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Peptic ulcer

Also listed as: Duodenal ulcer; Gastric ulcer; Stomach ulcer; Ulcer - peptic

Signs and Symptoms
Causes
Risk Factors
Diagnosis
 
Prevention
Treatment
Other Considerations
Supporting Research

Peptic ulcers -- open sores in the lining of the stomach, esophagus, or duodenum (the first part of the intestine) -- are common. According to the American College of Gastroenterology, about 20 million Americans will develop an ulcer during their life. Contrary to popular belief, ulcers are not caused by spicy food or stress. Instead, a type of bacteria called Helicobacter pylori is usually to blame. Long term use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil), can also cause ulcers.

Signs and Symptoms

  • Abdominal pain with a burning or gnawing sensation
  • Pain 2 - 3 hours after eating
  • Pain is often made worse by an empty stomach; 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, 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

The lining of the stomach is usually protected from the damaging effects of stomach acid. When that protection fails, an ulcer forms. There are a few different ways this happens.

  • Helicobacter pylori (H. pylori) -- H. pylori, a type of bacteria, is responsible for most ulcers. This organism weakens the protective coating of the stomach and first part of the intestine and allows damaging digestive juices to eat away at the sensitive lining below. As many as 20% of Americans over age 40 have H. pylori living in their digestive tract, but most do not develop ulcers.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) -- Long-term use of these pain relievers is the second most common cause of ulcers. These drugs block prostaglandins, substances in the stomach that help maintain blood flow and protect the area from injury. Some people are more susceptible to this side effect of NSAIDs than others. These drugs include ibuprofen (Advil, Motrin), naproxen (Aleve), and ketoprofen (OrudisKT), as well as prescription drugs. Some may be more likely to produce ulcers than others. If you must use long-term pain medications, talk to your doctor about which ones are safest.

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. Preliminary research also suggests that there may be a link between the use of medicines called selective serotonin reuptake inhibitors (SSRIs) and peptic ulcers.

Risk Factors

  • Heredity
  • Older age
  • Chronic pain from any cause such as arthritis, fibromyalgia, repetitive stress injuries (like carpal tunnel syndrome), or persistent back pain, causing long-term use of aspirin or NSAIDs
  • Alcohol abuse
  • Diabetes may increase your risk of having H. pylori
  • 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. But these factors do not cause an ulcer on their own.
  • Cigarette smoking

Diagnosis

First, your doctor will take a detailed history of your symptoms and risk factors, including how long you have had indigestion and pain, how strong the pain is, 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 any sign of bleeding. A blood test will check to see if you are anemic. These tests make sure that you have not had bleeding you don’t know about (called occult bleeding).

If there are no signs of bleeding and your symptoms are mild, your doctor may have you try medications that reduce stomach acid. If your symptoms persist or get worse despite the medication, further testing is needed.

You will have 1 of 2 tests to identify an ulcer:

  • Upper gastrointestinal (GI) series -- You will drink a chalky liquid called barium, then undergo a series of x-rays to check for an ulcer.
  • Endoscopy -- The doctor will carefully insert a thin tube with a tiny camera at the end (called an endoscope) down your throat, through the esophagus to the stomach and duodenum. The endoscope lets the doctor examine your digestive tract and take a sample of tissue to test for H. pylori, if needed. You will be 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 bacteria. The breath test, which is the least invasive, is at least 95% accurate.

Prevention

Preventing NSAID-related ulcers means 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 prevent the development of ulcers. This medicine may include an H2 blocker or a proton pump inhibitor, which reduce stomach acid.

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 getting rid of 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. Certain herbs, acupuncture, or homeopathy be helpful additions to usual medical care.

Lifestyle

Doctors used to recommend eating bland foods with milk and only small amounts of food with each meal. Now we know that such a diet isn’t needed to treat ulcers. Dietary and other lifestyle measures that should help 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 speed your recovery if you already have one.
  • Foods containing flavonoids, like apples, celery, cranberries (including cranberry juice), onions, garlic, and tea may inhibit the growth of H. pylori.
  • Some people may find that spicy foods make existing symptoms worse.
  • 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 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 NSAIDs. Consider taking a class; some early information suggests that, if you have an ulcer, a formal stress reducing program may be more helpful than listening to tapes on your own at home.

Medications

If you have H. pylori, you will probably be prescribed 3 medications. "Triple therapy," including a proton pump inhibitor to reduce acid production and 2 antibiotics, is commonly used to treat H. pylori-related gastritis and ulcers. Bismuth salicylate (Pepto-Bismol) may be used instead of the second 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 gastritis, as well as for symptoms (like indigestion) due to ulcers:

Antacids -- Available over the counter, they may relieve heartburn or indigestion but will not treat an ulcer. Antacids may block medications from being absorbed and thereby decrease the medicine's effectiveness. Doctors recommend taking antacids at least 1 hour before or 2 hours after taking medications. Ask your pharmacist or doctor for more information. Antacids include:

  • Aluminum hydroxide (Amphojel, AlternaGEL)
  • Magnesium hydroxide (Phillips' Milk of Magnesia)
  • Aluminum hydroxide and magnesium hydroxide (Maalox, Mylanta)
  • Calcium carbonate (Rolaids, Titralac, Tums)
  • Sodium bicarbonate (Alka-Seltzer)

H2 blockers -- reduce gastric acid secretion. They include:

  • Cimetidine (Tagemet)
  • Ranitidine (Zantac)
  • Nizatidine (Axid)
  • Famotidine (Pepcid)

Proton-pump inhibitors -- decrease gastric acid production. They include:

  • Esomeprazole (Nexium)
  • Lansoprazole (Prevacid)
  • Omeprazole (Prilosec)
  • Pantoprazole (Protonix)
  • Rabeprazole (Aciphex)

Surgery and Other Procedures

If bleeding from an ulcer does not stop by using medications and supportive care (like fluids and blood transfusion), a physician called a gastroenterologist will perform an endoscopy. He first identifies the ulcer and the area that is bleeding, then injects medications to stop the bleeding and stimulate the formation of a blood clot. If the bleeding recurs or you have a perforated ulcer or an obstruction, surgery may be required. 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 rich 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 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 may irritate the stomach lining 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.

These supplements may also help:

  • Probiotic supplement (containing Lactobacillus acidophilus), 5 - 10 billion CFUs (colony forming units) a day -- Probiotics or “friendly” bacteria may help maintain a balance in the digestive system between good and harmful bacteria such as H. pylori. Probiotics may help suppress H. pylori infection and may also help reduce side effects from taking antibiotics, the treatment for an H. pylori infection. Some probiotic supplements may need to be refrigerated for best results.
  • Vitamin C, 500 - 1,000 mg 1 - 3 times daily -- One study found that taking vitamin C along with triple therapy allowed the dose of one antibiotic to be lower. Vitamin C may also be helpful in treating bleeding stomach ulcers caused by aspirin use, but more research is needed.

Herbs

Herbs are a way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider before starting and during treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, 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.

  • Cranberry (Vaccinium macrocarpon) 400 mg twice daily -- Some preliminary research suggests cranberry may inhibit H. pylori growth in the stomach. Large amounts of cranberry may be inappropriate for people who are allergic to aspirin due to the fact that cranberry contains Salicylic Acid. Cranberry extracts also can contain high levels of a chemical called oxalate, which may increase the risk of developing kidney stones.
  • Mastic (Pistacia lentiscus) standardized extract, 1,000 - 2,000 mg daily in divided dosages -- Mastic is a traditional treatment for peptic ulcers and inhibits H. pylori in test tubes. More studies are needed to see whether it works in humans.
  • DGL-licorice (Glycyrrhiza glabra) standardized extract, 250 - 500 mg 3 times daily, chewed either 1 hour before or 2 hours after meals -- may help protect against stomach damage from NSAIDs. Glycyrrhizin is a chemical found in licorice that causes side effects and drug interactions. DGL is deglycyrrhizinated licorice, or licorice with the glycyrrhizin removed.

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 up 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 digestive tract, including peptic ulcers. A growing body of scientific evidence suggests that acupuncture can help reduce pain associated with endoscopy.

Chiropractic

Chiropractors report, and preliminary evidence suggests, that spinal manipulation may benefit some people 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. Those who received spinal manipulation had 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 intestine, and bowel obstruction. These problems can be very serious, even life threatening. Bleeding 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 point, swelling can occur, blocking food from passing through the digestive tract. Vomiting is generally the main symptom.

H. pylori ulcers increase the risk of stomach cancer.

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

Supporting Research

Bujanda L. The effects of alcohol consumption upon the gastrointestinal tract. Am J Gastroenterol. 2000;95(12):3374-3382.

Burger O, Ofek I, Tabak M, Weiss EI, Sharon N, Neeman I. A high molecular mass constituent of cranberry juice inhibits helicobacter pylori adhesion to human gastric mucus. FEMS Immunol Med Microbiol. 2000 Dec;29(4):295-301.

Burger O, Weiss E, Sharon N, Tabak M, Neeman I, Ofek I. Inhibition of Helicobacter pylori adhesion to human gastric mucus by a high-molecular-weight constituent of cranberry juice. Crit Rev Food Sci Nutr. 2002;42(3 Suppl):279-284.

Cabrera C, Artacho R, Gimenez R. Beneficial effects of green tea -- a review. J Am Coll Nutr. 2006;25(2):79-99.

De R, Kundu P, Swarnakar S, Ramamurthy T, Chowdhury A, Nair GB, Mukhopadhyay AK. Antimicrobial activity of curcumin against Helicobacter pylori isolates from India and during infections in mice. Antimicrob Agents Chemother. 2009 Apr;53(4):1592-7.

El-Serag HB, Satia JA, Rabeneck L. Dietary intake and the risk of gastro-esophageal reflux disease: a cross sectional study in volunteers. Gut. 2005;54(1):11-7.

Ferri. Ferri's Clinical Advisor 2010, 1st ed. Philadelphia, PA: Mosby, An Imprint of Elsevier. 2011.

Fox M, Barr C, Nolan S, et al. The effects of dietary fat and calorie density on esophageal acid exposure and reflux symptoms. Clin Gastroenterol Hepatol. 2007;5(4):439-44.

Fox M, Barr C, Nolan S, Lomer M, Anggiansah A, Wong T. The effects of dietary fat and calorie density on esophageal acid exposure and reflux symptoms. Clin Gastroenterol Hepatol. 2007;5(4):439-44.

Gorbach SL. Probiotics in the third millennium. Dig Liver Dis. 2002;34(Suppl 2):S2-S7.

Han KS. The effect of an integrated stress management program on the psychologic and physiologic stress reactions of peptic ulcer in Korea. J Holist Nurs. 2002;20(1):61-80.

Khayyal MT , el-Ghazaly MA, Kenawy SA, et al. Antiulcerogenic effect of some gastrointestinally acting plant extracts and their combination. Arzneimittelforschung 2001;51(7):545-553.

Kim JJ, Kim N, Lee BH, et al. Risk factors for development and recurrence of peptic ulcer disease. Korean J Gastroenterol. 2010;56(4):220-8.

Klausz G, Tiszai A, Lenart Z, et al., Helicobacter pylori-induced immunological responses in patients with duodenal ulcer and in patients with cardiomyopathies. Acta Microbiol Immunol Hung. 2004;51(3):311-20.

Kumar. Robbins and Cotran Pathologic Basis of Disease, Professional Edition, 8th ed. Philadelphia, PA: Saunders, An Imprint of Elsevier. 2009.

Lanza FL, Chan FK, Quigley EM; Practice Parameters Committee of the American College of Gastroenterology. Guidelines for prevention of NSAID-related ulcer complications. Am J Gastroenterol. 2009 Mar;104(3):728-38.

Lee SY, Shin YW, Hahm KB. Phytoceuticals: mighty but ignored weapons against Helicobacter pylori infection. J Dig Dis. 2008 Aug;9(3):129-39. Review.

Marteau P, Boutron-Ruault MC. Nutritional advantages of probiotics and prebiotics. Br J Nutr. 2002;87(Suppl 2)):S153-S157.

Marteau PR. Probiotics in clinical conditions. Clin Rev Allergy Immunol. 2002;22(3):255-273.

Martin B. Prevention of gastrointestinal complications in the critically ill patient. AACN Adv Crit Care. 2007;18(2):158-66.

McManus TJ. Helicobacter pylori: an emerging infectious disease. Nurs Pract. 2000;25(8):42-46.

Mota KS, Dias GE, Pinto ME, Luiz-Ferreira A, Souza-Brito AR, Hiruma-Lima CA, et al. Flavonoids with gastroprotective activity. Molecules. 2009 Mar 3;14(3):979-1012. Review.

Olafsson S, Berstad A. Changes in food tolerance and lifestyle after eradication of Helicobacter pylori. Scand J Gastroenterol. 2003;38(3):268-76.

Pasina L, Nobili A, Tettamanti M. Prevalence and appropriateness of drug prescriptions for peptic ulcer and gastro-esophageal reflux disease in a cohort of hospitalized elderly. Eur J intern Med. 2011;22(2):205-10.

Qasim A, O'Morain CA. Review article: treatment of Helicobacter pylori infection and factors influencing eradication. Aliment Pharmacol Ther. 2002;16(Suppl 1):24-30.

Ryan SW. Management of dyspepsia and peptic ulcer disease. Altern Ther Health Med. 2005;11(5):26-9; quiz 30.

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Solmaz A, Sener G, Cetinel S, Yüksel M, Yegen C, Yegen BC. Protective and therapeutic effects of resveratrol on acetic acid-induced gastric ulcer. Free Radic Res. 2009 Jun;43(6):594-603.

Sugimoto N, Yoshida N, Nakamura Y, Ichikawa H, Naito Y, Okanoue T, Yoshikawa T. Influence of vitamin E on gastric mucosal injury induced by Helicobacter pylori infection. Biofactors. 2006;28(1):9-19.

Vonkeman HE, Fernandes RW, van de Laar MA. Under-utilization of gastroprotective drugs in patients with NSAID-related ulcers. Int J Clin Pharmacol Ther. 2007;45(5):281-8.

Woodward M, Tunstall-Pedo H, McColl K. Helicobacter pylori infection reduces systemic availability of dietary vitamin C. Eur J Gastroenterol Hepatol. 2001;13(3):233-237.

Zaidi SF, Yamada K, Kadowaki M, Usmanghani K, Sugiyama T. Bactericidal activity of medicinal plants, employed for the treatment of gastrointestinal ailments, against Helicobacter pylori. J Ethnopharmacol. 2009 Jan 21;121(2):286-91.


Review Date: 10/13/2011
Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.
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