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 mucus 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.
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).
H. pylori is very common, infecting more than a billion people worldwide. It is estimated that half of the United States population older than age 60 has been infected with H. pylori. Infection usually persists for many years, leading to ulcer disease in 10 % to 15% of those infected. H. pylori is found in more than 80% of patients with gastric and duodenal ulcers. 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.
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 Probionibacterium.
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.
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.
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.
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.
Signs, symptoms & indicators of Gastric/Peptic Ulcers
Low tolerance of spicy foods
Black or 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.
Significant/frequent blood in stools
Rapid bleeding can cause bowel movements to become black or even bloody.
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.
Unexplained nausea
Unexplained vomiting
Bleeding ulcers may cause nausea and vomiting of acidified blood resembling “coffee grounds” material.
Dizziness when standing up
Patients with a bleeding ulcer may report a sense of passing out upon standing called orthostatic syncope.
Conditions that suggest Gastric/Peptic Ulcers
Heartburn / GERD
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]
Peritonitis
Sometimes an ulcer eats a hole in the wall of the stomach or duodenum. Bacteria 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.
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.
Stomach ulcer
Counter Indicators
Absence of stomach ulcer
Risk factors for Gastric/Peptic Ulcers
Trace/significant amounts of occult blood or history of occult blood
Counter Indicators
Absence of occult blood
Significant/moderate daily/mild daily aspirin use
(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.
Gastric/Peptic Ulcers suggests the following may be present
Heartburn / GERD
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]
Recommendations for Gastric/Peptic Ulcers
Glutamine
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 tid 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.
Propolis / Bee Products
An extensive article on the use of Manuka Honey can be viewedhere.
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.
Licorice Root (Glycyrrhiza glabra)
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 inhibiters (PPI). A typical dose of DGL will be 500mg tid either with or without a meal.
In a study of DGL in gastric ulcers, 33 gastric ulcer patients were treated with either DGL (760mg TID) or a placebo for one month. There was a significantly greater reduction in ulcer size in the DGL group (78%), than in the placebo group (34%). Complete healing occurred in 44% of those receiving DGL, but in only 6% of the placebo group. [Gut 1969:10; pp.299-303]
Increased Water Consumption
Consuming up to 12 cups of water per day can eliminate the helicobacter infection when present.
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.
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]
Antibiotics
Please see the link between H. Pylori and Antibiotics.
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. However, those who use NSAIDs may have a special need for supplemental glutamine. Fortunately, sufficient glutamine can undo the damage caused by NSAIDs, maintaining permeability at a healthy level. For heavy NSAID users, supplementing with glutamine can spell the difference between healthy gastrointestinal tract versus ulcers and the “leaky gut syndrome.” If you have symptoms that could be from stomach or peptic ulcers, NSAIDs should be avoided until these conditions are ruled out.
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.
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.
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]
But, Zinc Carnosine is much better.
Nutraceutical Therapy for Ulcers (and Gastritis). Excerpted from Holistic Primary Care, a Summer 2004 Special Report published by Metagenics. The report in its entirety may be viewed at www.needs.com
Zinc carnosine, a patented combination of two nutrients that have beneficial effects on the gastrointestinal mucosa, represents an important advance in the management of peptic ulcers. Widely used in Japan, where it is recognized as a drug by regulatory authorities, zinc carnosine given alone was shown by endoscope to resolve ulcers by 60 to 70%, a result comparable to conventional drug therapies and with a safety profile as good as or better than commonly used pharmaceuticals.
This novel compound contributes to ulcer healing through a number of different mechanisms, including the inhibition of Helicobacter pylori (H. pylori) – a bacterial strain thought to be causative of ulcers. Zinc carnosine has been shown to promote wound healing, reduce inflammation, improve secretion of the protective mucosal lining, and possess antioxidant effects. It can be used as a natural therapy, an antibiotic, or an alternative to conventional pharmaceuticals, such as proton pump inhibitors (i.e., Nexium) and H2 receptor antagonists (i.e., Pepcid), both of which serve to decrease hydrochloric acid (HCl). It can also be used as adjunctive therapy in combination with conventional ulcer drugs. Moreover, patients can safely take zinc carnosine with non-steroidal anti inflammatory drugs (NSAIDs) as a way of preempting their adverse gastric effects.
In many ways, zinc carnosine is an ideal complementary therapy for ulcers. Conventional allopathic medicines are suppressive and address the problem of peptic ulcers by controlling the corrosive aspects of stomach function (i.e., reducing acid secretion and eliminating H. pylori). Zinc carnosine enhances and strengthens the stomach’s natural defensive and self-protective capacities. It thus provides benefits characteristic of natural products and holistic strategies by treating the cause of the problem, but with the strong scientific pedigree of a pharmaceutical.
WHAT IS ZINC CARNOSINE?
Elemental zinc is known to speed healing of mucosal wounds and damaged cells, particularly in the gut. Carnosine is a naturally-occurring dipeptide, comprised of the amino acids, beta-alanine and L-histidine. It is a strong free-radical scavenger capable of blocking free radical chain reactions, inhibiting cell damage. It is also essential for DNA and RNA polymerase activity to aid cell damage.
Zinc carnosine was developed in an effort to provide a therapy that bolsters the ability of the gastric lining to repair and protect itself. A chelate of elemental zinc and carnosine in a 1:1 ratio, zinc carnosine entered the Japanese market as a pharmaceutical for ulcer treatment in the early 1990s and has been marketed there under the trade name Polaprezinc.
GASTRIC MUCOSAL BALANCE: A NEW WAY OF THINKING ABOUT ULCER DISEASE
The digestive tract has a curious challenge. It must produce caustic matter (stomach acid, pepsin, enzymes, bile) capable of breaking down many different substances, including animal tissue much like those comprising the digestive organs themselves. Consequently, the mucosa must produce sufficient quantities of mucus and other protective factors to keep digestive juices from going to work on its own walls. Digestive health hinges on the balance between secretions of digestive substances and maintenance of the mucosal wall.
Peptic ulcers are best understood as the net result of an imbalance between the caustic processes of digestion and stomach-wall maintenance. When the latter can’t keep up with the former, the stage is set for stomach-wall disruption and ultimately ulceration.
And even with the best pharmacotherapy, ulcer recurrences are common, suggesting that acid suppression and eradication of microbial pathogens are insufficient.
Hyper-secretion of stomach acid may play a role in some cases and this is clearly stress-related. However, under-secretion of mucus and/or a breakdown in stomach cell repair mechanisms likely play an equal, if not more significant, role. The current therapeutic challenge is to restore the delicate balance by addressing the factors that impair healing of the gastric lining and improve mucosal integrity.
CONVENTIONAL PHARMACOTHERAPIES AND THEIR LIMITATIONS
Pharmacologic treatment of ulcer disease is big business. Aside from costs, long-term treatment with acid-suppressing drugs can result in a number of untoward effects, many of which run counter to the primary objective of restoring digestive health.
Effective digestion is based upon maintaining strongly acidic pH in the stomach and a base pH in the intestines.Many people with heartburn and indigestion actually tend to have too little gastric acid, rather than too much, a condition especially common among the elderly. Thus, many older individuals with ulcers are already acidsuppressed before being given acid-suppressing drugs.
Further suppression via pharmacotherapy has downstream consequences, including poor digestion, malabsorption, and gradually deteriorating nutritional status. Acidsuppression therapy also reduces the secretion of gastric mucus, a natural response to reduced stomach acidity. However, when a patient discontinues acid suppression drugs and returns to normal acid secretion levels, the gastric lining is left even more vulnerable than it was initially. This accounts for the high recurrence rate following treatment cessation.
Bear in mind that stomach acid is among the body’s primary defense strategies, providing a way to destroy pathogens ingested with food. By reducing HCl, suppressive therapies increase the possibility that pathogenic organisms will be able to pass through the gastric phase and colonize the lower GI tract.When stomach acid production is deficient and gastric digestion incomplete, it is more difficult to maintain a healthy intestinal ecology. Similarly, antibiotics that kill off H. pylori knock off a lot of friendly flora as well, increasing the chances of intestinal overgrowth with pathogenic bacteria or yeasts. Plus, gastric acid triggers the release of enzymes in the small intestine, and reducing this stimulus results in an inadequate release of digestive juices.
BASIC RESEARCH
In rats subjected to aspirin-induced gastric mucosal injury, zinc carnosine markedly reduced lipid peroxidation, neutrophil accumulations, and inflammatory factors. The net result was significant reduction in mucosal erosions. A separate study, also in rats, showed that zinc carnosine could prevent the reduction in gastric mucus secretion that follows the exposure to alcohol, another ulcer trigger.
CLINICAL TRIALS: SAFE AND EFFECTIVE MONOTHERAPY
To date, there have been eight clinical trials of zinc carnosine for the treatment of peptic ulcers. Initial dose-ranging and safety studies evaluated doses of 75 to 600 mg per day, given under fasting conditions, as well as at meal times. The data indicate that zinc carnosine is entirely safe up to 600 mg per day. The only adverse effects were mild heartburn-like symptoms in two patients on the highest dose taken without food. There was no toxic accumulation of zinc in the lood, and the compound was readily excreted in urine and stool without adverse kidney or lower GI effects. Researchers demonstrate zinc carnosine to be highly effective when used continuously for 8 weeks. A fitting recommendation is one tablet, twice a day, of Zinlori 75 from Metagenics Inc. Beyond its applications in the management of peptic ulcers, zinc carnosine may have a role in treatment of gastritis and stomatitis.
Ozone / Oxidative Therapy
Cuban doctors are using capsules filled with ozonated oil to treat gastroduodenal ulcers, gastritis, giardia and peptic ulcers.
Vitamin B3 (Niacin)
In rare cases, niacin has aggravated peptic ulceration.
Key
| Weak or unproven link |
| Strong or generally accepted link |
| Proven definite or direct link |
| Very strongly or absolutely counter-indicative |
| May do some good |
| Likely to help |
| Highly recommended |
| May have adverse consequences |
| Avoid absolutely |
Glossary
Peptic Ulcer
A general term for gastric ulcers (stomach) and duodenal ulcers (duodenum), open sores in the stomach or duodenum caused by digestive juices and stomach acid. Most ulcers are no larger than a pencil eraser, but they can cause tremendous discomfort and pain. They occur most frequently in the 60 to 70 age group, and slightly more often in men than in women. Doctors now know that there are two major causes of ulcers: most often patients are infected with the bacteria Helicobacter pylori (H. pylori); others are regular users of non-steroidal anti-inflammatory drugs (NSAIDS), which include common products like aspirin and ibuprofen.
Stomach
A hollow, muscular, J-shaped pouch located in the upper part of the abdomen to the left of the midline. The upper end (fundus) is large and dome-shaped; the area just below the fundus is called the body of the stomach. The fundus and the body are often referred to as the cardiac portion of the stomach. The lower (pyloric) portion curves downward and to the right and includes the antrum and the pylorus. The function of the stomach is to begin digestion by physically breaking down food received from the esophagus. The tissues of the stomach wall are composed of three types of muscle fibers: circular, longitudinal and oblique. These fibers create structural elasticity and contractibility, both of which are needed for digestion. The stomach mucosa contains cells which secrete hydrochloric acid and this in turn activates the other gastric enzymes pepsin and rennin. To protect itself from being destroyed by its own enzymes, the stomach’s mucous lining must constantly regenerate itself.
Duodenum
First portion of the small intestine between the pylorus and jejunum.
Esophagus
Commonly called the "food pipe", it is a narrow muscular tube, about nine and a half inches long, that begins below the tongue and ends at the stomach. It consists of an outer layer of fibrous tissue, a middle layer containing smoother muscle, and an inner membrane, which contains numerous tiny glands. It has muscular sphincters at both its upper and lower ends. The upper sphincter relaxes to allow passage of swallowed food that is then propelled down the esophagus into the stomach by the wave-like peristaltic contractions of the esophageal muscles. There is no protective mucosal layer, so problems can arise when digestive acids reflux into the esophagus from the stomach.
Ulcer
Lesion on the skin or mucous membrane.
Bacteria
Microscopic germs. Some bacteria are "harmful" and can cause disease, while other "friendly" bacteria protect the body from harmful invading organisms.
Helicobacter Pylori
H. pylori is a bacterium that is found in the stomach which, along with acid secretion, damages stomach and duodenal tissue, causing inflammation and peptic ulcers. Although most people will never have symptoms or problems related to the infection, they may include: dull, 'gnawing' pain which may occur 2-3 hours after a meal, come and go for several days or weeks, occur in the middle of the night when the stomach is empty and be relieved by eating; loss of weight; loss of appetite; bloating; burping; nausea; vomiting.
pH
A measure of an environment's acidity or alkalinity. The more acidic the solution, the lower the pH. For example, a pH of 1 is very acidic; a pH of 7 is neutral; a pH of 14 is very alkaline.
Gastritis
Inflammation of the stomach lining. White blood cells move into the wall of the stomach as a response to some type of injury; this does not mean that there is an ulcer or cancer - it is simply inflammation, either acute or chronic. Symptoms depend on how acute it is and how long it has been present. In the acute phase, there may be pain in the upper abdomen, nausea and vomiting. In the chronic phase, the pain may be dull and there may be loss of appetite with a feeling of fullness after only a few bites of food. Very often, there are no symptoms at all. If the pain is severe, there may be an ulcer as well as gastritis.
Antacid
Neutralizes acid in the stomach, esophagus, or first part of the duodenum.
Chronic
Usually Chronic illness: Illness extending over a long period of time.
Gastrointestinal
Pertaining to the stomach, small and large intestines, colon, rectum, liver, pancreas, and gallbladder.
Endoscopy
A procedure that uses an Endoscope.
Cancer
Refers to the various types of malignant neoplasms that contain cells growing out of control and invading adjacent tissues, which may metastasize to distant tissues.
Benign
Literally: innocent; not malignant. Often used to refer to cells that are not cancerous.
Epigastric
Relating to the area immediately above the stomach.
Nausea
Symptoms resulting from an inclination to vomit.
Gastric Reflux Disease
Gastro-Esophageal Reflux Disease (GERD). A common relapsing condition affecting approximately 10% of the U.S. population and caused by an abnormal exposure of the lower esophagus to refluxed gastric contents, causing irritation and injury to the esophageal tissues. GERD develops as a result of relaxations of the transient lower esophageal sphincter. Typical presenting symptoms are heartburn, an epigastric burning sensation and acid regurgitation. However, some patients may present with atypical symptoms such as chest pain, shortness of breath, wheezing, and coughing.
Dyspepsia
Indigestion.
Peritoneum
Serous sac lining the abdominal cavity and covering most of the organs inside it.
Pylorus
The sphincter muscle at the distal (lower) opening of the stomach. The pylorus only allows food to pass through after the digestive enzymes of the stomach have properly processed it. Once through the pylorus on its way to the duodenum, the food is still only partially digested.
Metabolism
The chemical processes of living cells in which energy is produced in order to replace and repair tissues and maintain a healthy body. Responsible for the production of energy, biosynthesis of important substances, and degradation of various compounds.