Peptic ulcers are open sores or erosions in the lining of either the duodenum
(duodenal ulcers) or the stomach (gastric ulcers). The duodenum is the first
part of the small intestine. About 10% of all Americans get ulcers, and they can
recur. Contrary to popular belief, ulcers are not
caused by spicy food or stress but, rather,
are most commonly due to either an infection or long term use of certain
Signs and Symptoms
Abdominal pain with a burning or gnawing sensation
Pain 2 to 3 hours after eating
Pain is often aggravated by an empty stomach; for example, nighttime
pain is common
Pain may be relieved by antacids or milk
If you experience any of the following symptoms, this is considered an
emergency and you should call your doctor immediately:
Sudden increase in the abdominal pain or sharpness in the quality of
Vomiting blood or material that looks like coffee grounds
Blood in your stool or black, tarry stools
When the stomach's natural protections from the damaging effects of digestive
juices (including acid and pepsin [an enzyme that helps breakdown protein]) stop
working or the acid production is too overwhelming for these protective defenses
to work properly, you can get an ulcer. There are a few different ways this
Helicobacter pylori (H. pylori), a bacterial organism, is
responsible for most ulcers. This organism weakens the protective coating of the
stomach and duodenum and allows the damaging digestive juices to irritate the
sensitive lining below. Interestingly, as many as 20% of Americans over age 40
have this organism living in their digestive tract, but not all of these people
develop ulcers - in fact, most do not.
Non-steroidal anti-inflammatory drugs (NSAIDs)
- ongoing use of this class of medications is the
second most common cause of ulcers. These drugs (which include aspirin,
ibuprofen, naproxen, diclofenac, tolmetin, piroxicam, fenoprofen, indomethacin,
oxaprozin, ketoprofen, sulindac, nabumetone, etodolac, and salsalate) are acidic
and they block prostaglandins, substances in the stomach that help maintain
blood flow and protect the area from injury. Some of the specific drugs listed
are more likely to produce ulcers than others; therefore, if you must use long
term pain medications, talk to your doctor about which ones are safest.
- people with this uncommon condition have tumors in
the pancreas and duodenum that produce gastrin, a hormone that stimulates
gastric acid production. Diarrhea may precede ulcer formation.
Other causes of ulcers are conditions that can result in direct damage
to the wall of the stomach or duodenum such as heavy use of alcohol, radiation
therapy, burns, and physical injury.
Genetic factors may predispose you to developing an ulcer
Chronic pain, from any cause such as arthritis, fibromyalgia,
repetitive stress injuries (like carpal tunnel syndrome), or persistent back
pain, leading to ongoing use of aspirin or NSAIDs
Diabetes may increase your risk of having H. pylori
Living in crowded, unsanitary conditions increases the risk of H.
Immune abnormalities may, in theory, make it more likely for H.
pylori or other factors to cause damage to the lining of the stomach or
Lifestyle factors, including chronic
stress, coffee drinking (even decaf), and smoking, may make you more susceptible
to damage from NSAIDs or H. pylori if you are a carrier of this organism.
Again, however, these factors do not cause an ulcer on their own.
First, your doctor will take a detailed history of your symptoms and risk
factors, including for how long things like indigestion and pain have been
present, how strong these sensations are, if you have lost any weight recently,
what medications (over the counter and prescription) you have been taking, your
smoking and drinking habits, and if anyone in your family has had ulcers.
As part of the physical exam, your doctor will do a thorough check of your
abdomen and chest as well as rectal exam to look for, in part, any sign of
bleeding. A blood test will be drawn to check to see if you are anemic. These
types of tests are done to make sure that you have not had any bleeding about
which you have been unaware (called occult bleeding).
If there are no signs of bleeding and your symptoms are mild and not serious
or life-threatening, your doctor may have you try medications that suppress the
amount of acid in your stomach. This is done to see if you feel better, before
pursuing expensive and uncomfortable testing. If your symptoms persist or get
worse despite the medication, then further testing is necessary.
One of two tests will be performed to try to identify an
Upper gastrointestinal (GI) series
For the upper GI, you drink a chalky liquid called barium and then a series
of xrays may reveal an ulcer. The endoscopy, which is more accurate, involves
the careful insertion of a thin tube with a tiny camera at the end (called an
endoscope) into your mouth, down your throat, through the esophagus to the
stomach and duodenum. This allows both direct visualization of these organs for
an ulcer or other problems and sampling of tissue from the walls (called
biopsies) of the stomach and small intestines to test for H. pylori. You
are lightly sedated for this procedure.
Other tests that may be performed to look for H. pylori include a
blood test checking for antibodies to this organism, a breath test after
drinking a substance called urea, and a stool test looking for the organism in
the feces. The breath test, which is the least invasive, is proving to be at
least 95% accurate.
Preventing NSAID-related ulcers involves finding different medications or
alternative approaches to relieve your pain. For example, talk to your doctor
about taking a new class of medications called COX-2 inhibitors (including
celecoxib and rofecoxib) or acetaminophen instead. If you have to take NSAIDs
for a long time, your doctor may consider prescribing a medication to try to
prevent the development of ulcers like misoprostol, an H2 blocker (such as
cimetidine, famotidine, nizatidine, or ranitidine), or a proton pump inhibitor
(such as omeprazole, lansoprazole, or rabeprazole).
There are also certain
lifestyle measures that may make you less
prone to get an ulcer from either NSAIDs or H. pylori.
The main goals for treating a peptic ulcer include eliminating the underlying
cause (particularly H. pylori infection or use of NSAIDs), preventing
further damage and complications, and reducing the risk of recurrence.
Medication is almost always needed to
alleviate symptoms and must be used to eradicate H. pylori.
Surgery is required for certain serious or
complications of peptic
ulcers and may be considered if medications are not working. Even with
lifestyle factors, including making
changes in your
diet, are important. Plus, certain
homeopathy may prove to be a useful
addition to usual medical care, especially to help relieve symptoms or prevent
Doctors used to recommend eating bland foods with milk and only small amounts
of food with each meal. We now know that these eating habits are not necessary
for the treatment of ulcers. Dietary and other lifestyle measures that should
help, however, include:
Eat a diet rich in fiber, especially from fruits and vegetables; this
may reduce your risk of developing an ulcer in the first place and may speed
your recovery if you already have one. The vitamin A may be an added benefit
from these foods.
Foods containing flavonoids, like apples, celery, cranberries
(including cranberry juice), onions, and tea may inhibit the growth of H.
Receive treatment for alcohol abuse; your doctor can help get you
Cut down on coffee, including decaffeinated coffee, as well as
carbonated beverages all of which can increase stomach acid
Reduce stress with regular use of relaxation techniques such as yoga,
tai chi, qi gong, or meditation. These practices may also help lessen pain and
reduce your need for the damaging NSAIDs discussed. To incorporate any one of
these techniques into your daily activities, consider taking a class; some early
information suggests that, if you have an ulcer, a formal program may be more
beneficial than listening to tapes on your own at home.
If you have H. pylori, you will probably be prescribed three
different medications. "Triple therapy" (including a proton pump inhibitor [for
example, omeprazole] to reduce acid production and two antibiotics to get rid of
the organism) is commonly used to treat H. pylori-related ulcers. Instead
of one of the antibiotics, bismuth salicylate may be the third medication
recommended. This drug, available over the counter, coats and soothes the
stomach, protecting it from the damaging effects of acid. Two, rather than
three, drug regimens are currently being developed.
Some of the same drugs are used for non-H. pylori ulcers as well as
for symptoms (like indigestion) due to ulcers of any cause:
Antacids, available over the counter, may relieve heartburn or
indigestion but will not treat an ulcer
H2 blockers, such as cimetidine, ranitidine, nizatidine, and
famotidine, reduce gastric acid secretion.
Misoprostol - can be used preventively if you
take a lot of NSAIDs because it helps to protect the stomach from the damaging
effects of these pain killers. Does not cure existing ulcers.
Proton-pump inhibitors, including esomeprazole, lansoprazole,
omeprazole, pantoprazole, and rabeprazole, decrease gastric acid production.
This is the number one choice of medications for treating ulcers.
Sucralfate makes a coating over the ulcer crater, protecting it from
Surgery and Other Procedures
Once hospitalized, if bleeding from an ulcer does not stop by using
medications and supportive care (like fluids and, possibly, blood transfusion),
it can almost always be stopped via endoscopy (see earlier section called
Diagnosis for description of this procedure). The physician who performs the
procedure (a doctor with special training, known as a gastroenterologist) first
identifies the ulcer and the area that is bleeding. Then, that physician injects
adrenaline and other medications to stop the bleeding and stimulate the
formation of a blood clot. If the bleeding recurs after that procedure or you
have a perforated ulcer or an obstruction, surgery may be required. Also, if you
do not get better from medical or endoscopic treatment, surgery may be
considered. Approximately 30% of people who come to the hospital with a bleeding
ulcer need endoscopy or surgery.
Nutrition and Dietary Supplements
As described in an earlier section entitled Lifestyle, doctors used to
recommend eating bland foods with milk and only small amounts of food with each
meal. We now know that these eating habits are not necessary for the treatment
of ulcers. Dietary measures that should help, however, are as
Eat a diet rich in fiber, especially from fruits (including fruit
juices) and vegetables; this may reduce your risk of developing an ulcer in the
first place and may speed your recovery if you already have one. The vitamin A
may be an added benefit from these foods.
Foods containing flavonoids, like apples, celery, cranberries
(including cranberry juice), onions, and tea may inhibit the growth of H.
Avoid beverages that can irritate the lining of the stomach or
increase acid production including coffee (with or without caffeine), alcohol,
and carbonated beverages.
Supplements that are showing early promise for help in treating or preventing
ulcers are discussed below. More research is needed to further test the safety
and effectiveness of these substances.
Gamma-linolenic acid (GLA)
Very preliminary evidence from test tube and animal studies suggest that
gamma-linolenic acid (GLA) from evening primrose oil (EPO) may have anti-ulcer
properties. GLA is an essential fatty acid (EFA) in the omega-6 family that is
found primarily in plant-based oils, including EPO and borage seed oil. Although
studies are promising, it is too early to know how this might apply to people
with peptic ulcers.
Omega-3 Fatty Acids
In animal studies, treatment with omega-3 fatty acids reduced the risk of
ulcers caused by NSAIDs. More research is needed to evaluate whether omega-3
fatty acids (like ALA found in flaxseed and flaxseed oil or EPA and DHA found in
fish and fish oil) would have the same effects in people.
Healthy or "friendly" organisms, called probiotics, inhabit the lining of the
intestines and protect us from the entrance of "bad" infections that can cause
disease. Lactobacillus acidophilus (L. acidophilus) is the most commonly
used probiotic. In test tube studies, L. acidophilus and other probiotics
were able to kill or slow down the growth of H. pylori; research is
needed to understand whether that benefit would occur in people. One way in
which probiotics may help is by reducing side effects, such as diarrhea and
taste disturbance, from medications used to treat H. pylori
In one study, high-dose vitamin C treatment for four weeks effectively
treated H. pylori infection in some, but not all, people. In addition,
H. pylori appears to impair absorption of vitamin C. Having lower than
average levels of vitamin C may play a role in the higher risk of stomach cancer
for those with this organism in their gastrointestinal
Herbs may cause side effects or interact with medications. They should,
therefore, be used with caution and only under the guidance of a professionally
trained and qualified herbalist. With that said, there are many herbs, some of
which are described below, that may be recommended by an herbal specialist for
peptic ulcers. The herbalist would work with you to individualize your
Astragalus (Astragalus membranaceus) -
used traditionally to treat stomach ulcers.
Barberry (Berberis vulgaris)- This herb contains active
substances called berberine alkaloids. These substances have been shown to
combat infection and bacteria. For this reason, barberry is used to ease
inflammation and infection of the gastrointestinal tract. Barberry has also been
used traditionally to improve appetite.
Bilberry (Vaccinium myrtillus) - Studies in rats have found
that anthocyanidins (an antioxidant) from bilberry fruits help prevent stomach
ulcers related to a variety of factors including stress, medications, and
alcohol. Whether this will translate into help for people requires research.
Cat's Claw (Uncaria tomentosa) - The
bark and root of this herb have been used among indigenous people of the
rainforest for centuries to treat a variety of health problems including ulcers
and other gastrointestinal disorders. The benefits of this herb may be due to
its ability to reduce inflammation.
Cranberry (Vaccinium spp) - may have
properties that help prevent H. pylori infection.
Dong Quai (Angelica sinensis) - animal studies suggest that
dong quai may soothe ulcers, but studies in people are needed before a
definitive conclusion can be drawn.
Garlic (Allium sativum) - some studies
suggest that high amounts of garlic may protect against stomach cancer, which is
a potential complication of H. pylori peptic ulcers. This is
controversial, however, and high amounts of garlic may in fact cause
Licorice (Glycyrrhiza glabra) - this herb is a demulcent
(soothing, coating agent) that has long been valued for its use in food and
medicinal remedies, including treatment of ulcers. Some licorice root extracts,
known as deglycyrrhizinated licorice (DGL), still have the healing properties of
licorice without the harmful effects (like high blood pressure). DGL may be
better for stomach or duodenal ulcers than Glycyrrhiza glabra and may
even prove as effective as some prescription drugs for stomach ulcers.
Slippery elm (Ulmus fulva) - Although there has been little
scientific research on slippery elm, it has a long history of use based on
clinical experience. Gastritis (stomach inflammation) and peptic ulcer are among
the conditions that seem to respond well to slippery elm.
Turmeric (Curcuma longa) -Turmeric has long been used in both
Ayurvedic and Chinese medicine to treat digestive disorders. Scientific research
is beginning to test the merit of this traditional use. In an animal study, for
example, extracts of turmeric root reduced the release of acid from the stomach
and protected against injuries such as gastritis or inflammation of the
intestinal walls and ulcers. Further studies are needed to know to what extent
these protective effects apply to people as well. (Note: at very high doses,
turmeric may induce ulcers. It is very important to stick with the dose
recommended by an herbal specialist.)
Animal studies indicate that certain individual herbal extracts as well as a
combination of these extracts may help heal ulcers. More studies are needed,
however, to know whether these individual herbs or a particular combination of
them would help people.
The combination preparation used in these animal studies
Angelica (Angelica archangelica)
German chamomile (Matricaria recutita)
Lemon balm (Melissa officinalis)
Milk thistle (Silybum marianum)
Peppermint (Mentha x piperita)
Additional herbs that have been used clinically by herbal specialist to treat
peptic ulcers include:
Calendula (Calendula officinalis) -- used in the United States
during the 19th century to treat stomach ulcers
Capsaicin - the active ingredient in cayenne
(Capsicum frutescens/Capsicum spp)
Marshmallow (Althea officinalis)
Although few studies have examined the effectiveness of specific homeopathic
therapies, professional homeopaths may consider the following remedies for the
treatment of ulcers or its symptoms, based on their knowledge and experience.
Before prescribing a remedy, homeopaths take into account your constitutional
type. A constitutional type is defined as your physical, emotional, and
psychological makeup. An experienced homeopath assesses all of these factors
when determining the most appropriate treatment for you individually. For the
treatment of ulcers, even if you do seek homeopathic remedies as adjunctive
care, conventional treatment recommendations must be followed.
Argentum nitricum for abdominal bloating with belching and pain
Arsenicum album for ulcers with intense burning pains and
nausea; especially for people who cannot bear the sight or smell of food and are
Kali bichromicum for burning or shooting abdominal pain that is
worse in the wee hours of the morning (that is, after midnight)
Lycopodium for bloating after eating with burning that lasts
for hours; especially for people who feel hungry soon after eating and wake
Nitric acid for sharp, shooting pain that worsens at night and
is accompanied by feelings of hopelessness and even fear of dying
Nux vomica for digestive disturbances (including heartburn and
indigestion) that worsen after eating; particularly for those who crave alcohol,
coffee, and tobacco
Phosphorus for burning stomach pain that worsens at night;
those for whom this remedy is appropriate tend to feel very thirsty, craving
Pulsatilla for symptoms that vary a lot (that is, change
abruptly) and pain that gets worse from fatty foods; appropriate people are
distinctly not thirsty
Acupuncture has been used traditionally for a variety of conditions related
to the gastrointestinal tract, including peptic ulcers. A growing body of
scientific evidence suggests that acupuncture can help reduce pain associated
with endoscopy (the procedure used, as described earlier, to make a diagnosis of
ulcer or to treat its complications.)
Chiropractors report and preliminary evidence suggests that spinal
manipulation may benefit some individuals with uncomplicated gastric or duodenal
ulcers. In one small study, researchers compared the effectiveness of medication
to spinal manipulation over a period of up to 22 days. Participants who received
spinal manipulation experienced significant pain relief after an average of 4
days and were completely free of symptoms an average of 10 days earlier than
those who took medication. More research is needed to understand when and how
chiropractic might be helpful if you have peptic ulcer disease.
If you are pregnant or breastfeeding, you should consult with your physician
before taking any medication, including herbs.
Borage seed oil, and possibly other sources of GLA, should not be used during
pregnancy because they may be harmful to the fetus and induce early
Warnings and Precautions
Individuals with peptic ulcers should not take the herbs devil's claw
(Harpagophytum procumbens) or green tea (Camellia
Prognosis and Complications
With proper treatment, most ulcers heal within 6 to 8 weeks. However, they
may recur, particularly if H. pylori is not treated sufficiently.
Complications from ulcers include bleeding, perforation (rupture) of either
the stomach or the duodenum, and bowel obstruction. Each of these problems can
be very serious, even life-threatening. Bleeding, which is much less common
today because of appropriate and fast medical treatment, occurs in up to 15% of
people with peptic ulcers. Obstruction tends to happen where the stomach meets
the small intestines. If there is an ulcer at this junction, swelling can occur,
blocking the passage of food products through the gastrointestinal tract. If
this happens, significant vomiting is generally the main symptom.
H. pylori ulcers increase the risk of stomach cancer.
The good news is that the incidence of ulcers and its complications continues
to decline as people seek treatment for symptoms early and doctors respond
quickly to eliminate symptoms and the causative agents, like H. pylori
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Review Date: December 2002
Reviewed By: Participants in the review process include: Robert A. Anderson, MD,
President, American Board of Holistic Medicine, East Wenatchee, WA; Shiva
Barton, ND, Wellspace, Cambridge, MA; Gary Guebert, DC, DACBR, (Chiropractic
section October 2001) Login Chiropractic College, Maryland Heights, MO;
Jacqueline A. Hart, MD, Department of Internal Medicine, Newton-Wellesley
Hospital, Boston, Ma and Senior Medical Editor A.D.A.M., Inc.; Joseph Trainor,
DC, (Chiropractic section October 2001) Integrative Therapeutics, Inc., Natick,
MA; Terry Yochum, DC, Rocky Mountain Chiropractic Center, Arvada,
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to any person or property as a matter of product liability, negligence, or
otherwise. No warranty, expressed or implied, is made in regard to the contents
of this material. No claims or endorsements are made for any drugs or compounds
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guide to self-medication. The reader is advised to discuss the information
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practitioner and to check product information (including package inserts)
regarding dosage, precautions, warnings, interactions, and contraindications
before administering any drug, herb, or supplement discussed