Peptic ulcer and its dietary management

What is peptic ulcer?

According to Kuipers & Blaser (2011) peptic ulcer is a distinct breach in the mucosal lining of the stomach (gastric ulcer) or the first part of the small intestine (duodenal ulcer), a result of caustic effects of acid and pepsin in the lumen. Histologically, peptic ulcer is identified as necrosis of the mucosa which produces lesions equal to or greater than 0.5 cm (1/5″). It is the most common ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. Helicobacter pylori is one of the most common causes of peptic ulcer. Ulcers can also be caused or worsened by drugs such as aspirin, ibuprofen, and other NSAIDs.

Four times as many peptic ulcers arise in the duodenum—the first part of the small intestine, just beyond the stomach—as in the stomach itself. About 4% of gastric ulcers are caused by a malignant tumor, so multiple biopsies are needed to exclude cancer. Duodenal ulcers are generally benign.

The appearance of an ulcer can be either the classic erosive, concave, crater-like ulcer (the image held by most patients) or convex, perhaps resembling a colonic polyp. As a generalization, the erosive concave type tends to be located in the stomach proper while the convex type tends to be found in the pylorus/duodenum.

These convex growths have an extensive variety of shapes and forms, but in all forms the ulcer projects above the level of the surrounding tissue. For extended periods these growths characteristically lack any surface breaks in the mucosal tissue and also initially lack any visual differentiation from the surrounding tissue even in larger sizes.

Causes of peptic ulcer

Kato et al (1992) highlighted the major causative factor (60% of gastric and up to 90% of duodenal ulcers) is chronic inflammation due to Helicobacter pylori that colonizes the antral mucosa. The immune system is unable to clear the infection, despite the appearance of antibodies. Thus, the bacterium can cause a chronic active gastritis (type B gastritis), resulting in a defect in the regulation of gastrin production by that part of the stomach, and gastrin secretion can either be increased, or as in most cases, decreased, resulting in hypo- or achlorhydria. Gastrin stimulates the production of gastric acid by parietal cells. In H. pylori colonization responses to increased gastrin, the increase in acid can contribute to the erosion of the mucosa and therefore ulcer formation. Studies in the varying occurrence of ulcers in third world countries despite high H. pylori colonization rates suggest dietary factors play a role in the pathogenesis of the disease.

Another major cause is the use of NSAIDs. The gastric mucosa protects itself from gastric acid with a layer of mucus, the secretion of which is stimulated by certain prostaglandins. NSAIDs block the function of cyclooxygenase 1 (cox-1), which is essential for the production of these prostaglandins. COX-2 selective anti-inflammatories (such as celecoxib or the since withdrawn rofecoxib) preferentially inhibit cox-2, which is less essential in the gastric mucosa, and roughly halve the risk of NSAID-related gastric ulceration.

Salih and Ersan (2007) stated that the incidence of duodenal ulcers has dropped significantly during the last 30 years, while the incidence of gastric ulcers has shown a small increase, mainly caused by the widespread use of NSAIDs. The drop in incidence is considered to be a cohort-phenomenon independent of the progress in treatment of the disease. The cohort-phenomenon is probably explained by improved standards of living which has lowered the incidence of H. pylori infections.

Kato et al (1992) asserted that although some studies have found correlations between smoking and ulcer formation, others have been more specific in exploring the risks involved and have found that smoking by itself may not be much of a risk factor unless associated with H. pylori infection. Some suggested risk factors such as diet, and spice consumption, were hypothesized as ulcerogens (helping cause ulcers) until late in the 20th century, but have been shown to be of relatively minor importance in the development of peptic ulcers. Caffeine and coffee, also commonly thought to cause or exacerbate ulcers, have not been found to affect ulcers to any significant extent. Similarly, while studies have found that alcohol consumption increases risk when associated with H. pylori infection, it does not seem to independently increase risk, and even when coupled with H. pylori infection, the increase is modest in comparison to the primary risk factor.

 Signs and symptoms of peptic ulcer

Bhat (2013) listed some of the symptoms of a peptic ulcer to include;

• abdominal pain, classically epigastric strongly correlated to mealtimes. In case of duodenal ulcers the pain appears about three hours after taking a meal;
• bloating and abdominal fullness;
• waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus – although this is more associated with gastroesophageal reflux disease);
• nausea, and copious vomiting;
• loss of appetite and weight loss;
• hematemesis (vomiting of blood); this can occur due to bleeding directly from a gastric ulcer, or from damage to the esophagus from severe/continuing vomiting.
• melena (tarry, foul-smelling faeces due to presence of oxidized iron from haemoglobin);
• rarely, an ulcer can lead to a gastric or duodenal perforation, which leads to acute peritonitis, extreme, stabbing pain, and requires immediate surgery.

Complications of peptic ulcer

If left untreated, peptic ulcers according to Haile (1984) can result in:

• Internal bleeding. Bleeding can occur as slow blood loss that leads to anaemia or as severe blood loss that may require hospitalization or a blood transfusion. Severe blood loss may cause black or bloody vomit or black or bloody stools.
• Peptic ulcers can eat a hole through the wall of your stomach or small intestine, putting you at risk of serious infection of your abdominal cavity (peritonitis).
• Scar tissue. Peptic ulcers can also produce scar tissue that can block passage of food through the digestive tract, causing you to become full easily, to vomit and to lose weight.

 Risk factor of peptic ulcer

Kurata and Nogawa (1997) said that you may have an increased risk of peptic ulcers if you:

• Smoke. Smoking may increase the risk of peptic ulcers in people who are infected with H. pylori.
• Drinking of alcohol. Alcohol can irritate and erode the mucous lining of your stomach, and it increases the amount of stomach acid that’s produced.

Test and diagnosis of peptic ulcer

In order to detect an ulcer by Lozano (2006) stated you may have to undergo diagnostic tests, such as:

1. Tests for H. pylori

Your doctor may recommend tests to determine whether the bacterium H. pylori is present in your body. Tests can test for H. pylori using your:

• Blood
• Breath
• Stool

Which type of test you undergo depends on your situation.

For the breath test, you drink or eat something that contains radioactive carbon. H. pylori breaks down the substance in your stomach. Later, you blow into a bag, which is then sealed. If you’re infected with H. pylori, your breath sample will contain the radioactive carbon in the form of carbon dioxide.

1. Using a scope to examine your upper digestive system (endoscopy)

During endoscopy, your doctor passes a hollow tube equipped with a lens (endoscope) down your throat and into your esophagus, stomach and small intestine. Using the endoscope, your doctor looks for ulcers.

If your doctor detects an ulcer, small tissue samples (biopsy) may be removed for examination in a lab. A biopsy can also identify the presence of H. pylori in your stomach lining.

Your doctor is more likely to recommend endoscopy if you are older, have signs of bleeding, or have experienced recent weight loss or difficulty eating and swallowing. 

1. X-ray of your upper digestive system

Sometimes called a barium swallow or upper gastrointestinal series, this series of X-rays creates images of your esophagus, stomach and small intestine. During the X-ray, you swallow a white liquid (containing barium) that coats your digestive tract and makes an ulcer more visible.

Prevention of peptic ulcer

You may reduce your risk of peptic ulcer as advised by Blum (1981) if you:

• Protect yourself from infections: It is not clear just how H. pylori spreads, but there is some evidence that it could be transmitted from person to person or through food and water. You can take steps to protect yourself from infections, such as H. pylori, by frequently washing your hands with soap and water and by eating foods that have been cooked completely.
• Use caution with pain relievers: If you regularly use pain relievers that increase your risk of peptic ulcer, take steps to reduce your risk of stomach problems. For instance, take your medication with meals.

Work with your doctor to find the lowest dose possible that still gives you pain relief. Avoid drinking alcohol when taking your medication, since the two can combine to increase your risk of stomach upset.

Dietary management of peptic ulcer

According to American Dietetics Association (2003), peptic ulcer can be effective managed by the following dietary guidelines

• Eat mostly fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products.
• Eat lean meats, poultry (such as chicken and turkey), fish, beans, eggs, and nuts.
• Choose fats that are better for your health such as olive oil and canola oil.
• Eat fewer foods that have added salt.
• Eat fewer foods that have added sugar

Recommended foods

Note: The chart shows general recommendations for healthy eating. If you have pain after eating particular foods, avoid those foods (even if they are listed on the chart).

Foods not recommended

Sample 1-day menu

Approximate nutrition analysis: Calories: 1,952; Protein: 117g (24% of calories); Carbohydrate: 282g (57% of calories); Fat: 41g (19% of calories); Cholesterol: 224mg; Sodium: 1,875mg; Fiber: 23g

Conclusion

Peptic ulcer no matter its form, obviously has a very discomforting and painful effect on the sufferer. But these effects and be managed by early detection and treatment including eating the right kind of diet can help avoid getting the case aggravated. Unhealthy lifestyles such as smoking and alcohol intake should be avoided by peptic ulcer sufferers or even at just the brink of suspicion of its occurrence.