Gastric/Peptic/Duodenal Ulcers

Gastric/Peptic/Duodenal Ulcers: Overview

A peptic ulcer is a hole in the gut lining of the stomach, duodenum, or esophagus.  A peptic ulcer of the stomach is called a gastric ulcer; of the duodenum, a duodenal ulcer; and of the esophagus, an esophageal ulcer.  An ulcer occurs when the lining of these organs, normally protected by a thick mucous layer, is corroded by the acidic digestive juices which are secreted by the stomach cells.  Peptic ulcer disease is common, affecting millions of Americans yearly.

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Incidence; Causes and Development

Duodenal ulcer has historically occurred more frequently in men, but more recent data suggest similar rates in both men and women.

For many years excess acid was believed to be the major cause of ulcer disease.  Accordingly, treatment emphasis was on neutralizing and inhibiting the secretion of stomach acid.  While acid is still considered significant in ulcer formation, the leading cause of ulcer disease is currently believed to be infection of the stomach by a bacteria called Helicobacter pylori (H.  pylori).

Although H. pylori is often the cause of inflammation and ulceration, research had uncovered that when stomach pH is higher, other microorganisms besides H. pylori overgrow causing inflammation, gastritis and ulceration also.  These include Lactobacillus, Enterobacter, Staphylococcus and Propionibacterium.  [Gastroenterology, Jan 2002]

Duodenal ulcers are caused by an imbalance between acid and pepsin (an enzyme) secretion, and the defenses of the mucosal lining.  A slight reduction in stomach acid may result in the overgrowth of H. pylori, while lack of stomach acid can result in the overgrowth of other organisms.  Good acid production is necessary for killing microorganisms; poor acid production or acid neutralization with antacids contributes to overgrowth.  If H. pylori is already causing problems, acid neutralization may reduce overgrowth and symptoms but chronic use can contribute to the overgrowth of other organisms, flourishing at the higher pH, causing similar symptoms to return.

Signs and Symptoms

Symptoms of ulcer disease are variable.  Many ulcer patients experience minimal indigestion or no discomfort at all.  Some report upper abdominal burning or hunger pain one to three hours after meals and in the middle of the night.  These pain symptoms are often promptly relieved by food or antacids.  The pain of ulcer disease correlates poorly with the presence or severity of active ulceration.  Some patients have persistent pain even after an ulcer is completely healed by medication.  Others experience no pain at all, even though ulcers return.  Ulcers often come and go spontaneously without the individual ever knowing, unless a serious complication such as bleeding or perforation occurs.

Diagnosis and Tests

The diagnosis of an ulcer is made by either a barium upper GI X-ray or an upper endoscopy (EGD – esophagogastroduodenoscopy).  The barium upper GI X-ray is easy to perform and involves no risk or discomfort.  Barium is a chalky substance administered orally.  Barium is visible in X-rays, and outlines the stomach on X-ray film.  However, barium X-rays are less accurate and may not detect ulcers up to 20% of the time.

An upper endoscopy is more accurate, but involves sedation of the patient and the insertion of a flexible tube through the mouth to inspect the stomach, esophagus, and duodenum.  Upper endoscopy has the added advantage of having the capability of removing small tissue samples (biopsies) to test for H.  pylori infection.  Biopsies can also be examined under a microscope to exclude cancer.  While virtually all duodenal ulcers are benign, gastric ulcers can occasionally be cancerous and for this reason biopsies are often performed.

This disease may also alter the results of the following tests:

Laboratory Findings

  • Peptic ulcer – normal or increased gastric acid; there is no correlation of the amount of gastric acid with the presence of peptic ulceration; lack of gastric acid excludes the diagnosis of peptic ulcer.
  • Zollinger-Ellison syndrome – increased volume of gastric secretions, increased basal acid secretion (greater than 60% of the maximal acid secretion following betazole {Histalog} or pentagastrin stimulation), and increased fasting serum gastrin level.
  • Pyloric obstruction with gastric retention and vomiting – dehydration and azotemia; decreased serum Na, CI, K; increased C02 content and increased pH (metabolic alkalosis).
  • Perforationleukocytosis with left shift, dehydration, increased amylase, increased lipase.
  • Hemorrhage – acute, normocytic anaemia, chronic, microcytic hypochromic anaemia; occult blood in stool.

Treatment and Prevention

Many doctors are successfully treating ulcers without the use of antacids and often these natural methods work whether or not the issue of H.  pylori infection is directly addressed.

Treatment often involves using a combination of medications.  By using more than one kind of medication, multiple factors can be addressed: killing the Helicobacter pylori bacteria, reducing acid levels, and providing protection to the duodenum.  This combination strategy often provides the best chance of allowing the ulcers to heal and reducing the chance that the ulcers will come back.  However, it is important for patients to take all of the medications exactly as prescribed.

The medications may include:

  • antibiotics to kill Helicobacter pylori
  • acid blockers (e.g., cimetidine, ranitidine, famotidine)
  • proton pump inhibitors (e.g., omeprazole)
  • medications that protect the tissue lining (e.g., sucralfate)
  • bismuth (may help protect the lining and kill the bacteria)

Long-term therapy may be required.

Self-help measures can help – avoid smoking; avoid tea, coffee, alcohol, and caffeine containing soft drinks; and avoid aspirin.  In addition, eat several small meals a day at regular intervals.

Prognosis; Complications; Seek medical attention if...

Duodenal ulcers tend to recur if untreated.  The recurrence rate is reduced if patients are treated and eradicate Helicobacter pylori.  Symptoms also improve if dietary modifications occur and if patients stop smoking.

Peptic ulcers may lead to emergency situations.  Severe abdominal pain, with or without evidence of bleeding, may indicate that the ulcer has perforated the stomach, duodenum or intestine.  Vomiting of a substance that resembles coffee grounds or the presence of black tarry stools may indicate serious bleeding.  Peritonitis and bowel obstruction are other possible complications.

Call your health care provider if ulcer symptoms worsen, do not improve with treatment, or new symptoms develop.

Signs, symptoms & indicators of Gastric/Peptic/Duodenal Ulcers:

Lab Values - Chemistries

Counter-indicators

Symptoms - Abdomen

Mild/major/moderate/severe upper-right pain after food

The pain usually occurs 2-3 hours after a meal and is relieved by antacids or by eating more food.

Moderate/severe/significant epigastric pain

Most patients with ulcers complain of pain or discomfort that is located in the upper part of the stomach, often in the area immediately below or around the lower part of the breast bone.  This is called epigastric pain.  Symptoms may be associated with meals, or occur in-between meals, or sometimes even occur at night to the point where one can be woken up from sleep.  This pain may be relieved by meals also.

Abdominal pain reduced by eating

Stomach ulcer symptoms are usually worse on an empty stomach and better after eating – especially foods that help neutralize stomach acid.

Meals worsen epigastric pain

If you have a stomach ulcer, the pain usually begins about 15 to 20 minutes after eating, especially after large meals.

Infrequent meal-induced pain or meal-induced pain for under a week or meal-induced pain for 1-4 weeks or meal-induced pain for over a month

Stomach ulcers normally cause pain within 1-1½ hours of eating a meal; duodenal ulcers usually result in pain that starts 1½-2 hours after a meal.

Symptoms - Bowel Movements

(Slightly/very) black/tarry stools

Bleeding from an ulcer may occur in the stomach or the duodenum, and sometimes is the only symptom.  Rapid bleeding causes bowel movements to become black or even bloody.

Frequent/significant red blood in stools

Rapid bleeding can cause bowel movements to become black or even bloody.

Symptoms - Gas-Int - General

Occasional/regular/frequent unexplained vomiting

Bleeding ulcers may cause nausea and vomiting of acidified blood resembling "coffee grounds" material.

Symptoms - General

Dizziness when standing up

Patients with a bleeding ulcer may report a sense of passing out upon standing called orthostatic syncope.

Symptoms - Skeletal

Pain between shoulder blades

'Ruptured' gastric ulcers which have gone through the stomach wall can cause a sharp pain which sometimes can be described as a pain felt in the region between the shoulder blades.

Conditions that suggest Gastric/Peptic/Duodenal Ulcers:

Digestion

Esophageal Stricture (narrowing)

A chronic ulcer causes swelling and inflammation of the gastric and duodenal tissues.  Over time, scarring may close the pylorus, the lower end of the esophagus, thus preventing the passage of food and causing vomiting and weight loss.

Heartburn / GERD / Acid Reflux

There is a relatively high prevalence of GERD amongst patients with duodenal or gastric ulcers.  Persistent dyspepsia/heartburn symptoms after eradication of H.  pylori and ulcer resolution might suggest the treatment of GERD as a separate entity.  [Am J Gastroenterol 2000;95: pp.101-105]

Infections

Peritonitis

Sometimes an ulcer eats a hole in the wall of the stomach or duodenumBacteria and partially digested food can spill through the opening into the sterile abdominal cavity, called the peritoneum.  This causes peritonitis, an inflammation of the abdominal cavity and wall.  A perforated ulcer usually requires immediate hospitalization and surgery.

Symptoms - Gas-Int - General

Risk factors for Gastric/Peptic/Duodenal Ulcers:

Addictions

Cigarette Smoke Damage

Smoking is associated with the development, delayed healing and recurrence of peptic ulcers, as well as resistance to treatment.

Digestion

Gastritis

Severe inflammation of the stomach lining (gastritis) can result in ulceration.

Hormones

Hyperparathyroidism

Patients with hyperparathyroidism may be more likely to develop peptic ulcers, high blood pressure, and pancreatitis.

Infections

Helicobacter Pylori Infection

The average person's lifetime chance of suffering from a peptic ulcer is 5-10%, but this rises to 10-20% in those who are Helicobacter pylori positive.  H.  Pylori infection usually persists for many years, leading to ulcer disease in 10-15% of those infected.  H. pylori is found in more than 80% of patients with gastric and duodenal ulcers.

Mental

Stress

In general the duodenum isn't as well protected with mucus as is the stomach and is more prone to ulcers.  A deficiency of pancreatic juices to neutralize the acid chyme from the stomach, or stress causing sympathetic inhibition of enzyme secretion can lead to duodenal ulcer formation.

Supplements and Medications

Regular/frequent aspirin use

Inflammation may be caused by aspirin and nonsteroidal anti-inflammatory medications (NSAIDs), but the bacterium H.  pylori is generally responsible.

Symptoms - Food - Beverages

(High) coffee consumption

The caffeine, oils and acids in coffee irritate the stomach lining, which can cause excessive production of stomach acid and lead to a variety of digestive disorders.  Decaf can also bring on a similar increase in stomach acid.  Research has shown a definite link between coffee drinking and ulcers.  Some anti-ulcer drugs, like cimetidine (Tagamet), slow down the rate at which the body metabolizes caffeine.  So not only does coffee increase the acid, but the drugs extend caffeine's effects by keeping it circulating longer.

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Gastric/Peptic/Duodenal Ulcers suggests the following may be present:

Digestion

Infections

Helicobacter Pylori Infection

The average person's lifetime chance of suffering from a peptic ulcer is 5-10%, but this rises to 10-20% in those who are Helicobacter pylori positive.  H.  Pylori infection usually persists for many years, leading to ulcer disease in 10-15% of those infected.  H. pylori is found in more than 80% of patients with gastric and duodenal ulcers.

Recommendations for Gastric/Peptic/Duodenal Ulcers:

Amino Acid / Protein

Glutamine

Preliminary studies have shown that supplements of glutamine may protect against aspirin-induced gastric lesions and enhance healing of painful peptic ulcers.

Fresh cabbage juice has for a long time been used successfully against ulcers, probably due to its glutamine content.  The amino acid glutamine works over time in doses as low as 500mg three times daily (for one month) to heal stomach and small intestine lesions.  A study of ulcers found that 1600mg of glutamine per day had a 50% cure rate within 2 weeks and 92% within 4 weeks.

Botanical

Robert's Formula

Robert's Formula is a time-honored herbal preparation for upper GI inflammation.  It sometimes contains bismuth, which kills H.  Pylori, usually found in upper GI ulceration, as well as other microorganisms.

Mastic Gum

Mastic gum has killed H.  pylori and cured peptic ulcers after just 2 weeks of use.  500mg to 1gm twice per day for 2 weeks causes structural changes in H. pylori (of which there are at least 7 strains) resulting in its weakening and death.  [Mastic Gum kills H. pylori, NEJM 1998 Dec 24;339(26): p.1946]

Goldenseal

Goldenseal tea.  See the link between Peptic Ulcers and Water Consumption Increase.

Flax Seed, Flaxseed Oil, Linseed Oil

Flax seed tea.  See the link between Peptic Ulcers and Water Consumption Increase.

Comfrey

Comfrey leaf tea may be beneficial.

Licorice Root

Licorice root, particularly deglycyrrhized licorice, can be a useful adjunct to antibiotic treatment because it accelerates the healing of the stomach lining.  Deglycyrrhized licorice root (DGL) and glutamine have been used to get people off of antacids, H2 blockers and proton pump inhibitors (PPI).

Not recommended

Diet

Increased Water Consumption

Consuming up to 12 cups of water per day can eliminate the helicobacter infection when present.  Drink lots of water, golden seal tea, and flax seed tea.

Spicy Foods Avoidance

Avoid spicy foods when you're having pain, or any other food that adds to the pain.

Cabbage Family Vegetables

Try 4 ounces of fresh raw cabbage juice 4 times daily.

Alcohol Avoidance

No proven relationship exists between peptic ulcer disease and the intake of alcohol.  However, since alcohol can cause gastritis, moderation in alcohol consumption is often recommended.

Caffeine/Coffee Avoidance

Since coffee stimulates gastric acid secretion, moderation in coffee consumption is often recommended.

Digestion

Bromelain

In an extensive study of the effect of bromelain on the stomach lining, it was found that bromelain increased the uptake of sulfur by 50% and glucosamine by 30-90%.  Increased uptake of these substances allows the tissue to heal more rapidly.  [Hawaii Med J 1976;2: pp.39-47]

Drug

Antibiotics

While the mechanism of how H.  pylori causes ulcers is not well understood, its elimination by antibiotics has clearly been shown to heal ulcers and prevent ulcer recurrence.

Not recommended
NSAIDs

Prostaglandins are substances that are important in helping the gut linings resist corrosive acid damage.  NSAIDs cause ulcers by interfering with prostaglandins in the stomach.

Habits

Tobacco Avoidance

Cigarette smoking not only causes ulcer formation, but also increases the risk of ulcer complications such as bleeding, stomach obstruction and perforation.  Cigarette smoking is also a leading cause of ulcer medication treatment failure: smoking slows the healing of ulcers.

Lab Tests/Rule-Outs

Mineral

Zinc

In a double-blind study on 18 patients, those taking zinc sulfate supplements had a gastric ulcer healing rate three times that of patients treated with a placebo.  [The healing of gastric ulcers by zinc sulfate.  Med J Aust 2(21): pp.793-6, 1975]

Oxygen / Oxidative Therapies

Ozone / Oxidative Therapy

Cuban doctors are using capsules filled with ozonated oil to treat gastroduodenal ulcers, gastritis, giardia and peptic ulcers.

Psychological

Stress Management

Decrease your stress level.

Vitamins

Not recommended
Vitamin B3 (Niacin)

In rare cases, niacin has aggravated peptic ulceration.

Preventive measures against Gastric/Peptic/Duodenal Ulcers:

Habits

Aerobic Exercise

Active men had one-half to one-third the risk of developing a duodenal ulcer over 20 years compared with their sedentary counterparts.  Men who walked or ran at least 10 miles per week were 62% less likely than inactive subjects to develop an ulcer.  Men who walked or ran less than 10 miles each week had about half the ulcer risk of those with no regular exercise.

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