• Abdominal distress 45 to 60 minutes after meals or during the night; both relieved by food, antacids, or vomiting
• Abdominal tenderness
• Chronic but periodic symptoms
• Ulcer crater or deformity in the stomach or upper small intestine visible on X-ray or endoscopic exam
• Positive test for blood in the stool
A peptic ulcer is an erosion of the tissue, producing a crater-like lesion. When it occurs in the stomach it is called a gastric ulcer; when it occurs in the first portion of the small intestine, it is called a duodenal ulcer. Duodenal ulcers are more common, occurring in an estimated 6 to 12% of the adult population in the United States. Duodenal ulcers are four times more common in men than in women, and four to five times more common than gastric ulcers.
Although symptoms of a peptic ulcer may be absent or quite vague, most peptic ulcers are associated with abdominal discomfort noted 45 to 60 minutes after meals or during the night. In the typical case, the pain is described as gnawing, burning, cramp-like, or aching, or as “heartburn.” Eating or taking antacids usually results in great relief.
Causes
Even though duodenal and gastric ulcers occur at different locations, they appear to be the result of similar mechanisms: damage to the protective factors that line the stomach and duodenum.
Gastric acid is extremely corrosive (pH 1 to 3), and though it is very effective at digesting food, it would eat right through the skin or mucous membrane. To protect against ulcers, the lining of the stomach and small intestine has a layer of slippery mucus called mucin. Other protective factors include the constant renewal of intestinal cells and the secretion of factors that neutralize the acid when it comes into contact with the lining of the stomach and intestine.
Contrary to popular opinion, excessive secretion of gastric acid output is rarely a factor in the development of gastric ulcers. In fact, patients who have gastric ulcers tend to secrete normal or even reduced levels of gastric acid. In duodenal ulcer patients, however, almost half have increased gastric acid output. This increase may be due to an increased number of acid-producing cells, known as parietal cells. As a group, patients with duodenal ulcers have twice as many parietal cells in their stomach as people without ulcers.
Even with an increase in gastric acid output, under normal circumstances there are enough protective factors to prevent either gastric or duodenal ulcer formation. However, when the integrity of these protective factors is impaired, an ulcer can form. A loss of integrity can be a result of infection by the bacterium Helicobacter pylori, use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), excessive use of alcohol, nutrient deficiency, stress, and many other factors. Of these factors, H. pylori and NSAIDs are by far the most significant.
The role of the bacterium H. pylori in peptic ulcer disease has been extensively investigated. It has been shown that 90 to 100% of patients with duodenal ulcers, 70% with gastric ulcers, and about 50% of people over the age of 50 test positive for this bacterium.1 Physicians can determine if it is present by measuring the level of antibodies to H. pylori in the blood or saliva, or by culturing material collected during an endoscopy.
Predisposing factors for H. pylori infection are low gastric acid output and low antioxidant content in the gastrointestinal lining. Helicobacter pylori infection increases gastric pH, thereby setting up a positive-feedback scenario.2 In other words, H. pylori infection leads to ulcer formation, and ulcer formation leads to H. pylori infection—a vicious circle.
Use of aspirin and other nonsteroidal anti-inflammatory drugs is associated with a significant risk of peptic ulcer. In addition, the combination of NSAID use and smoking is particularly harmful to the ulcer patient. Although most studies documenting the relative frequency of peptic ulcers as a consequence of aspirin and NSAIDs have focused on their use in the treatment of arthritis and headaches, in one study the risk of gastrointestinal bleeding due to peptic ulcers was evaluated for aspirin at daily dosages of 300, 150, and 75 mg—dosages commonly recommended to prevent heart attacks and strokes.3 The study was conducted at five test hospitals in England and found an increased risk of gastrointestinal bleeding due to peptic ulcer at all dosage levels. However, the dosage of 75 mg per day was associated with 40% less bleeding than 300 mg per day and 30% less bleeding than 150 mg per day. The researchers concluded: “No conventionally used prophylactic aspirin regimen seems free of the risk of peptic ulcer complications.”
Stress is universally believed to be an important causative factor in peptic ulcers. However, this link is not well established in the medical literature. One of the big problems is that studies attempting to examine this assumption about stress and ulcers have been poorly designed. Several studies have shown that the number of stressful life events is not significantly different in peptic ulcer patients compared with carefully selected, ulcer-free controls.4 The data suggest that the significant factor is not simply the amount of stress but rather an individual’s response to it.5 Psychological factors are probably important in some people with peptic ulcer disease, but not in others. As a group, ulcer patients have been characterized as tending to repress emotions. At the very least, we encourage our patients with ulcers to discover enjoyable outlets of self-expression as well as to develop effective stress management in their lives.
Smoking is a significant factor in the occurrence and severity of peptic ulcers. Increased frequency of occurrence, decreased response to peptic ulcer therapy, and an increased mortality due to peptic ulcers are all related to smoking. Smoking causes ulcers by at least three mechanisms. First of all, smoking increases the backflow (reflux) of bile salts into the stomach. Bile salts are extremely irritating to the stomach and initial portions of the duodenum. Bile salt reflux induced by smoking appears to be the primary reason for the increased peptic ulcer rate in smokers. Smoking also decreases the secretion of bicarbonate (an important neutralizer of gastric acid) by the pancreas and accelerates the passage of food from the stomach into the duodenum, thus not allowing the acid enough time to interact with food.6
The psychological aspects of smoking are also important, since the chronic anxiety and psychological stress associated with smoking appear to worsen ulcer activity.
Clinical and experimental evidence points to food allergy as a primary factor in many cases of peptic ulcer.7–10 In one study, 98% of patients who had X-ray evidence of peptic ulcer had coexisting lower- and upper-respiratory-tract allergic disease.9 In another study, 25 of 43 allergic children had peptic ulcers as diagnosed by X-rays.10 A diet that eliminates food allergens has been used with great success in treating and preventing recurrent ulcers.8,9 It is ironic that many people with peptic ulcers soothe their stomachs by consuming milk, a highly allergenic food. Milk should be avoided on this basis alone. However, population studies offer additional evidence that increased milk consumption leads to a greater likelihood of ulcer. The reason is probably that milk significantly increases stomach acid production.11
Therapeutic Considerations
Individuals experiencing any symptoms of a peptic ulcer need competent medical care. Complications such as hemorrhage, perforation, and obstruction represent medical emergencies that require immediate hospitalization.
Obviously, the best treatment of a peptic ulcer involves identification of the causative factor and its appropriate elimination.
Fiber
A diet rich in fiber and low in refined sugar is associated with a reduced rate of duodenal ulcers as compared with a low-fiber diet. The therapeutic use of a high-fiber diet or soluble fiber supplement in patients with recently healed duodenal ulcers reduces the recurrence rate by half.12 This is probably a result of fiber’s ability to delay the emptying of the stomach, counteracting the rapid movement of food into the duodenum that is normally seen in ulcer patients. In addition to a high-fiber diet, several fiber supplements (e.g., pectin, guar gum, and psyllium) have been shown to produce beneficial effects.13,14
Cabbage
Raw cabbage juice was first documented as having remarkable success in treating peptic ulcers in 1949.15,16 One liter per day of the fresh juice, taken in divided doses, resulted in total ulcer healing in an average of only 10 days. Further research has shown that the high glutamine content of the juice is probably responsible for its efficacy in treating ulcers. In a double-blind clinical study of 57 patients, 24 using 1.6 g per day of glutamine and the rest using conventional therapy (antacids, antispasmodics, milk, and a bland diet), glutamine proved to be the more effective treatment. Half of the patients using glutamine showed complete healing (according to radiographic analysis) within two weeks, and 22 of the 24 showed complete relief and healing within four weeks.17 Although the mechanism for these results is not known, the authors postulate that it is related to the role of glutamine in the biosynthesis of certain mucoproteins. This could stimulate mucin synthesis, which would benefit peptic ulcer patients.
In addition, isothiocyanates such as sulforaphane, from vegetables in the brassica family, have shown considerable activity against H. pylori. In one double-blind study, 48 H. pylori–infected patients were randomly assigned to consume broccoli sprouts (70 g per day for eight weeks), which contain sulforaphane, or to consume an equal amount of alfalfa sprouts, which do not contain sulforaphane, as a placebo. Broccoli sprouts decreased markers for both H. pylori and gastric inflammation. Values returned to their original levels two months after treatment was discontinued.18
Bismuth is a naturally occurring mineral that can both act as an antacid and exert activity against H. pylori. The best-known and most widely used bismuth preparation is bismuth subsalicylate (Pepto-Bismol). However, bismuth subcitrate has produced the best results against H. pylori in the treatment of peptic ulcers.19,20 In the United States, bismuth subcitrate preparations are available through compounding pharmacies. To find a compounding pharmacist in your area, call the International Academy of Compounding Pharmacists at (800) 927–4227.
An advantage of bismuth preparations over standard antibiotic approaches to eradicating H. pylori is that although the bacterium may develop resistance to various antibiotics, it is unlikely to develop resistance to bismuth.21,22
The usual dosage for bismuth subcitrate is 240 mg twice per day before meals. For bismuth subsalicylate, the dosage is 500 mg four times per day. Bismuth preparations are extremely safe when taken at prescribed dosages. Bismuth subcitrate may cause a temporary and harmless darkening of the tongue, the stool, or both. Bismuth subsalicylate should not be taken by children recovering from the flu, chicken pox, or other viral infection, as it may mask the nausea and vomiting associated with Reye’s syndrome, a rare but serious illness.
Vitamins A and E
Vitamins A and E have been shown to inhibit the development of stress ulcers in rats and are important factors in maintaining the integrity of the mucosal barrier.23,24 High-dose vitamin A therapy was shown to be useful in the treatment of chronic gastric ulcers in one clinical trial, but we recommend using it only at smaller dosages, for nutritional support.25
Zinc
Zinc increases mucin production in vitro and has been shown to have a protective effect against peptic ulcers in animal studies and a curative effect in humans.26 Zinc bound to carnosine is perhaps the most beneficial. Carnosine is a small protein composed of the amino acids histidine and alanine. It is found in relatively high concentrations in several body tissues, most notably skeletal muscle, heart muscle, and the brain. The exact biological role of carnosine is still under investigation, but numerous animal studies have demonstrated that it possesses strong and specific antioxidant properties, protects against radiation damage, improves heart function, and promotes wound healing. Zinc bound to carnosine exerts significant protection against ulcer formation and has ulcer-healing properties. Clinical studies with humans demonstrate the same effects, including an ability to antagonize H. pylori, which is linked to indigestion and stomach cancer as well as to peptic ulcer. When 60 patients with H. pylori infection who were suffering from indigestion were given either antibiotics alone or antibiotics plus zinc carnosine for seven days, better results were seen with the group getting zinc carnosine (94% success rate vs. 77%).27
Licorice
Licorice root (Glycyrrhiza glabra) has historically been regarded as an excellent medicine for peptic ulcer. However, one of the substances in licorice, glycyrrhizinic acid, has known side effects that include salt and water retention, leading to hypertension. A procedure was developed to remove glycyrrhizinic acid from licorice, forming deglycyrrhizinated licorice (DGL). The result is a very successful antiulcer agent without any known side effects.28–31 Researchers think that DGL works by stimulating the secretion of the protective substance mucin that lines the stomach and intestines. Clinical studies have demonstrated that DGL is as effective as cimetidine in preventing recurrence of ulcers.28
DGL contains several flavonoids that have been shown to inhibit H. pylori.32 In addition, unlike antibiotics, the flavonoids were also shown to augment natural defense factors that prevent ulcer formation. The activity of the most potent flavonoid was shown to be similar to that of bismuth subcitrate.
QUICK REVIEW
• Individuals with peptic ulcer must be monitored by a physician, because complications can be serious if not effectively treated.
• Ulcers are usually the result of a breakdown in protective factors that line the stomach or small intestine.
• The bacterium Helicobacter pylori has been linked to both duodenal and gastric ulcers.
• Use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with a significant risk of developing an ulcer.
• Smoking contributes to the occurrence and severity of peptic ulcers.
• An allergy to milk may be a causative factor in many cases of ulcers.
• A diet rich in fiber is associated with a reduced rate of duodenal ulcers.
• Raw cabbage juice is well documented as having remarkable success in treating peptic ulcers.
• Bismuth is a naturally occurring mineral that can act as an antacid and exert activity against H. pylori.
• Zinc carnosine has been shown to heal ulcers and help control H. pylori.
• DGL, a special form of licorice, has been shown to be as effective as ulcer medications like Tagamet and Zantac in head-to-head comparison studies.
• Rhubarb or aloe vera preparations can be used to stop the bleeding of an ulcer.
It appears that in order to be effective in healing peptic ulcers, DGL must mix with saliva. DGL may promote the release of salivary compounds that stimulate the growth and regeneration of stomach and intestinal cells. DGL in capsule form has not been shown to be effective.
The standard dosage for DGL is two to four 380-mg chewable tablets between meals or 20 minutes before meals. Taking DGL after meals is associated with poor results. DGL therapy should be continued for at least 8 to 16 weeks after symptoms disappear.
Mastic
Mastic is a resin obtained from the mastic tree (Pistacia lentiscus). Originally liquid, the resin is sun-dried into brittle, translucent drops. When chewed, the resin softens and becomes a bright white and opaque gum. The flavor is bitter at first, but after being chewed the drops release a refreshing, slightly piney or cedary flavor.
People in the Mediterranean region have used mastic as a medicine for gastrointestinal ailments for several thousand years. Recent studies indicate that it may be of benefit in healing peptic ulcers. In a double-blind clinical trial carried out on 38 patients with symptomatic and endoscopically proved duodenal ulcer, the patients were given either mastic gum (1 g per day) or a placebo for two weeks. Symptomatic relief was obtained in 16 patients on mastic (80%) and in 9 patients on the placebo (50%), while endoscopically proved healing occurred in 14 patients on mastic (70%) and only 4 patients on the placebo (22%).33
In another study, mastic gum showed some bactericidal activity on H. pylori, but it was not sufficient to eradicate the bacteria, compared with conventional drug therapy.34
Rhubarb and Aloe Vera
In cases of active intestinal bleeding, rhubarb (Rheum species) and aloe vera preparations can be extremely effective. In one double-blind study, rhubarb extract stopped bleeding from gastric or duodenal ulcers in more than 90% of 312 patients, and accomplished this in less than 60 hours.35
The beneficial actions of rhubarb are due to the presence of anthraquinones and flavonoids, which stop the bleeding by acting as astringents (basically, drying agents). Aloe vera contains similar compounds. In cases of active gastrointestinal bleeding, we recommend rhubarb or aloe vera preparations. The most accessible treatment may be drinking aloe vera juice, about 4 cups per day, during these times.
TREATMENT SUMMARY
Peptic ulcer disease has a number of causes, all of which lead to an ulcerative lesion in either the stomach or the duodenum. Patients must be carefully evaluated to determine which of the factors discussed earlier in this chapter are most relevant to their situation. This can be difficult, however, so a more general approach may be necessary.
The first step is to identify and eliminate or reduce all factors implicated in peptic ulcers: H. pylori, food allergy, cigarette smoking, stress, and drugs (especially aspirin and other NSAIDs). Once the causative factors have been controlled, attention should be directed at healing the ulcers, inhibiting exacerbating factors (e.g., reducing excess acid secretion if present), and promoting tissue resistance. Finally, make diet and lifestyle changes in order to prevent further recurrence.
WARNING: Peptic ulcer complications—hemorrhage, perforation, and obstruction—are medical emergencies that require immediate hospitalization.
Eliminate common food allergens, especially milk. Eat a diet high in dietary fiber, and consume fresh cabbage juice and other vegetable juices on a regular basis.
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Key individual nutrients:
Vitamin C: 500 mg three times per day
Vitamin E (mixed tocopherols): 100 IU per day
Zinc: 20 to 30 mg per day (but do not supplement with extra zinc if using zinc carnosine)
Vitamin D3: 2,000 to 4,000 IU per day (ideally, measure blood levels and adjust dosage accordingly)
• Fish oils: 1,000 mg EPA + DHA per day
• One of the following:
Grape seed extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Pine bark extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Some other flavonoid-rich extract with a similar flavonoid content, super greens formula, or another plant-based antioxidant that can provide an oxygen radical absorption capacity (ORAC) of 3,000 to 6,000 units or higher per day
• Specialty supplements:
Glutamine: 1,000 mg three times per day
Zinc carnosine: 75 mg once or twice per day
• One of the following:
DGL (deglycyrrhizinated licorice): 380 to 760 mg taken 20 minutes before meals three times per day
Mastic gum: 350 to 1,000 mg three times per day
Aloe vera juice: 2 to 4 cups per day