6 Things I Learned About Ulcers

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Credit…Heidi Younger

• April 13, 2017

Halfway through February, I could no longer sleep through the night. At 2 a.m., I’d find myself chugging milk from the carton to extinguish a fire at the top of my rib cage. The gnawing feeling high in my stomach alternated with nausea so arresting I kept a bucket next to my laptop and considered taking a pregnancy test, even though I was 99 percent sure I wasn’t expecting.

One day on the subway platform, I doubled over and let out a groan so pathetic it prompted a complete stranger to ask, “Are you all right?” Then I knew it was time to seek medical attention. New Yorkers don’t address strangers on the subway, I told myself. It’s like breaking the fourth wall.

The next day, my primary care doctor told me I probably had an ulcer, a raw spot or sore in the lining of the stomach or small intestine. Here are some of the things I learned about ulcers during the odyssey that followed.

■ Anyone can get an ulcer. Back in the 1980s, when doctors and most everyone else thought psychological stress or spicy foods led to ulcers, two Australian scientists discovered that the main culprit was actually a bacterium called Helicobacter pylori. That discovery eventually won them a Nobel Prize in 2005, and ushered in an era of using antibiotics to cure ulcers.

But that didn’t wipe out ulcers altogether. Far from it. Indeed, my tribe of fellow sufferers are legion. Nearly 16 million adults nationwide reported having an ulcer in 2014,according to the Centers for Disease Control and Prevention’s National Center for Health Statistics. The largest group, roughly 6.2 million, were 45 to 64 years old. Those 18 to 44 accounted for 4.6 million, 65- to 74-year-olds for 2.6 million, and those 75 and older for 2.4 million.

I got a blood test to see if I was infected with H. pylori; the test came back negative, so I didn’t need antibiotics. Regular use of nonsteroidal anti-inflammatory drugs, like ibuprofen or aspirin, can also lead to an ulcer, but I wasn’t taking those medicines. My ulcer turned out to be “idiopathic,” which is a fancy way of saying that doctors have no idea why it happened.

■ It takes time to figure out what you can eat. My doctor told me I needed standard therapy: Take omeprazole, an acid-suppressing drug, for a month to give the open sore in my stomach time to heal. While some untreated ulcers start bleeding heavily or require surgery or hospitalization, he assured me I’d feel better soon.

In the meantime, I needed to figure out how to get nourishment. But having an ulcer, I’d learned, is like being a contestant on a twisted game show called “What to Eat?”. Choose poorly, and my stomach would burn like lava, leaving me listless. Choose wisely, and I’d be rewarded with a momentary reprieve, until hunger struck again. Every few hours the “game” would start over.

Maddeningly, I wasn’t sure which foods might be safe to eat until I tried them. For instance, why did a seemingly innocuous bag of salted peanuts lead to agony?

The truth is gastroenterologists don’t know why certain food causes indigestion and heartburn for patients with stomach ulcers. There are a few rules of the road: Avoid alcohol, or anything with caffeine or high in fat.

Fatty foods “sit in the stomach for a long time and fester,” said Lori Welstead, a registered dietitian who works at the digestive disease center at University of Chicago Medicine. Perhaps that was the trouble with peanuts?

Dr. David Y. Graham, a past president of the American College of Gastroenterology, perhaps summed it up most succinctly, “There’s a general rule: Don’t eat what hurts you.”

Ulcer patients must serve as their own guinea pigs, experimenting on their guts until they find sustenance that doesn’t come with a side of discomfort for them. I didn’t realize that until weeks after my diagnosis.

■ An empty stomach won’t help — and probably will hurt. Like a heartbroken soul who swears off dating to avoid future pain, I started eating less and less. So did Megan McMillen, a nurse in Morgantown, W.Va., after she discovered she had an ulcer around Valentine’s Day.

“You’re scared if you eat something what the consequences will be,” she said, so she quit eating for two days. But the downside of hunger was nausea — and an empty stomach can be doubly painful.

Without any food in there, the ulcer is bathed in stomach acid all the time, said Dr. David Greenwald, the director of clinical gastroenterology and endoscopy at Mount Sinai Hospital in New York. “It’s a really common thing people report that when they have an ulcer, any food makes it transiently better.”

■ Don’t eat at bedtime. Another big mistake: eating just before sleep, said Dr. Graham, a professor of gastroenterology at Baylor College of Medicine in Houston.

“If you want pain at nighttime, eat at bedtime,” he said. That’s because when you eat, your stomach makes a lot of acid to digest the food. But “once the food is gone,” he said, acid levels remain high. A result: You’ll most likely be jolted awake by pain.

■ Don’t worry about acidic foods. I had never trusted Dr. Google before, but I was desperate. So I found a pH chart online that laid out which foods were acidic no-nos, which were neutral, and which were alkaline, so supposedly not as acidic in the stomach. The lower the pH, on a scale of 3 to 10, the more acidic the food, and the more I should avoid it, the chart told me.

This little rainbow chart became my bible. I cut out goat cheese, canned tuna, beef, pork and all nuts except almonds, which were rated as alkaline. My go-to meal became a whole avocado paired with a pound of strawberries.

Sadly, it took a full week for this so-called health reporter to even ask whether my pH chart or any of the many other food charts online were backed by reputable research.

Ms. Welstead, the Chicago-based dietitian, set me straight. “The pH of foods is not evidence-based for nutrition therapy or in the medical field,” she said. “Stomach acid is so so acidic, the foods you’re eating are not necessarily going to affect that stomach acid.”

The bad news was I had fallen down a rabbit hole of misinformation. I felt a little better after talking to Laurie Keefer, a health psychologist who specializes in digestive diseases at the Icahn School of Medicine at Mount Sinai, who told me her patients with ulcers often feel “out of control.”

Dr. Keefer advised me not to amplify distress by “trying to control things that probably aren’t going to move the needle on your symptoms.” Like hokey pH charts.

■ Don’t discount stress. “There’s absolutely no evidence that psychological stress or anxiety causes an ulcer,” Dr. Greenwald said. But, he and other experts caution, stress may make symptoms worse.

“If you have some discomfort from an ulcer, and on top of that you have anxiety and stress maybe over having the ulcer, your symptoms may actually be a little bit more pronounced,” Dr. Greenwald said.

In fact, “there is a growing adoption of behavioral health specialists in gastroenterology practices,” Dr. Keefer said. “We actually call it psycho-gastroenterology.”

She is embedded in the comprehensive gastrointestinal program at Mount Sinai, so after patients see a nutritionist for an ulcer or Crohn’s disease or irritable bowel syndrome, they can stop in for a psychological consultation. “It’s much less stigmatizing” that way, she said.

“Stress, anxiety and worry will only slow your recovery,” Dr. Keefer said. “Stress is anything that requires the body to adapt. If you’re spending resources on your stress, your body is not spending resources on recovery.”

It took about five weeks for my ulcer to heal. So I suppose I could have a burrito loaded with hot sauce. But I’m not fully over my fear. I still haven’t forgiven a probiotic yogurt drink that set my stomach on fire in the first days after diagnosis. I’m dead sure I never will.

A version of this article appears in print on  , Section D, Page 1 of the New York edition with the headline: What to Eat?. Order Reprints | Today’s Paper | Subscribe

Stomach ulcer – NHS

Stomach ulcers, also known as gastric ulcers, are sores that develop on the lining of the stomach.

You can also get ulcers in part of the intestine just beyond the stomach, which are called duodenal ulcers.

Stomach ulcers and duodenal ulcers (sometimes called peptic ulcers) cause the same symptoms and treatment for both is the same.

Signs and symptoms

The most common symptom of a stomach ulcer is a burning or gnawing pain in the centre of the tummy (abdomen).

But stomach ulcers aren’t always painful and some people may experience other symptoms, such as indigestion, heartburn and acid reflux and feeling sick.

When to seek medical advice

You should visit your GP if you think you may have a stomach ulcer.

Contact your GP or NHS 111 immediately if:

• you are passing dark, sticky, tar-like stools
• you have a sudden, sharp pain in your tummy that gets steadily worse

Go to your nearest accident and emergency (A&E) department or call 999 if:

• you are vomiting blood – the blood can appear bright red or have a dark brown, grainy appearance, similar to coffee grounds

These could be a sign of a serious complication, such as internal bleeding.

Causes of stomach ulcers

Stomach ulcers happen when there’s damage to the layer that protects the stomach lining from the acids in your stomach.

This is usually a result of:

• an infection with Helicobacter pylori (H. pylori) bacteria
• taking anti-inflammatory medicines (NSAIDs), such as ibuprofen or aspirin – particularly if they’re taken for a long time or at high doses

It used to be thought that stress or certain foods might cause stomach ulcers, but there’s little evidence to suggest this is the case.

Stomach ulcers can affect anyone but are more common in people aged 60 or over. Men are more affected than women.

How stomach ulcers are treated

Treatment will depend on what caused the ulcer.

Most people will be prescribed a medication called a proton pump inhibitor (PPI) to reduce the amount of acid in their stomach.

You’ll also need antibiotics if your ulcers were caused by a H. pylori infection.

Stomach ulcers can come back after treatment, although this is less likely to happen if the underlying cause is addressed.

Possible complications

Complications of stomach ulcers are relatively uncommon, but they can be very serious and potentially life threatening.

The main complications include:

• bleeding at the site of the ulcer
• the stomach lining at the site of the ulcer splitting open (perforation)
• the ulcer blocking the movement of food through the digestive system (gastric obstruction)

Read more about the complications of stomach ulcers.

Page last reviewed: 14 January 2022
Next review due: 14 January 2025

Peptic ulcer of the stomach and duodenum in the elderly and senile | Ivashkin V.T., Sheptulin A.A.

Peptic ulcer of the stomach and duodenum is not a rare disease in elderly and senile people. According to our long-term observations, patients over 60 years of age account for about 10% of all patients with peptic ulcer. There appears to be no age limit at which this disease can occur (in the literature, for example, there is a description of a 103-year-old patient with a perforated peptic ulcer).

Speaking of peptic ulcer in elderly and senile people, it is necessary to distinguish between 2 variants of the development of the disease.

It is necessary to single out a long-term peptic ulcer, which arose for the first time in young and middle age and preserved the frequency of alternation of exacerbations and remissions in elderly patients. According to various sources, this option accounts for 30 to 50% of all cases of peptic ulcer in the elderly. A long-term peptic ulcer (the term “old peptic ulcer” used by some authors seems to us stylistically less successful) differs from that in young and middle-aged people only by a higher frequency of combined forms of damage (stomach and duodenum), longer exacerbations and slower scarring ulcer defect.

Peptic ulcer of the stomach and duodenum, which first appeared in old age, is characterized by a certain peculiarity of the clinical picture and course. To designate this variant of the development of the disease, we usually use the term “late peptic ulcer” . The expression “senile ulcers”, often used in such cases, which on the whole correctly interprets the essence of the existing changes, can hardly be considered successful from a deontological point of view. In the pathogenesis of late peptic ulcer in elderly and senile people, the role of factors contributing to the weakening of the protective properties of the mucous membrane of the gastroduodenal zone increases. The significance of these factors (first of all, atherosclerotic changes in the vessels of the stomach, reducing the trophism of its mucous membrane) becomes especially noticeable in cases where the disease occurs without the participation of pyloric Helicobacter (in 20-30% of patients with gastric ulcers). Peptic ulcer disease in such patients often develops against the background of hypertension, coronary heart disease, obliterating atherosclerosis of the vessels of the lower extremities, diabetes mellitus, chronic nonspecific lung diseases, diabetes mellitus and other diseases that contribute to microcirculation disorders in the gastric mucosa.

Late gastroduodenal ulcers (often localized in the subcardiac region and body of the stomach) often occur with an erased and atypical clinical picture [1]. Pain syndrome and dyspeptic disorders are often very mild. There may be no periodicity of pain and their connection with food intake, as well as seasonality of exacerbations. The level of hydrochloric acid secretion in elderly patients with peptic ulcer (especially when the ulcer is localized in the stomach) is usually significantly lower than in young and middle-aged patients.

Low-symptom and blurring of the clinical picture of peptic ulcer in the elderly is combined with a more severe course of the disease. This is manifested primarily in the larger size of the ulcer (especially in the case of localization in the stomach) compared with young and middle-aged patients. So, according to our data, more than 1/3 of cases of gastric ulcers in elderly patients have large (more than 2 cm in diameter) or giant (more than 3 cm in diameter) sizes . We observed a 70-year-old patient whose gastric ulcer (with very minor clinical manifestations) was 6 cm in diameter. The patient had widespread atherosclerosis (including severe obliterating atherosclerosis of the vessels of the lower extremities) and atherosclerotic aneurysm of the abdominal aorta largely determined the “trophic” genesis of this ulcer.

In elderly patients with peptic ulcer, the frequency of gastrointestinal bleeding (melena) is almost twice as high as in young and middle-aged patients (observed in more than 1/4 of elderly patients with peptic ulcer). Iron deficiency anemia (often as a result of latent blood loss) is detected in elderly patients even more often (according to our data, in 1/3 of cases).

When a stomach ulcer is found in elderly and senile patients, it is important to confirm the benign nature of the ulcer. It should be borne in mind that malignancy (malignancy) of a long-term gastric ulcer is much less common than is commonly believed (the risk of malignancy of a gastric ulcer is generally no higher than the risk of gastric cancer in a patient who does not have an ulcer). As our own experience and literature data show, the vast majority of malignant gastric ulcers are not malignant benign ulcers, but the primary ulcerative form of gastric cancer.

In favor of the primary ulcerative form of stomach cancer, such signs as short (usually less than 1 year) testify:

At the same time, the infiltrative-ulcerative form of gastric cancer can give an X-ray and endoscopic picture of a benign ulcer, so the final conclusion about the nature of ulceration can be made only after a repeated histological examination of biopsy specimens taken from the edges and bottom of the ulcer.

Treatment of elderly and senile patients with peptic ulcer is based on the generally accepted scheme. Upon detection of pyloric Helicobacter (by morphological or urease method), anti-Helicobacter therapy is carried out according to one of the schemes for 7 days: proton pump blockers

• omeprazole 20 mg twice daily, lansoprazole 30 mg twice daily, pantoprazole 40 mg twice daily)

• metronidazole (0. 5 g twice daily), proton pump blockers + amoxicillin (1 g twice daily)

• metronidazole (0.5 g 2 times a day), proton pump blockers + amoxicillin (0.5 g 2 times a day)

The combination of ranitidine-bismuth-citrate (400 mg 2 times a day) with clarithromycin (250 mg 2 times a day) and metronidazole (0.5 g 2 times a day) has also worked well. In parallel with eradication therapy, basic course of antisecretory drugs (ranitidine 150 mg 2 times a day, famotidine 20 mg 2 times a day or omeprazole 20 mg 1 time a day) is carried out, which usually lasts 4–6 weeks (with duodenal ulcer) and 6–8 weeks (for gastric ulcer). Due to the often slow scarring of gastroduodenal ulcers in elderly and senile patients, the course of basic antisecretory therapy necessary for complete healing of the ulcer may last up to 10–12 weeks in such patients. Additionally, for the relief of pain and dyspeptic disorders with a symptomatic purpose, antacids. If successful eradication of Helicobacter pylorus is confirmed, which is carried out no earlier than 4 weeks after the end of antisecretory therapy, subsequent maintenance antiulcer drugs are usually not required.

If an elderly patient has a peptic ulcer that is not associated with pyloric Helicobacter, only antisecretory therapy is performed to heal the ulcer. Once ulcer scarring has been achieved, these patients should be treated with daily maintenance antisecretory drugs to avoid recurrence (H ₂ blockers or proton pump blockers), most often in half doses.

Damage to the stomach and duodenum when taking non-steroidal anti-inflammatory drugs

A separate group consists of ulcerative lesions of the stomach and duodenum resulting from the use of non-steroidal anti-inflammatory drugs (NSAIDs) . These lesions (NSAID-gastropathy) are a very important problem in modern gastroenterology and gerontology. Studies conducted in the USA, Canada, Australia and other countries have shown that 10-20% of elderly and senile people regularly take NSAIDs (acetylsalicylic acid, ketoprofen, indomethacin, etc. ) for deforming osteoarthritis, neuralgia and myalgia, spinal osteochondrosis . In this case, the risk of ulcerative lesions of the stomach and duodenum, primarily due to inhibition of the synthesis of prostaglandins in the mucous membrane, is 20–25%. The frequency of hospitalizations in the elderly for gastrointestinal complications associated with the use of NSAIDs is 4 times higher than in young and middle-aged patients. If an elderly patient has anamnestic indications of the presence of a previous peptic ulcer, then the risk of developing erosive and ulcerative lesions when taking NSAIDs increases by 14–17 times (!) [2, 3].

NSAID-associated gastroduodenal ulcers are often acute, multiple, and manifest clinically as sudden gastrointestinal bleeding (chalking or vomiting of coffee grounds-like contents). The highest probability of occurrence of ulcerogenic side effects is noted when taking such NSAIDs as piroxicam, ketoprofen, indomethacin, the lowest – when taking ibuprofen. It must be remembered that ulcerative lesions of the stomach and duodenum can occur even when taking small doses of acetylsalicylic acid (less than 300 mg per day), often prescribed to the elderly, for example, to prevent complications in coronary heart disease. In addition, changing the dosage forms of the drug also does not completely exclude the possibility of NSAID gastropathy.

Treatment of gastroduodenal ulcers associated with the use of NSAIDs in the elderly includes, first of all, dose reduction or complete withdrawal of the non-steroidal anti-inflammatory drug. If its cancellation for some reason turns out to be impossible, antiulcer therapy is carried out against the backdrop of continued use of NSAIDs. At the same time, the healing time of ulcerative lesions naturally increases.

The drugs of choice for the treatment of gastroduodenal ulcers associated with NSAIDs are proton pump blockers, which are prescribed in standard doses of (omeprazole 20 mg per day, lansoprazole 30 mg per day, pentoprazole 40 mg per day). With a complicated course, multiple ulcers and their large sizes, slow healing dynamics, and if it is necessary to continue taking NSAIDs, the doses of proton pump blockers can be doubled.

Synthetic prostaglandin analogues (mesoprostol 200 mg 4 times a day) or H blockers can be used instead of proton pump blockers for the treatment of gastroduodenal ulcers associated with NSAIDs.0137 2 histamine receptors (ranitidine 150 or 300 mg 2 times a day, famotidine 20 or 40 mg 2 times a day), although the effectiveness of these drugs, as recent studies show, is lower than that of proton pump blockers.

The feasibility of conducting eradication anti-Helicobacter therapy in patients with NSAID gastropathy has not yet been finally determined. Nevertheless, most gastroenterologists believe that such treatment (according to one of the above schemes) significantly reduces the likelihood of recurrence of gastroduodenal ulcers and increases the resistance of the gastric and duodenal mucosa to the repeated action of NSAIDs.

To prevent the development of gastroduodenal ulcers when using NSAIDs in elderly patients (especially those with concomitant diseases of the cardiovascular system and liver, as well as a history of peptic ulcer or receiving anticoagulants) standard doses of proton pump blockers are indicated (for example, omeprazole 20 mg per day), mesoprostol (100-200 mg 4 times a day) or H ₂ blockers of histamine receptors (preferably in double doses), as well as conducting – in cases of detection of pyloric Helicobacter – eradication therapy that reduces the risk of erosive and ulcerative lesions of the mucous membrane of the stomach and duodenum while taking NSAIDs.

An important part of the prevention of gastroduodenal ulcers associated with the use of NSAIDs in the elderly is a careful consideration of indications and contraindications for the appointment of these drugs. In many cases (especially when short-term use of analgesics and antipyretics is necessary), it is advisable to replace NSAIDs with drugs that do not adversely affect the mucous membrane of the stomach and duodenum (paracetamol). The combination of paracetamol and NSAIDs allows you to reduce the dose of the latter and thereby reduce the risk of ulcerogenic action.

Literature

1. Brooks P. Use and benefits of nonsteroidal anti-infalammatory drugs. Am J Med. 1998; 104(3A): 9S–13S.

2. Griffin M.R. Epidemiologi of nonsteroidal anti-inflammatory drug-associated gastrointestinal injuri. Ibid: 23S–9s.

3. Soll H. Petic ulcer and its complications. Sleisenger & Fordtran’s Gastrointestinal and liver disease (Ed. Feldman et al.) 1998; 6th Editon, 1:620–78

Annexes to article

Low symptoms and blurring of the clinical picture of peptic ulcer in the elderly is combined with its more severe course

The final conclusion about the nature of ulceration can only be made after repeated histological examination of biopsies taken from the edges and bottom of the ulcer

Fig. 1. Gastric ulcer

Treatment of gastroduodenal ulcers associated with NSAIDs in the elderly includes primarily dose reduction or complete withdrawal of NSAIDs

Peptic ulcer of the stomach and duodenum – MOSITALMED

Peptic ulcer of the stomach and duodenum is a disease in which an ulcerative defect of the mucous membrane is formed. The disease is observed when the balance between the factors of aggression and protection of the mucous membrane is disturbed. As a result, under the influence of provoking factors, the submucosal and muscle layers are affected, and after healing, cicatricial changes remain. The peak incidence occurs in the autumn-spring period.

Treatment of gastric and duodenal ulcers is carried out on an outpatient basis and in a hospital. The clinic “MOSITALMED” has an inpatient department equipped with comfortable wards, operating rooms and manipulation rooms with everything necessary to provide both planned and emergency medical care.

Causes of peptic ulcer of the stomach

The appearance of a peptic ulcer of the gastric mucosa occurs when exposed to a number of causes, including:

• Helicobacter pylori infection;
• taking non-steroidal anti-inflammatory drugs, antibiotics and glucocorticoids;
• abdominal trauma;
• nerve strain;
• alcohol abuse;
• excessive consumption of coffee;
• smoking;
• unbalanced diet with insufficient content of vitamins and excessive consumption of rough, hot, salty and sweet foods;
• hereditary predisposition

Symptoms of peptic ulcer of the stomach and duodenum

The main symptom of peptic ulcer of the stomach and duodenum is pain.

Duodenal ulcer is characterized by pain on an empty stomach and 2-3 hours after eating in the epigastric region or right hypochondrium. Their intensity decreases after eating and taking antacids and increases at night.

An ulcer in the stomach presents with pain half an hour after eating and is accompanied by heartburn, nausea and vomiting, which brings relief. It is localized in the upper abdomen and intensifies after a heavy meal and physical activity.

Perforation of the ulcer is manifested by acute, unbearable, dagger pain in the projection of the stomach. It can mimic heart disease, leading to misdiagnosis, worsening of the condition and prognosis of the disease. This form of the disease is treated only by surgical intervention by stitching the wound.

Treatment of peptic ulcer of the stomach and duodenum

Treatment of peptic ulcer of the stomach and duodenum includes diet, drug therapy and physiotherapy. If Helicobacter pylori infection is confirmed, a course of antibiotic therapy is prescribed.

To restore the acid-base balance, antacids and drugs that have an enveloping and protective effect on the mucous membrane of the stomach and duodenum are used. In order to monitor the effectiveness of therapy, endoscopic examinations are carried out with an interval of 2 weeks.

Diet for gastric and duodenal ulcers implies the exclusion of fried, salty, smoked, pickled and sweet.