GIT ulcers of recent have become one of the commonest diseases affecting both old and young. These are ulcers that affect organs of the digestive tract i.e. mouth, esophagus, stomach, small and large intestine.
They are popularly known as peptic ulcers because they describe ulcerative disorders that affect upper gastrointestinal tract.
Peptic ulcers as a way of definition can be an erosion of the mucous membrane which may occur at different locations of the gastrointestinal tract and is occasionally accompanied by inflammation and infection of the GIT.
A lot of patients do not get cured and have often complained of recurrence of this condition even after taking medications for it.
The reasons may be due to poor diagnosis as there is need for proper diagnosis of PUD so that it can be effectively treated.
Most patients who visit or present to the physician with stomach ache or chest pain are often prescribed Peptic ulcer medications, these patients are supposed to undergo some further checks such as endoscopy to define or look out for a mucus bridge.
Where a mucus bridge is not effectively defined, you cannot conclude that is ulcer.
Types of Peptic Ulcer Disease
Based on the location, there are three types of peptic ulcer disease namely:
- Gastric ulcer: These are ulcers that are found to develop inside the stomach.
- Esophageal Ulcer: These ulcers develop on the wall of the esophagus.
- Duodenal ulcer: These ulcers are found to develop in the duodenum. Duodenum is the upper part of the small intestines.
Causes of Peptic Ulcer Disease (PUD)
Below are the major causes of PUD, these factors causing the lining of the GIT to break down including:
- Helicobacter pylori: This is the bacteria that cause stomach infection and inflammation in people with peptic ulcers. It is found in about 50% of people with ulcers and the presence of these bacteria is believed to delay healing.
- Frequent use of Non-steroidal anti-inflammatory drugs and Aspirin
- Consumption of too much alcohol
- Radiation therapy
- Stomach cancer
Genetic factors: Some people harbor strains of H. pylori that contain genes that may make the bacteria more dangerous and increase the risk for ulcers.
How important these genetic factors are in the development of ulcers depends on a person’s ethnicity.
Immune Abnormalities: Some experts suggest that certain individuals have abnormalities in their intestinal immune response which allow the bacteria to injure the lining.
Lifestyle factors: Lifestyle factors such as excessive stress, chronic consumption of coffee and smoking were long believed to be the primary causes of ulcer but of recent it was discovered that they only increase your vulnerability to ulcers especially in some carriers of H. pylori.
Interrupted sleep: people who do shift night work have shown to have higher incidence of ulcers than those that do day work.
Researches have shown that interrupted sleep has the ability to weaken immune systems and reduces its ability to protect against harmful bacterial substances.
Peptic Ulcers Symptoms
Common symptoms of peptic ulcer include:
- Stomachache: Burning stomach pains that extends from navel to the chest, which can range from mild to severe and in some cases these pains may wake you up at night.
- Changes in appetite
- Nausea and Vomiting
- Dark or bloody stool
- Rapid weight loss
- Chest pain
Complications of Peptic Ulcer Disease
- Severe pain
- Lack of sleep
- Severe vomiting
- Age: Peptic ulcers affect all age groups, but rare in children. Most cases of duodenal ulcers begin at age 25years and continue until age 75 years. The risk for gastric ulcers peaks at 55-65 years.
- Sex: Men are more at risk than women.
- Alcoholism: Drinking too much alcohol
- Occupation: Night time workers are more at risk of peptic ulcers than daytime workers.
- Taking NSAIDs for long
- People with history of ulcer disease
- Regular and Persistent pains on an empty stomach
- Dyspepsia lasting for more than one month
Diagnosis of Peptic Ulcers
There are basically two types of test to diagnosis PUD namely:
Upper Endoscopy: This test is done by a professional who passes a long tube that has a camera attached down your GIT to look for areas with ulcers. It also helps the physician to collect tissue samples for examination.
It is worthy of note that not all ulcer cases require upper endoscopy, although it is highly recommended in people at high risk of stomach cancer such as people above 45 years, people who experience anemia, weight loss, GI bleeding, and those who find it difficult swallowing.
Upper gastrointestinal series: This test is recommended for people with lower risk of stomach cancer, or who don’t find it difficult swallowing.
In this procedure, you will be asked to drink a thick liquid called barium swallow, this liquid will make it possible for your physician to see the areas of ulcers and treat it appropriately. Then an x-ray of your stomach, esophagus and small intestine will be taken.
Additionally, your doctor will ask you to do H. pylori test which will further help him determine infection in your stomach.
The Test to Determine H. pylori
H. pylori can simply be detected using blood, breath and stool tests with a relatively high degree of accuracy. Candidates for H. pylori tests are not fully known but some patients with dyspepsia and high risk conditions like weight loss, anemia, recurrent or bleeding ulcers have been screened for H. pylori.
The following are tests used to diagnose H. pylori infection before and after treatment:
Stool test: This is a test done to detect genetic fingerprints of H. pylori in faeces. It can also be done after antibiotic therapy to confirm that H. pylori have been fully eradicated and the infection treated.
Blood test: This test is very fast and results are obtained within minutes. It is used to determine antibodies to H. pylori with an 80-90 percent accuracy reported.
The most common blood test is ELISA (Enzyme-Linked Immunosorbent Assay).
Breath Test: The carbon isotope-urea breath test (UBT) can identify 90-99 percent of people with H. pylori. Two weeks to the test, the patient is advised to stop taking antibiotics, antacids e.g. bismuth containing medications and the popular proton pump inhibitors (PPI).
Then the patient is given a substance containing urea treated with carbon atoms. If H. pylori are presents the bacteria convert the urea in the substance to carbon-dioxide which is detected and recorded in the patient’s exhaled breath after 10 minutes.
It is also used to confirm that H. pylori have been fully treated.
Misdiagnosis of Peptic Ulcer
Most patients with peptic ulcers are often missed due to misdiagnosis; therefore differential diagnosis should be done to rule out other diseases that may look like Peptic ulcer disease. Below are disease conditions that may be confused with peptic ulcers:
Gastroesophageal reflux disease (GERD): About 50% of patients with GERD also develop Dyspepsia. Common symptoms of GERD include: heartburn, radiating pain that goes to the esophagus which usually develops after meals and that can be relieved with antacids, dysphagia or difficulty swallowing, Acid reflux or regurgitation, loss of appetite, weight loss, anemia, vomiting.
Irritable Bowel Syndrome: Main symptoms include: Dyspepsia, nausea and vomiting, bloating, abdominal pain, common in women than men.
Heart disease: Heart pain such as heart attack or angina is more likely to occur with exercise and may radiate to the neck, jaws or arms. Most patients with Heart disease have family history, are smokers, have hypertension or are obese.
Gall stones: The most striking symptom of gallstones is a steady gripping or gnawing pain on the right side under the rib cage which can be quite severe and can radiate to the upper back.
Some patients may experience pain around the breast bone. These pains occur after a fatty or heavy meal, but one thing with gallstones is that there is no dyspepsia.
Treatment for Peptic Ulcer Disease
There are several approaches in which your ulcers can be treated, they include:
- Non-pharmacological approach
- Pharmacological approach
- Surgical approach
This approach involves making changes to your lifestyle and diet plan. These lifestyle changes include:
- Stop smoking
- Stop too much alcohol consumption
- Avoid long use of Aspirin, ibuprofen, Naproxen and other NSAIDs that are believed to cause ulcer
- Never use milk to relief ulcer pain because milk also causes the production of more stomach acid and digestive juices, which may worsen ulcers.
- Avoid sleeping 2-3 hours after a heavy meal
This approach involves the use of peptic ulcer medications and there are several types of medications that are used to treat peptic ulcer disease. The choice of the best treatment for your ulcer depends largely on the cause of your peptic ulcer.
Treatment of an NSAID-induced peptic ulcer with H. pylori infection
The approach to this treatment involves the use of proton pump inhibitors or histamine receptor blockers, antibiotics and antacids.
Proton pumps Inhibitors (PPI):
PPIs binds to H+/K+ exchanging ATPase (proton pump) in gastric parietal cells which results in the reduction of stomach acid and protection of the lining of the stomach and small intestine (duodenum). They do not have the capacity to kill H. pylori, but they help to fight the H. pylori infection.
Examples of PPIs include:
Histamine receptor blockers:
They work by blocking H2 receptors of gastric parietal cells which leads to inhibition of gastric secretions. Examples include
Antibiotics are included in the treatment of peptic ulcer to eradicate H. pylori and treat the infection. The choice of antibiotics to cure most H. pylori induced peptic ulcer may differ all over the world because of how difficult it is to fully kill the bacteria.
Common antibiotics prescribed include:
Medications containing bismuth subsalicylate coat and protect peptic ulcer from stomach acid. It can kill H. pylori however it should not be used as a substitute to antibiotics therapy but should be prescribed with antibiotics.
Antacids are often prescribed alongside other medications to provide temporary relief from heartburn and dyspepsia, they neutralize stomach acid, and protect the stomach by increasing mucus and bicarbonate secretions.
It does not kill H. pylori. Advisably, you should not combine antacids with other medications, take antacids between meals and at bedtime.
The basic salts that are commonly used in antacids include: Aluminium, Magnesium and calcium salts.
Treatment of NSAID-induced peptic ulcer
Non-steroidal anti-inflammatory drugs are drugs that are used to relief pains and inflammations. Overuse of these drugs can cause peptic ulcer and worsen your condition.
If NSAIDs are the main cause of your peptic ulcer you may be advised to stop or reduce taking NSAIDs or use alternative drug that does not cause ulcer.
Goal of therapy:
- To reduce stomach acid
- To relieve pain
- To help the ulcer heal
- To improve quality of life
The drugs that are commonly used include:
Proton Pump Inhibitors: They reduce stomach acid and protect the mucosal lining of the stomach and small intestine. Examples
Histamine receptor blockers
These drugs reduce the production of stomach acid by blocking Histamine. They include
Sucralfate Protectants coat ulcers and protect them against stomach acid and other enzymes so that the ulcers can heal.
Some habits such as smoking and alcoholism should be avoided because they can limit or worsen the healing of peptic ulcer.
Treatment of H.pylori-induced peptic ulcer
Goal of therapy:
- Eradicate H. pylori
- Heal H. pylori infection
- To relief symptoms
- Improve patient quality of life
The treatment approaches as explained by the National Institute of Diabetes and Digestive and Kidney Diseases include the use of:
Triple Therapy combination
The course of therapy is 7-14 days
- Two Antibiotics: The antibiotics such as clarithromycin + metronidazole, clarithromycin + amoxicillin, or clarithromycin + tinidazole.
- A Proton Pump Inhibitor: Omeprazole, rabeprazole, esomeprazole, pantoprazole, Lantoprazole.
Quadruple therapy Combination
This therapy is given to patients who are allergic to penicillins e.g. amoxicillin, or have previously used macrolides e.g. clarithromycin or have H. pylori even after treatment with triple therapy medications.
The treatment course is 14 days.
- a PPI: pantoprazole, Lantoprazole, Omeprazole, rabeprazole
- Bismuth subsalicylate
- Two Antibiotics: tetracycline + metronidazole
Sequential therapy combination
You might be prescribed the following for an initial 5 days
- a PPI: pantoprazole, Lantoprazole, Omeprazole, rabeprazole
- Penicillin: amoxicillin
Then your physician will prescribe you the following for another 5 days:
- A PPI: pantoprazole, Lantoprazole, Omeprazole, rabeprazole
- A Macrolide: clarithromycin
- A Nitroimidazole: tinidazole
While taking these medications, you may come down with few side effects which such as
- Your stool may be dark
- Lack of appetite or your mouth will be tasteless
- Your tongue may be dark
- Vaginal candidiasis
Whenever you notice any of those side effects, you should talk to your physician about it.
Surgery becomes an option if you develop a hole in your stomach wall or if you experience severe bleeding.
Prevention of Peptic Ulcer Disease
To help prevent a peptic ulcer disease you should do the following:
- Quit smoking
- Don’t consume too much alcohol.
- Reduce long term use of NSAIDs and aspirin.
- Avoid taking caffeine, coffee and acidic fruits e.g. oranges
- Reduce intake of spicy foods
- Avoid Overeating and eating within two to three hours before bed because it may worsen symptoms of acid reflux disease
Foods to eat when you have Peptic ulcer
Scientists have been exploring the different kinds of diet for peptic ulcer that may play a vital role in the fight against an H. pylori infection.
In addition to taking the normal peptic ulcer medications prescribed by your doctor eating these foods may also help fight the bacteria causing organism, most of which are rich in antioxidants which may help boost your immune system and help you fight the infection and protect you against stomach cancer.
Foods like blueberries, cherries, and bell peppers are packed with a lot of antioxidants. Leafy greens such as kale and spinach contain calcium and B vitamins.
Broccoli contains sulforaphane, a compound that exhibits activity against H. pylori. Some researches show that the fatty acids contained in olive oil can also help treat H. pylori infection.
Fermented probiotic foods have shown promise in clinical studies for ulcer treatment. These probiotic foods, such as miso, sauerkraut, and kimchi, may prevent reinfection.
Turmeric is currently being studied as a potential treatment for ulcers as well.
These diets include:
- Leafy greens, such as kale and spinach: contain calcium and B vitamins
- Olive oil: Olive oil contains fatty acids that can help treat H. pylori infection.
- Broccoli: contains sulforaphane which helps protect against H. pylori activity.
- Cherries contains antioxidants.
- Bell peppers contains antioxidants.
- Probiotic-rich foods, such as yogurt kimchi, miso, and sauerkraut. Clinical studies has shown that probiotics such as kimchi, miso, and sauerkraut may prevent reinfection. It should be taken as part of your diet plan when taking ulcer medications because it reduces symptoms associated with antibiotics and improves the effectiveness of the antibiotics.
- Berries e.g. blueberries contains antioxidants.
- Decaffeinated green tea
- Turmeric: contains active ingredient curcumin. Research has shown that Curcumin extracts have activity against H. pylori.
Foods to avoid when you have GERD and Peptic ulcer
Foods that should be avoided when you have ulcer or GERD worse include:
- Consumption of too much alcohol
- Spicy foods
- Acidic foods, such as oranges
- Caffeinated drinks
- Coffee drinks