Peptic ulcer disease

The symptoms of peptic ulcer disease may vary from person to person, depending on the site of the ulcer and age. An ulcer in the stomach is called a gastric ulcer, whereas an ulcer in the duodenum (part of the small intestine) is called a duodenal ulcer. One of the most common symptoms of peptic ulcer disease is gnawing pain in the abdomen. However, not everyone with this condition experiences symptoms. Some people do not notice any signs of the disease until complications such as internal bleeding or abdominal perforation develop. The telltale signs and symptoms of peptic ulcer disease include the following:

• Pain in the stomach: Peptic ulcer-related pain radiates from the middle of your stomach and travels to the neck region, the naval area, or your back. It is characterized by a gnawing or burning sensation. One can differentiate between gastric ulcer and duodenal ulcer based on the timing of the appearance of their symptoms after meal consumption. Pain occurs shortly after meals in the case of gastric ulcer and 90-180 minutes after meals in the case of duodenal ulcer. People with duodenal ulcers often experience nocturnal pain (pain during the night).
• Bloating: Bloating can make you feel like your stomach is full of air or gas, which can be a very uncomfortable feeling.
• Blood in vomit: Also known as hematemesis, this is a severe condition that requires immediate medical attention.
• Blood in stool: If your stools are black, it might indicate gastrointestinal bleeding.
• Other gastric ulcer symptoms include:
  • A feeling of fullness in the abdomen
  • Vomiting and nausea
  • Weight loss
• The warning symptoms that require urgent medical care include:
  • Unexplained weight loss
  • Iron deficiency
  • Gastrointestinal bleeding
  • Dysphagia or difficulty swallowing
  • Excessive vomiting

Here’s more on the common causes of a stomach ache and when to consult a doctor for a stomach ache.

Peptic ulcers develop when digestive acid works against the defense mechanism of the stomach and erodes the protective lining. The common causes of peptic ulcers include:

• Helicobacter pylori (H. pylori) infection
• Excessive consumption of non-steroidal anti-inflammatory drugs (NSAIDs)

H. pylori Infection

H. pylori can affect individuals of all ages and is one of the most prevalent causes of peptic ulcer disease (PUD). The infection often goes unnoticed, as it may not cause symptoms in its early stages. The bacteria reside in the stomach lining and generally do not cause issues; however, in some cases, they can irritate the lining, making it weak and susceptible to stomach acid, ultimately leading to the development of ulcers.

Non-steroidal Anti-inflammatory Drugs (NSAIDs)

Although doctors prescribe NSAIDs to treat pain, inflammation, and fever, some individuals take them without symptoms. Prolonged or excessive use of NSAIDs can result in side effects, including stomach ulcers.

Lifestyle Factors

Several lifestyle factors may also contribute to the formation of ulcers in the stomach or duodenum, including:

• Eating spicy food
• Drinking alcohol
• Experiencing stress

• H. pylori infection
• Advanced age
• Frequent and unnecessary intake of NSAIDs
• Long-term use of glucocorticoids and anticoagulant medications
• Health conditions such as lung, kidney, or liver disease
• Smoking
• Heavy alcohol consumption
• Family history of peptic ulcers
• Hispanic or African American ethnicity

To begin with, your doctor will ask you about your symptoms and whether you have been taking NSAIDs. They may also test you for H. pylori infection.

Medical Examination for H. pylori Infection

If your doctor suspects you have an H. pylori infection, they will suggest taking the following tests:

• Urea breath test: This is a breath test in which your doctor will ask you to consume a special drink containing urea. Your breath will then be analyzed for the bacteria based on the amount of carbon dioxide you exhale after drinking the solution.
• Stool antigen test: In this test, the doctor will analyze your stool sample for the presence of the bacteria.
• Helicobacter pylori IgG test: Your doctor will take a blood sample and test it for antibodies against the H. pylori bacteria.

Gastroscopy

During this procedure, your doctor will use a flexible and thin endoscope equipped with a camera. They will administer a mild sedative and spray a local anesthetic before inserting the tube through your mouth to visualize the interior of your stomach and intestine. This is usually an outpatient procedure, allowing you to return home the same day. In addition to enabling direct visualization of the gastric mucosa, endoscopy facilitates photographic documentation of any mucosal defects and tissue biopsy to rule out malignancy or H. pylori infection.

Prevention of peptic ulcers can be challenging. The exact mechanisms of how the bacteria spread and why some individuals develop peptic ulcers without H. pylori infection are not fully understood. Researchers and medical experts globally are working on developing a vaccine to address peptic ulcer disease. Some preventive measures you may practice include the following:

• Avoid irritants: The food you eat goes directly to your stomach. It is essential to avoid food items that can irritate it, particularly spicy foods, oily foods, and citrus fruits.
• Quit smoking: Heavy smoking increases the risk of developing duodenal ulcers compared to non-smokers. Therefore, it is advisable to quit smoking. If you find it challenging to stop smoking despite efforts, consider consulting a counselor. Tobacco is harmful to health.
• Control alcohol consumption: Excessive alcohol intake can lead to the development of peptic ulcers and other health complications. It is advisable to drink alcohol in moderation, and if possible, to stop drinking altogether.
• Limit intake of painkillers: Many individuals take painkillers, especially NSAIDs, unnecessarily. Taking these medications without food can increase the risk of developing peptic ulcers. To protect the stomach's lining, take NSAIDs with food and only when necessary.
• Control stress: Practice guided meditation and engage in regular exercise to relax your mind and body. This will help you cope with increasing stress levels. Lifestyle modifications such as eating the right foods at the right times, staying hydrated, and ensuring quality sleep can also help prevent peptic ulcers.

If you are diagnosed with peptic ulcer disease, your doctor will determine the treatment plan based on the underlying cause. With appropriate treatment, healing may take around one to two months.

If Helicobacter pylori infection and/or the use of NSAIDs is the cause of your ulcer, your doctor is likely to prescribe a course of antibiotics along with a proton pump inhibitor (PPI). If NSAIDs are the sole cause of your peptic ulcer, your doctor may recommend a PPI. Occasionally, H2-receptor antagonists may be prescribed instead of PPIs. For short-term relief from ulcer symptoms, your doctor might prescribe antacids. Additionally, your doctor may recommend a follow-up gastroscopy procedure 4 to 6 weeks after treatment to check whether your ulcer has healed.

Medicines

Antibiotics

If H. pylori infection has caused the ulcer, your doctor will likely prescribe antibiotics. Mild side effects may include diarrhea, malaise, and a metallic taste in your mouth. These medications help eliminate the bacteria to promote faster healing. Commonly prescribed antibiotics include:

• Amoxicillin
• Clarithromycin
• Metronidazole
• Tetracycline
• Nitroimidazole
• Levofloxacin
• Doxycycline

Proton Pump Inhibitor (PPI)

This class of medication reduces acid production in the stomach to prevent further damage to the ulcer. Treatment typically lasts for 4 to 8 weeks. Examples of PPIs include:

• Omeprazole
• Pantoprazole
• Rabeprazole
• Lansoprazole

While PPIs generally do not have severe side effects, they may include:

• Nausea
• Diarrhea
• Constipation
• Headache
• Stomach pain
• Dizziness

Long-term use of PPIs may lead to potential adverse effects such as:

• Acute kidney disease
• Chronic kidney disease
• Hypomagnesemia
• Clostridium difficile infections

H2-Receptor Antagonists

H2-receptor antagonists, also known as H2 blockers, reduce acid production in the stomach similarly to PPIs. Examples include:

• Famotidine
• Nizatidine

Potential side effects, though uncommon, may include:

• Stomach pain
• Dizziness
• Headaches
• Constipation or diarrhea
• Rashes

Antacids

Since the medications mentioned above may take several hours to act, your doctor may recommend antacids for immediate relief. Antacids neutralize stomach acid and can provide quick relief from acidity. Some may contain alginate, which creates a protective coating over the stomach lining. These medications are available over-the-counter (OTC). Possible side effects include:

• Nausea
• Flatulence
• Constipation (from aluminum-containing preparations)
• Diarrhea (from magnesium-containing preparations)
• Stomach cramps

Note: If NSAIDs are the cause of your stomach ulcer, your doctor may review your use of these medications. They might suggest an alternative painkiller like paracetamol, which is not associated with ulcers. Your doctor may also prescribe a COX-2 inhibitor. If you have been taking low-dose aspirin to reduce the risk of blood clots, inform your doctor, who will advise you on whether to continue.

Surgery

If you are unresponsive to the above treatment options or not compliant, your doctor may recommend surgery to heal the peptic ulcer. Surgical procedures may include:

• Vagotomy: Cutting off one or more branches of the vagus nerve to reduce gastric secretion.
• Antrectomy: Surgical removal of the gastric or pyloric region of the stomach.
• Pyloroplasty: Widening the opening in the lower part of the stomach to allow food to empty directly into the small intestine.
• Artery tying off: If a stomach ulcer is bleeding, your doctor may cut off an artery to stop blood supply to the area.

What you eat and how you eat play a crucial role in peptic ulcer management at home. Here are some do's and don'ts for people with peptic ulcer disease.

Do's

• Make sure to eat food at regular intervals. For example, eat small meals in small portions every 3 hours.
• Have your meal 2 to 3 hours before going to bed.
• Chew your food slowly and thoroughly.
• Consume fresh fruits and vegetables.
• Drink plenty of water.

Don'ts

• Do not consume excessive amounts of sour, fried, and spicy foods.
• Avoid caffeinated beverages such as tea and coffee.
• Do not drink alcohol, chew tobacco, or smoke.
• Never self-medicate.
• Avoid painkillers such as NSAIDs.

Usually, peptic ulcer disease does not cause any complications. However, if not diagnosed and treated in a timely manner, it can lead to severe complications. The following are the possible complications associated with peptic ulcer disease:

• Internal bleeding: This is the most prevalent complication of peptic ulcer disease. It mainly occurs if an ulcer is located near a blood vessel. Internal bleeding can be categorized into two types:
  • Long-term and slow bleeding: This can lead to various complications including anemia, pale skin, breathlessness, increased heartbeat, and fatigue.
  • Rapid bleeding: This can result in blood in vomit and passing black stools.
• Perforation: Although rare, this complication can be painful. It occurs when the protective lining of the stomach perforates, allowing bacteria to enter and infect the peritoneum (the lining of the abdomen). This condition is known as peritonitis. If not treated promptly, it can spread into the bloodstream and cause sepsis, potentially leading to multiple organ failure.
• Gastric outlet obstruction: Sometimes, a scarred or swollen ulcer can block the passage of food in the digestive system, leading to gastric outlet obstruction. Symptoms include:
  • Feeling bloated or full all the time
  • Bouts of vomiting that contain undigested food
  • Unexplained weight loss
• Cancer: Infection with Helicobacter pylori as an etiological factor increases the risk of developing stomach cancer from the ulcer.

Here are some quick home remedies for peptic ulcers:

• Fenugreek (Methi): Fenugreek seeds are enriched with antioxidants that help reduce the severity of gastric ulcers. Boil a cup of fenugreek leaves in water, add salt to taste, and drink this concoction twice a day. Fenugreek seeds offer additional health benefits.
• Cabbage (Bandha gobi) juice: Cabbage juice strengthens the lining of your stomach and aids in healing. Drink fresh cabbage juice regularly before going to bed.
• Banana (Kela): Bananas are rich in antibacterial properties that slow the progression of peptic ulcer disease. Eat a banana after breakfast every day.
• Honey (Shehed/Madhu): Honey possesses antimicrobial properties and acts as a natural healer. It helps reduce inflammation and promotes stomach health. Consume one tablespoon of honey before breakfast or add it to your meals.
• Garlic (Lehsun): Garlic has antibacterial and antimicrobial properties that combat infections. Consume 2 to 3 cloves of garlic every morning for optimal benefits.
• Slippery elm (Indian elm): The bark of the slippery elm plant soothes the mucus membranes lining the stomach and duodenum. Grind the bark to a powder, mix one cup of warm water with the powder, and drink this concoction three times a day.

Yoga for peptic ulcers: Practicing yoga asanas enhances blood circulation in your digestive organs, aiding in the healing of stomach ulcers. Common yoga poses for peptic ulcers include:

• Mandukasana
• Sasakasana
• Yoga Mudrasana
• Ardhamatyendrasana
• Vakrasana
• Pawan Muktasan
• Gomukhasana

With adequate treatment and care, PUD heals over time. However, you need to monitor your diet and habits to reduce the chances of relapse.

Determine Your Personal Tolerance

There is no proof that spicy or citrus foods influence ulcer disease. However, some people report worsened symptoms after consuming these kinds of foods. It is critical to discover what works best for you. If you find that specific foods make your symptoms worse, restrict or avoid them to feel your best, but do not eliminate an entire food category.

Take Care of Your Mental Health

Peptic ulcers can be caused indirectly by stress, worry, and depression. Ulcers can be exacerbated by poor eating habits and harmful lifestyle choices that may arise from mental health issues.

Change Your Diet

In addition to medications, physicians frequently advise patients with ulcers to make lifestyle and dietary modifications until complete healing occurs. Although patients were previously recommended to eat a bland diet, recent evidence does not support this dietary adjustment as useful. While spicy foods might aggravate ulcers in certain individuals, medical practitioners are increasingly emphasizing a high-fiber diet rich in vegetables and fruits. The following can be added to the diet:

• Fiber and Vitamin A: Foods such as liver, carrots, broccoli, sweet potatoes, kale, spinach, and collard greens are all high in Vitamin A.
• Flavonoid-rich foods and green tea: Garlic, onions, and colorful fruits and vegetables including cranberries, strawberries, blueberries, broccoli, carrots, and snap peas have high flavonoid content.
• Cranberry juice: Consuming two 250 ml cups of cranberry juice each day may lower the risk of H. pylori proliferation in the stomach. Cranberry aids in preventing inflammation by either preventing bacteria from adhering or disengaging it from the body after it has attached.

Individuals suffering from ulcers should avoid or limit coffee and alcohol.

• Coffee: Both caffeinated and decaffeinated coffee can increase acid production and aggravate symptoms in people with peptic ulcers.
• Alcoholic beverages: Alcoholic drinks can damage the protective mucosal lining of the gastrointestinal system, resulting in further inflammation and bleeding.