Peptic Ulcer

Also Listed As: Duodenal Ulcer; Gastric Ulcer; Stomach Ulcer; Ulcer, Peptic

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, rather, 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 to 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), 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 – in fact, 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 and 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 for how long things like indigestion and pain have been present, how strong these sensations are, if you have lost any 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 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, then further testing is necessary.

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

• Upper gastrointestinal (GI) series
• Endoscopy

For the upper GI, you drink a chalky liquid called barium and then a series of xrays may reveal an ulcer. The endoscopy, which is more accurate, 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.

Preventive Care

Preventing NSAID-related ulcers involves finding different medications or alternative approaches to relieve your pain. For example, talk to your doctor about taking a new class of medications called COX-2 inhibitors (including celecoxib and rofecoxib) or acetaminophen instead. If you have to take NSAIDs for a long time, your doctor may consider prescribing a medication to try to prevent the development of ulcers like misoprostol, an H2 blocker (such as cimetidine, famotidine, nizatidine, or ranitidine), or a proton pump inhibitor (such as omeprazole, lansoprazole, or rabeprazole).

There are also certain lifestyle measures that may make you less prone to get an ulcer from either NSAIDs or H. pylori.

Treatment Approach

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, 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 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 [for example, omeprazole] to reduce acid production and two antibiotics to get rid of the organism) is commonly used to treat H. pylori-related ulcers. Instead of one of the antibiotics, bismuth salicylate may be the third medication recommended. This drug, available over the counter, coats and soothes the stomach, protecting it from the damaging effects of acid. Two, rather than three, 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
• H2 blockers, such as cimetidine, ranitidine, nizatidine, and famotidine, reduce gastric acid secretion.
• Misoprostol – can be used preventively if you take a lot of NSAIDs because it helps to protect the stomach from the damaging effects of these pain killers. Does not cure existing ulcers.
• Proton-pump inhibitors, including esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole, decrease gastric acid production. This is the number one choice of medications for treating ulcers.
• Sucralfate 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 (see earlier section called Diagnosis for description of this procedure). The physician who performs the procedure (a doctor with special training, known as a gastroenterologist) first identifies the ulcer and the area that is bleeding. Then, that physician injects 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. Also, if you do not get better from medical or endoscopic treatment, surgery may be considered. Approximately 30% of people who come to the hospital with a bleeding ulcer need endoscopy or surgery.

Nutrition and Dietary Supplements

As described in an earlier section entitled 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 measures that should help, however, are as follows:

• Eat a diet rich in fiber, especially from fruits (including fruit juices) 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, and tea may inhibit the growth of H. pylori.
• Avoid beverages that can irritate the lining of the stomach or increase acid production including coffee (with or without caffeine), alcohol, and carbonated beverages.

Supplements that are showing early promise for help in treating or preventing ulcers are discussed below. More research is needed to further test the safety and effectiveness of these substances.

Gamma-linolenic acid (GLA)
Very preliminary evidence from test tube and animal studies suggest that gamma-linolenic acid (GLA) from evening primrose oil (EPO) may have anti-ulcer properties. GLA is an essential fatty acid (EFA) in the omega-6 family that is found primarily in plant-based oils, including EPO and borage seed oil. Although studies are promising, it is too early to know how this might apply to people with peptic ulcers.

Omega-3 Fatty Acids
In animal studies, treatment with omega-3 fatty acids reduced the risk of ulcers caused by NSAIDs. More research is needed to evaluate whether omega-3 fatty acids (like ALA found in flaxseed and flaxseed oil or EPA and DHA found in fish and fish oil) would have the same effects in people.

Probiotics
Healthy or "friendly" organisms, called probiotics, inhabit the lining of the intestines and protect us from the entrance of "bad" infections that can cause disease. Lactobacillus acidophilus (L. acidophilus) is the most commonly used probiotic. In test tube studies, L. acidophilus and other probiotics were able to kill or slow down the growth of H. pylori; research is needed to understand whether that benefit would occur in people. One way in which probiotics may help is by reducing side effects, such as diarrhea and taste disturbance, from medications used to treat H. pylori

Vitamin C
In one study, high-dose vitamin C treatment for four weeks effectively treated H. pylori infection in some, but not all, people. In addition, H. pylori appears to impair absorption of vitamin C. Having lower than average levels of vitamin C may play a role in the higher risk of stomach cancer for those with this organism in their gastrointestinal tract.

Herbs

Herbs may cause side effects or interact with medications. They should, therefore, be used with caution and only under the guidance of a professionally trained and qualified herbalist. With that said, there are many herbs, some of which are described below, that may be recommended by an herbal specialist for peptic ulcers. The herbalist would work with you to individualize your treatment.

• Astragalus (Astragalus membranaceus) – used traditionally to treat stomach ulcers.
• Barberry (Berberis vulgaris)- This herb contains active substances called berberine alkaloids. These substances have been shown to combat infection and bacteria. For this reason, barberry is used to ease inflammation and infection of the gastrointestinal tract. Barberry has also been used traditionally to improve appetite.
• Bilberry (Vaccinium myrtillus) - Studies in rats have found that anthocyanidins (an antioxidant) from bilberry fruits help prevent stomach ulcers related to a variety of factors including stress, medications, and alcohol. Whether this will translate into help for people requires research.
• Cat's Claw (Uncaria tomentosa) – The bark and root of this herb have been used among indigenous people of the rainforest for centuries to treat a variety of health problems including ulcers and other gastrointestinal disorders. The benefits of this herb may be due to its ability to reduce inflammation.
• Cranberry (Vaccinium spp) – may have properties that help prevent H. pylori infection.
• Dong Quai (Angelica sinensis) - animal studies suggest that dong quai may soothe ulcers, but studies in people are needed before a definitive conclusion can be drawn.
• Garlic (Allium sativum) – some studies suggest that high amounts of garlic may protect against stomach cancer, which is a potential complication of H. pylori peptic ulcers. This is controversial, however, and high amounts of garlic may in fact cause gastrointestinal distress.
• Licorice (Glycyrrhiza glabra) - this herb is a demulcent (soothing, coating agent) that has long been valued for its use in food and medicinal remedies, including treatment of ulcers. Some licorice root extracts, known as deglycyrrhizinated licorice (DGL), still have the healing properties of licorice without the harmful effects (like high blood pressure). DGL may be better for stomach or duodenal ulcers than Glycyrrhiza glabra and may even prove as effective as some prescription drugs for stomach ulcers.
• Slippery elm (Ulmus fulva) - Although there has been little scientific research on slippery elm, it has a long history of use based on clinical experience. Gastritis (stomach inflammation) and peptic ulcer are among the conditions that seem to respond well to slippery elm.
• Turmeric (Curcuma longa) -Turmeric has long been used in both Ayurvedic and Chinese medicine to treat digestive disorders. Scientific research is beginning to test the merit of this traditional use. In an animal study, for example, extracts of turmeric root reduced the release of acid from the stomach and protected against injuries such as gastritis or inflammation of the intestinal walls and ulcers. Further studies are needed to know to what extent these protective effects apply to people as well. (Note: at very high doses, turmeric may induce ulcers. It is very important to stick with the dose recommended by an herbal specialist.)

Other
Animal studies indicate that certain individual herbal extracts as well as a combination of these extracts may help heal ulcers. More studies are needed, however, to know whether these individual herbs or a particular combination of them would help people.

The combination preparation used in these animal studies included:

• Angelica (Angelica archangelica)
• German chamomile (Matricaria recutita)
• Lemon balm (Melissa officinalis)
• Licorice
• Milk thistle (Silybum marianum)
• Peppermint (Mentha x piperita)

Additional herbs that have been used clinically by herbal specialist to treat peptic ulcers include:

• Calendula (Calendula officinalis) — used in the United States during the 19th century to treat stomach ulcers
• Capsaicin – the active ingredient in cayenne (Capsicum frutescens/Capsicum spp)
• Marshmallow (Althea officinalis)

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 your constitutional type. A constitutional type is defined as your physical, emotional, and psychological 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 wee hours of the morning (that is, 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 a lot (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 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 an average of 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, you should consult with your physician before taking any medication, including herbs.

Borage seed oil, and possibly other sources of GLA, should not be used during pregnancy because they may be harmful to the fetus and induce early labor.

Warnings and Precautions

Individuals with peptic ulcers should not take the herbs devil's claw (Harpagophytum procumbens) or green tea (Camellia sinensis).

Prognosis and Complications

With proper treatment, most ulcers heal within 6 to 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 its complications continues to decline as people seek treatment for symptoms early and doctors respond quickly to eliminate symptoms and the causative agents, like H. pylori and NSAIDs.

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