulcers as well as for symptoms (like indigestion) due to ulcers of any cause:

• Antacids, available over the counter, may relieve heartburn or indigestion but will not treat an ulcer. Antacids include aluminum hydroxide (Amphojel, AlternaGEL), magnesium hydroxide (Phillips' Milk of Magnesia), aluminum hydroxide and magnesium hydroxide (Maalox, Mylanta), calcium carbonate (Rolaids, Titralac, Tums), and sodium bicarbonate (Alka-Seltzer). Antacids may block medications from being absorbed and thereby decrease the medicine's effectiveness. It is recommended to take antacids at least 1 hour before or 2 hours after taking medications. Ask your pharmacist or doctor for more information.
• H2 blockers, such as cimetidine (Tagemet), ranitidine (Zantac), nizatidine (Axid®, and famotidine (Pepcid), reduce gastric acid secretion.
• Proton-pump inhibitors, including esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), and rabeprazole (Aciphex), decrease gastric acid production.
• Sucralfate (Carafate) makes a coating over the ulcer crater, protecting it from further damage.

Surgery and Other Procedures

Once hospitalized, if bleeding from an ulcer does not stop by using medications and supportive care (like fluids and, possibly, blood transfusion), it can almost always be stopped via endoscopy. The physician (a gastroenterologist) who performs the procedure first identifies the ulcer and the area that is bleeding. The physician will then inject adrenaline and other medications to stop the bleeding and stimulate the formation of a blood clot. If the bleeding recurs after that procedure or you have a perforated ulcer or an obstruction, surgery may be required. If you do not get better from medical or endoscopic treatment, surgery may be considered. About 30% of people who come to the hospital with a bleeding ulcer need endoscopy or surgery.

Nutrition and Dietary Supplements

Following these nutritional tips may help reduce symptoms:

• Foods containing flavonoids, like apples, celery, cranberries (including cranberry juice), onions, garlic, and tea may inhibit the growth of H. pylori.
• Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers).
• Eat foods high in B-vitamins and calcium, such as almonds, beans, whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables.
• Avoid refined foods, such as white breads, pastas, and especially sugar.
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy) or beans for protein.
• Use healthy oils, such as olive oil or vegetable oil.
• Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid beverages that can irritate the lining of the stomach or increase acid production, including coffee (with or without caffeine), alcohol, and carbonated beverages.
• Drink 6 - 8 glasses of filtered water daily.
• Exercise at least 30 minutes daily, 5 days a week.

You may address nutritional deficiencies with the following supplements:

• A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-vitamins, and trace minerals, such as magnesium, calcium, zinc, and selenium.
• Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil 2 - 3 times daily, to help decrease inflammation and improve immunity. Cold-water fish, such as salmon or halibut, are good sources, but supplementation is recommended.
• Probiotic supplement (containing Lactobacillus acidophilus), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. Some probiotic supplements may need to be refrigerated for best results. Your child may also take probiotic supplements. Talk to your health care provider before giving your child any dietary supplements.
• Alpha-lipoic acid, 25 - 50 mg twice daily, for antioxidant support.
• Vitamin C, 500 - 1,000 mg 1 - 3 times daily, as an antioxidant and for immune support.
• L-glutamine, 500 - 1,000 mg 3 times daily, for support of gastrointestinal health and immunity.
• Grapefruit seed extract (Citrus paradisi), 100 mg capsule or 5 - 10 drops (in favorite beverage) 3 times daily when needed, for antibacterial, antifungal, and antiviral activity, and for immunity.
• Resveratrol (from red wine), 50 - 200 mg daily, to help decrease inflammation and for antioxidant effects.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

• Green tea (Camelia sinensis) standardized extract, 250 - 500 mg daily, for antioxidant, anti-inflammatory, and heart health effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
• Cat's claw (Uncaria tomentosa) standardized extract, 20 mg 3 times a day, for inflammation and antibacterial, or antifungal activity.
• Reishi mushroom (Ganoderma lucidum), 150 - 300 mg 2 - 3 times daily, for inflammation and for immunity. You may also take a tincture of this mushroom extract, 30 - 60 drops 2 - 3 times a day.
• Olive leaf (Olea europaea) standardized extract, 250 - 500 mg 1 - 3 times daily, for antibacterial or antifungal activity and immunity. You may also prepare teas from the leaf of this herb.
• DGL-licorice (Glycyrrhiza glabra) standardized extract, 250 - 500 mg 3 times daily, chewed either 1 hour before or 2 hours after meals. Glycyrrhizin is a chemical found in licorice that causes side effects and drug interactions. DGL is deglycyrrhizinated licorice, or licorice with the glycyrrhizin removed.
• Mastic (Pistacia lentiscus) standardized extract, 1,000 - 2,000 mg daily in divided dosages, for activity against H. Pylori.
• Peppermint (Mentha piperita) standardized, enteric coated tablet, 1 tablet 2 - 3 times daily, for symptoms of peptic ulcer. Each tablet contains 0.2 ml peppermint oil.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of ulcers or its symptoms, based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for you individually. For the treatment of ulcers, even if you do seek homeopathic remedies as adjunctive care, conventional treatment recommendations must be followed.

• Argentum nitricum for abdominal bloating with belching and pain
• Arsenicum album for ulcers with intense burning pains and nausea; especially for people who cannot bear the sight or smell of food and are thirsty
• Kali bichromicum for burning or shooting abdominal pain that is worse in the hours after midnight
• Lycopodium for bloating after eating with burning that lasts for hours; especially for people who feel hungry soon after eating and wake hungry
• Nitric acid for sharp, shooting pain that worsens at night and is accompanied by feelings of hopelessness and even fear of dying
• Nux vomica for digestive disturbances (including heartburn and indigestion) that worsen after eating; particularly for those who crave alcohol, coffee, and tobacco
• Phosphorus for burning stomach pain that worsens at night; those for whom this remedy is appropriate tend to feel very thirsty, craving cold beverages
• Pulsatilla for symptoms that vary (that is, change abruptly) and pain that gets worse from fatty foods; appropriate people are distinctly not thirsty

Acupuncture

Acupuncture has been used traditionally for a variety of conditions related to the gastrointestinal tract, including peptic ulcers. A growing body of scientific evidence suggests that acupuncture can help reduce pain associated with endoscopy (the procedure used, as described earlier, to make a diagnosis of ulcer or to treat its complications).

Chiropractic

Chiropractors report and preliminary evidence suggests that spinal manipulation may benefit some individuals with uncomplicated gastric or duodenal ulcers. In one small clinical study, researchers compared the effectiveness of medication to spinal manipulation over a period of up to 22 days. Participants who received spinal manipulation experienced significant pain relief after an average of 4 days and were completely free of symptoms on average 10 days earlier than those who took medication. More research is needed to understand when and how chiropractic might be helpful if you have peptic ulcer disease.

Other Considerations:

Pregnancy

If you are pregnant or breastfeeding, talk to your doctor before taking any medication, including herbs.

Prognosis and Complications

With proper treatment, most ulcers heal within 6 - 8 weeks. However, they may recur, particularly if H. pylori is not treated sufficiently.

Complications from ulcers include bleeding, perforation (rupture) of either the stomach or the duodenum, and bowel obstruction. Each of these problems can be very serious, even life-threatening. Bleeding, which is much less common today because of appropriate and fast medical treatment, occurs in up to 15% of people with peptic ulcers. Obstruction tends to happen where the stomach meets the small intestines. If there is an ulcer at this junction, swelling can occur, blocking the passage of food products through the gastrointestinal tract. If this happens, significant vomiting is generally the main symptom.

H. pylori ulcers increase the risk of stomach cancer.

The good news is that the incidence of ulcers and their complications continue to decline as people seek treatment for symptoms early and doctors respond quickly to eliminate symptoms and the causes, like H. pylori and NSAIDs.