18. Ulcer

OTHER NAMES
peptic disease; benign gastric ulcer; stomach ulcer
DEFINITION
An ulcer in the lining of the stomach.
CAUSES, INCIDENCE, AND RISK FACTORS
A benign gastric ulcer is a disease that is caused by an imbalance between acid and pepsin (an enzyme) secretion and the defenses of the stomach mucosal lining. The inflammation may be precipitated by aspirin and nonsteroidal anti-inflammatory medications (NSAIDs). The risk factors are aspirin and NSAID use, chronic gastritis, blood type of group A, and over 50 years. The incidence is 8 out of 10,000 people.
PREVENTION
Use caution in taking aspirin and NSAIDs if prone to gastric ulcers.
SYMPTOMS
- abdominal pain
- may wake the person at night
- may be relieved by antacids or milk
- may occur 2 to 3 hours after a meal
- may be worse by not eating
- nausea
- abdominal indigestion
- vomiting, especially vomiting blood
- weight loss
- fatigue
SIGNS AND TESTS
- an upper GI series showing a gastric ulcer
- an EGD (esophagogastroduodenoscopy) and biopsy showing a benign gastric ulcer
Note: There may be no symptoms.
Treatment Options

Treatment Strategy

 The treatment approach as determined by the National Institutes of Health (NIH) Consensus Development Conference advocates the eradication of H. pylori with concurrent use of antisecretory agents for first occurrences and recurrence. Unless recurrent bleeding is life-threatening, maintenance with antisecretory agents may not be warranted. Gastric ulcers generally take longer and are more difficult to heal than duodenal ulcers.

Drug Therapies

 _... For H. pylori "triple therapy" is considered most efficacious, but variations of the regimen are commonly used. H. pylori that is resistant to antibiotics, especially to the macrolides and imidazoles (e.g., metronidazole), is problematic worldwide. Side effects of triple therapy include diarrhea and pseudomembranous colitis. Two-week treatment may be combined with H2-receptor antagonists and proton- pump inhibitors. _... Amoxicillin 500 mg qid OR tetracycline 500 mg bid _... Bismuth subsalicylate (Pepto-Bismol) 2 tablets qid _... Metronidazole 250 mg tid _... H2-receptor antagonists (e.g., cimetidine 400 mg bid, ranitidine 150 mg bid) inhibit gastric acid secretion; serious side effects are infrequent (e.g., reversible hepatitis with ranitidine). _... Proton-pump inhibitors (e.g., omeprazole 20 mg/day, lansoprazole 30 mg/day) decrease gastric acid secretion. _... Antacids are used for relief of symptoms and to aid healing of ulcers. _... Sucralfate (1,000 mg qid) acts to protect the ulcer crater with an adherent coating; acts only locally (not absorbed); used for up to two months. _... Colloidal bismuth compounds (e.g., bismuth subcitrate 240 mg bid, bismuth subsalicylate 500 mg qid) can eradicate H. pylori and are also antacids. They increase gastric mucosal secretion of prostaglandins, bicarbonate, and glycoprotein mucus. _... Surgery is indicated for perforation, gastric outlet obstruction, hemorrhaging, and patients who do not respond to medical treatments. To be considered in the aggressive treatment of GU if other therapies fail.

Complementary and Alternative Therapies

 Nutritional and herbal support help to heal gastric mucosa, fight infection, and reduce recurrence. In addition, mind-body techniques such as meditation, progressive muscle relaxation, tai chi, yoga, and stress management may alleviate symptoms and enhance healing.

Nutrition

 _... Avoid dairy, caffeine, alcohol, and sugar. Coffee, even decaffeinated, should be eliminated because of irritating oils. _... Eliminate any known food allergens. Food allergies can be tested for using an IgG ELISA food allergy panel, or by an elimination diet. _... Include sulfur-containing foods such as garlic, onions, broccoli, cabbage, brussels sprouts, and cauliflower in the diet. Sulfur is a precursor to glutathione that provides antioxidant protection to the gastric mucosa. N-acetylcysteine (200 mg bid) is also a precursor to glutathione. _... Bananas contain potassium and plantain, both of which yield benefits. _... Acidophilus (one capsule with meals) can help normalize bowel flora and inhibit H. pylori. _... Essential fatty acids (1,000 to 1,500 mg bid to tid) reduce inflammation and inhibit the growth of H. pylori. _... Vitamin C (1,000 mg tid) decreases nitrosamines which are linked to stomach cancer and inhibits H. pylori. _... Zinc (30 to 50 mg/day) enhances healing. _... Vitamin E (400 IU/day) enhances healing and provides antioxidant protection. _... Vitamin A (50,000 IU/day for two weeks followed by 10,000 to 25,000 IU/day) for longer term maintenance. _... Glutamine (500 to 3,000 mg tid) promotes healing of ulcers. Cabbage juice (1 quart/day) is high in glutamine, although it may initially be irritating.

EXPECTATIONS (PROGNOSIS)
Most ulcers heal with medication in 6 to 8 weeks. Recurrence is common, but recurrent ulcers usually heal quickly and are not serious.
COMPLICATIONS
Complications are that a hemorrhage, perforation (hole), and obstruction may occur. 

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Compiled and Shared By: Habib Anwar 

habib.anwar@hotmail.com