Understanding Peptic Ulcer

Published by Dr Gigi on August 13, 2018

Peptic ulcer simply refers to any ulcer (open sores) affecting either the lining of the stomach or the upper part of the small intestine. It may occur at any age, however, chances of peptic ulcer increases with age. Contrary to the common old wives’ tale, stress alone and diet (spicy food) do not cause peptic ulcer. These factors do not cause peptic ulcers but may irritate the lining of the stomach in someone with pre-existing ulcer condition.

Who Is Predisposed To Ulcer

Duodenal ulcers are more common in males, while in females, stomach ulcers are more common than duodenal ulcers.

Adults aged 55 to 65 years including women aged 70 and above are more likely to have peptic ulcers¹.

Sites Affected By Peptic Ulcer Disease

Ulcers can develop in the esophagus, stomach, small intestine.

Types

Gastric ulcer: refers to erosion of the lining of the stomach.

Duodenal ulcer. refers to erosion of the lining of the upper small intestine (duodenum).

Causes of Ulcer

Normally, certain factors such as mucus, prostaglandins, bicarbonate maintain the integrity of the stomach lining by providing protective measures against the harmful effects of acid, non steroidal anti-inflammatory drugs and ulcer causing bacteria (H. pylori). The development of peptic ulcer often occur when this defense mechanism is overwhelmed.

• Bacteria: The bacteria, Helicobacter pylori is commonly found in most individuals with peptic ulcer. The transmission of H. pylori is spread from person to person, through consuming water or food contaminated with feces of a person with H pylori infection. The bacteria is capable of colonizing the stomach and upper intestines with the aid of certain enzymes such as urease, vacuolating cytokines and Lipopolysaccharides. H pylori infection causes intense inflammatory response that damages the stomach and/or intestinal lining.
• Drugs: Chronic use of non steroidal anti-inflammatory drugs such as Ibuprofen, Aspirin, Naproxen increases one’s risk of developing ulcer. Individuals at risk of NSAID induced peptic ulcer are usually advanced in age, use higher doses of the drug, or have history of previous ulcer disease.
• Zollinger Ellison syndrome: In this rare condition, one or more tumors (called gastrinomas) form in the upper part of the small intestine and/or pancreas. These tumors produce high levels of gastrin, a hormone that induces the stomach to produce acid. The resulting high acidity leads to multiple ulcer sites that never heal.
• Genetics: an individual is three times more likely to develop peptic ulcer if a parent or sibling suffers from peptic ulcer.
• Smoking: cigarette smoking doubles one’s risk of developing peptic ulcer disease, delays the healing of ulcer, increases the chances of recurrence and complications. It increases the secretion of acid and inhibits the production of bicarbonate. Duodenal ulcer is more common in smokers.
• Alcohol: alcohol damages the lining of the stomach or small intestine.
• Inflammatory diseases of the bowel such as Crohn’s disease.

Signs and Symptoms

• Abdominal pain and discomfort usually felt in the upper abdomen. Pain is associated with mealtimes, as gastric ulcer is commonly aggravated by food and pain from duodenal ulcer is often relieved by meals. Individuals with gastric ulcer tend to avoid food with consequent weight loss, and many with duodenal ulcer may experience weight gain.
• Nausea or vomiting.
• Bloating.
• Feeling full with relatively small amount of food.
• Burping or regurgitating acidic stomach content.
• Feeling of burning sensation in the chest, also known as heartburn.
• Weight gain or weight loss.
• Loss of appetite.
• Dark colored feaces (Melena).
• Hematemesis: vomiting up blood.
• Ulcer perforation: rarely, untreated ulcer can bore through the wall of the stomach or intestine and cause bloody vomit. Ulcer perforation, presents as sudden pain that radiates to the back or tip of the shoulder.

Diagnosis and Testing

Diagnosis of peptic ulcer is mainly based on clinical symptoms and often does not require special tests. History of complete resolution of pain and other symptoms in response to antacids strongly suggest peptic ulcer. In any case, it is essential to investigate further if symptoms still persist after appropriate treatment to rule out other causes.

1. Urease breath test. This is a simple test and efficient test that utilizes the presence of urease, which is an enzyme produced by H pylori. In this test, the individual is given a labeled harmless solution to ingest, the metabolites of the solution are then sampled to detect the presence or absence of H pylori.
2. Stool antigen testing, is non invasive. Not often done.
3. Endoscopy. Endoscopy is the most appropriate test for detecting peptic ulcer. The ulcer is visualized with the aid of a special instrument (endoscope) that has a camera attached to it. The size, location and severity of the ulcer can be determined using the endoscope.
4. Ulcer site biopsy. At the time of endoscopy, a biopsy (collection of a small tissue) of the site may be obtained and cultured to isolate H pylori bacteria. This is expensive and not all centers perform the test.

Natural Remedy

1. Boost your immunity: smoking, alcohol and poor diet lower one’s immunity and foster highly inflammatory environment.
2. De-stress: Stress alone does not cause peptic ulcer, however chronic stress may increase one’s chances of developing peptic ulcer. Regular exercise, meditation, yoga, and adequate sleep are healthy habits that help relieve stress.
3. Reduce use of non-steroidal anti-inflammatory drugs: prolonged ingestion of NSAIDS increases one’s risk of developing ulcer.
4. Diet modification: There is no evidence that any type of food can cause ulcer. However certain foods may cause discomfort. Eating right goes a long way to mitigate the symptoms and discomfort associated with peptic ulcer disease. Unhealthy eating habits like skipping meals, consuming spicy food, fried and high fat content foods, peppermint and mint, taking caffeinated drinks, alcoholism, consuming veggies like tomatoes, all worsen the symptoms of peptic ulcer.
5. Water: It is important to maintain adequate hydration especially in patients experiencing nausea and vomiting.
6. Probiotics: Probiotics reduce H pylori bacteria load and infection.
7. Yogurt: Yogurt contain the ‘good bacteria’ that prevent growth of H pylori. At least, 1 cup of unsweetened, unflavored yogurt daily is highly recommended.

Fruits and Vegetables

1. Juices: fruits and veggies rich in alkaline, like pawpaw juice, celery, cabbage neutralize the acid in the stomach.
2. Grapes: grapes are effective in providing relief from indigestion and help settle the stomach.
3. Pineapple juice: the bromelain enzyme (2) found in pineapple juice and stem induces the body to produce anti-inflammatory substances that alleviate symptoms associated with ulcer.
4. Apples: apples contain pectin and glycine which are both effective in reducing acid production in the stomach. They contain flavonoids that help combat inflammation. Apple infusion relaxes the stomach and provides natural antacid effects.
5. Bananas: Bananas have antioxidants that boost immunity. They are highly effective in combating inflammation and neutralizing stomach acid. A recent study (3) showed Banana metabolites inhibit COX-2 enzyme activity in a way similar to Ibuprofen, consequently mimicking its ability to reduce pain and swelling.
6. Cruciferous vegetables: broccoli, cauliflower, kale and Brussel sprouts all contain sulforaphane. Sulforaphane inhibits the growth of H pylori.
7. Cabbage: glutamine is an amino acid found in cabbage that helps prevent peptic ulcers, heal existing ulcers and improve blood flow to the gut. Eating 2 cups of cabbage daily is recommended to get the full benefits.

Herbs and Spices

1. Celery: celery is high in flavonoids and tannin antioxidants that reduce inflammation of the stomach lining and inhibit the growth of H. pylori bacteria.
2. Fennel seeds and/or tea.
3. Chamomile tea: Chamomile has a soothing effect on the stomach and promotes the healing of peptic ulcers.
4. Cardamom: cardamom and cinnamon have cooling effect on the lining of the stomach. According to a study conducted by researchers at Helwan University in 2010 (4), cinnamon reduces gastric acid secretion and increases blood flow to the stomach promoting the healing of ulcers.
5. Aloe vera juice: aloe vera juice cools the stomach and reduces inflammation.

Micronutrients

1. Selenium: selenium protects the stomach lining from the injuries caused by drugs like ibuprofen reserpine, alcohol. It reduces infection complications and at the same time improve healing.
2. Zinc: Zinc is important for the maintenance of the immune system, protective against oxidative stress and promotes peptic ulcer healing.
3. Vitamins: Vitamin A and C are beneficial in the eradication of H pylori Vitamin C is more effective when taken in smaller doses (500mg daily) over a long period of time, compared to short courses of high dose vitamin C.

 Medications

The goal of medical treatment is to treat the underlying cause of the ulcer. Antacids and other acid reducing medications only alleviate symptoms of peptic ulcer temporarily. The most common culprit in the development of peptic ulcer is H. pylori, therefore in order to achieve complete resolution, the doctor prescribes medications to eradicate the bacteria.

Medications are usually taken over a period of 7-14 days, which usually is adequate to completely eradicate the bacteria. The eradication therapy often include triple or quadruple regimen, comprised of a proton pump inhibitor (Omeprazole), macrolide antibiotic (Clarithromycin), Amoxicillin and/or Metronidazole antibiotics. Another quadruple therapy may include bismuth citrate, Omeprazole, tetracycline, and metronidazole. This is often given as second line treatment where the tripple regimen fails.5

Complications

• Bleeding. Bleeding is the most common complication and presents as sudden onset bloody vomit (hematemesis) or dark colored stools. It is associated with about 5-10% death rate.
• Perforation and bleeding. Untreated ulcer may result in perforation of the stomach, and may extend into an adjacent blood vessel to cause bleeding. This requires immediate surgical intervention. The death rate from this is about 15-20%.
• Stomach outlet obstruction. Ulcers close to the outflow tract of the stomach or the adjacent part of duodenum may cause scars and swelling that may result in obstruction. Vomiting of freshly ingested food is often the sign seen in this condition.
• Stomach cancer. Individuals with long term untreated peptic ulcer may be at risk of stomach cancer.

References

1. Kurata JH, Haile BM, Elashoff JD. Sex differences in peptic ulcer disease. Gastroenterology. 1985 Jan;88(1 Pt 1):96-100.
2. Properties and therapeutic application of bromelain: a review.
3. Nieman DC, Gillitt ND, Sha W, Esposito D, Ramamoorthy S. Metabolic recovery from heavy exertion following banana compared to sugar beverage or water only ingestion: A randomized, crossover trial. Atkin SL, ed. PLoS ONE. 2018;13(3):e0194843. doi:10.1371/journal.pone.0194843.
4. Amr AR, Maysa ME. Anti-ulcer Effect of Cinnamon and Chamomile Aqueous Extracts in Rat Models. Journal of American Science, 2010;6(12)
5. Lanas A, Chan FK. Peptic Ulcer Disease. Lancet, Aug 2017. 390(10094): 613-624.