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Ulcer pain at night: 13 Stomach Ulcer Symptoms, Treatment, Diet, Causes & Surgery

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How to Sleep Better With a Stomach Ulcer (6 Ways)

  • This article has been written and medically reviewed by Darshan Shingala (M.D, MPH) – a qualified and practicing medical doctor – for maximum factual accuracy and reliability.

Stomach ulcers are open sores on the inside of the stomach that can cause pain and make it difficult to get to sleep.

So how do you get better sleep when you have a stomach ulcer?

To sleep better with a stomach ulcer: sleep on your side or back; use pillows or an adjustable bed to elevate your head and limit the up-flow of stomach acid; take doctor prescribed ulcer medications; avoid spicy foods; eat 3-4 hours before bed; limit stress; stop smoking; avoid alcohol, and follow good sleep hygiene.

The rest of this article provides more details on these strategies for sleeping better when you have a stomach ulcer.

Although this article has been written by a qualified medical doctor, you should always speak to your own doctor to get the best medical advice for your unique condition.

Related: find out if it’s safe to sleep with an Apple watch on here.

6 Ways to Sleep Better With a Stomach Ulcer

How to Sleep With a Stomach Ulcer

In addition to watching the video above, you can try the 6 techniques below to help you get better sleep when you have a stomach ulcer:

1: Use an Adjustable Bed to Find the Best Sleeping Position

Getting comfortable at night when you have a stomach ulcer can be difficult.

So what’s the best sleeping position if you have a stomach ulcer?

The location of stomach ulcers can vary, so there’s no single best sleeping position if you have a stomach ulcer – instead, try sleeping on your left/right side or back to find out which position is the most comfortable for you (however, sleeping on your stomach will probably make the pain worse) and consider using an adjustable bed to help you.

If stomach ulcers are a chronic issue for you, then you might like to consider investing in an adjustable bed because being able to alter the position of your body incrementally can help you to find a pain-free spot so that you can sleep more comfortably.

Adjustable beds can also help alleviate snoring and the symptoms of GERD, acid reflux, and even back pain by elevating the upper portion of the bed.

See the best adjustable beds and mattresses to buy here now.

2: Take Doctor Prescribed Ulcer Medications

Your primary care physician is likely to prescribe you with a combination of medications to reduce the discomfort caused by your stomach ulcers and help you get to sleep.

Although the treatment for peptic ulcers depends on the cause, the overall aim of your medical treatment would involve limiting the colonization of H. pylori bacterium if present, eliminating or reducing your use of NSAIDs, and speeding up the healing process of your peptic ulcer.

The following medications could be included in your treatment plan and if you take them in accordance with your prescription, the symptoms of your ulcers can be managed better, thereby helping you to sleep well:

i) Antibiotics to Kill H. Pylori

If your stomach ulcers are H. pylori-induced, then your doctor may prescribe you with a combination of antibiotics to kill the H. pylori bacterium.

These medications may include amoxicillin, clarithromycin, tetracycline, levofloxacin, metronidazole, and tinidazole.

ii) Medications to Inhibit the Production of Gastric Acid

Proton pump inhibitors are commonly prescribed drugs for the treatment of peptic ulcers.

Proton pump inhibitors block the action of a part of gastric cells which is responsible for producing hydrochloric acid in the stomach.

Hence, medications such as omeprazole, lansoprazole, rabeprazole, esomeprazole, and pantoprazole reduce the content and production of stomach acid to combat stomach ulcers.

Another class of drugs, known as histamine (H-2) blockers, such as famotidine, cimetidine, and ranitidine, are often prescribed to reduce the amount of stomach acid which is released into the digestive tract.

These medications are available both by prescription and over the counter.

iii) Medications to Neutralize the Stomach Acid

Usually available over the counter, antacids are neutralizing medications that react with the stomach acid and provide near-instant pain relief.

However, depending on the composition of these drugs, some of them may have minor side effects such as constipation or diarrhea.

iv) Medications to Protect the Stomach Lining

Your doctor may include some cytoprotective medications in your drug regimen to help protect the inner lining of your stomach from further damage.

These medications include sucralfate and misoprostol.

3: Avoid Trigger Foods Before Bed

It’s important to avoid foods that may aggravate your stomach ulcer and cause pain – especially before bed in order to limit the disruption of your sleep.

Your doctor or nutritionist is likely to provide you with a list of food items that can relieve or exacerbate the symptoms of your ulcerous disease.

For example, it is often suggested that patients with gastric ulcers must try to avoid the consumption of certain foods that are known to aggravate acid reflux or indigestion such as spicy food dishes containing spices like cayenne and tabasco.

It has been noted that spicy foods are likely to boost your metabolism due to their active ingredient, capsaicin, and this metabolism-boosting property can trigger heartburn in some people.

Spices are also thermogenic because they have the capacity to increase the basal temperature of the body which in turn can make you feel more awake.

Since each individual responds differently to different food items, it can sometimes be challenging to identify which foods may trigger your symptoms – so it’s recommended that you maintain a food diary and take regular notes of your meals, drinks, and snacks.

You can share the notes of your food diary on a weekly basis with a qualified nutritionist and it will surely assist you in managing your symptoms.

4: Allow 3-4 Hours Between Your Last Meal and Bedtime

In general, it is recommended for all people to consume a light dinner at least 3 to 4 hours before going to bed so that you feel settled and comfortable when you go to sleep.

But, when you are dealing with a digestive disorder, such as peptic ulcers in the stomach or duodenum, you must try to avoid a high-protein or a high-fat meal before bedtime.

Research suggests that the consumption of a dense meal – such as a high-protein meal or a high-fat meal – right before bed contributes to sleep disturbances.  

It is also recommended that while recovering from stomach ulcers, you maintain a strict time schedule for your meals.

As far as your last meal is concerned, it would be best to not consume dinner too close to your bedtime.

Ideally, as mentioned above, one should consume their last meal at least 3-4 hours prior to going to sleep.

5: Reduce Stress and Unhealthy Habits

Numerous scientific studies have shown that excessive stress and unhealthy lifestyle habits, such as alcohol consumption and smoking, can significantly contribute to your ulcerous disease.

Not only can stress, smoking and alcohol make your ulcers worse, but they can also contribute to the recurrence of your ulcers once they have been treated or healed.

Follow the tips below to improve your outlook:

5.1: Limit Stress

Patients have reported that their signs and symptoms of peptic ulcers become worse when they are in stressful situations.

It is understandable that not all types of stress are avoidable, but you must make an effort to learn different coping mechanisms such as exercise, meditation, writing a daily journal, or spending time with friends and family.

You must know that stress not only interferes with your disease, but it also interferes with your sleep.

5.2: Quit Smoking

Smoking disturbs the protective factors in your stomach, and it makes the gastric environment more susceptible to develop ulcers.

Studies show that smoking also increases stomach acid – which is responsible for aggravating the disease.

5.3: Limit or Avoid Alcohol

Alcohol acts as an irritant to the mucosa of the stomach.

Consumption of alcohol, especially in large quantities such as while binge drinking, can erode the inner lining of the esophagus and stomach – leading to excessive inflammation and bleeding.

6: Minimize Distractions Before Bed

In order to sleep well at night, especially while recovering from stomach ulcers, it is recommended that you make a conscious effort to minimize any distractions at night time, such as a noisy environment, excessively bright lights, and extended use of electronic devices.

More details below:

6.1: Block Out Noise With Earplugs

Aim to create a calm and silent zone in your bedroom.

This will help you to unwind, relax and fall asleep quickly.

To achieve this, you may consider using earplugs, noise-canceling devices, or you can try to play a soft calming music at low volume in the background.

I personally find that listening to the brown noise in the video below with my earphones in is an excellent way to block out annoying ambient sounds before sleep (then I switch to earplugs once I’m ready to sleep):

10 HOURS BROWN NOISE Noise Blocker for Sleep, Study, Tinnitus , Insomnia

6.2: Dim the Lighting and Black Out Your Bedroom

Excessively bright and flashy lighting can substantially disrupt your sleep cycle.

You can try dimming your bedroom lights a few hours prior to going to bed before eventually switching off all the lights closer to bedtime.

Please make sure that the lights in your bedroom are not too bright, flashy, or flickery because bad bedroom lighting can potentially trigger headaches in some people.

You should also consider applying any of these 19 ways to black out your bedroom for better sleep.

6.3. Limit the Use of Electronic Devices

Recent studies show that the blue light emitted from electronic devices is responsible for poor sleep quality.

Thus, it would be a good idea to limit the use of electronic devices such as mobile phones, laptops, tablets, and television before bedtime.

As a nighttime ritual, you can observe a no-screen time for up to 2-3 hours before going to bed.

This can be a soothing addition to your sleep hygiene and interestingly, according to recent studies, if you struggle with nightmares or bad dreams, limiting your screen time may reduce their frequency of occurrence.

How Stomach Ulcers Can Affect Sleep

Below is a short guide that explains what a stomach ulcer is, the common symptoms, and how they can affect sleep:

Stomach Ulcers Are Open Sores in the Stomach Tissue

Stomach ulcers, otherwise also referred to as gastric ulcers or peptic ulcers, are open sores that develop on the innermost lining of the stomach tissue.

Peptic ulcer disease can be classically defined as a break in the continuity of the mucosal layer of the stomach or duodenum.

This can be due to an imbalance between the protective gastric factors such as prostaglandins, mucus, bicarbonate, and mucosal blood flow, and the aggressive gastric factors such as gastric acid, pepsin, Helicobacter pylori infection, and non-steroidal anti-inflammatory drug use.

Pain and Bloating Are the Most Common Symptoms

The common symptoms of peptic ulcers are sharp burning stomach pain, discomfort in the epigastric region, feeling of fullness, bloating, belching, heartburn, nausea, and intolerance to fatty foods.

The less common symptoms of peptic ulcers are loss of appetite, sudden changes in the pattern of appetite, frequent vomiting, occasional vomiting with blood which may appear red or black, black or tarry stools with dark blood in feces, and unexplained weight loss.

H. Pylori Bacteria Can Cause Stomach Ulcers

Although in general there can be several causes of peptic ulcer disease, the most common causes associated with developing a peptic ulcer include a persistent untreated infection with the Helicobacter pylori (H. pylori) bacteria.

H.pylori are spiral-shaped bacteria that can erode the inner lining of the stomach and duodenum, thereby causing peptic ulcer disease, also known as an H. pylori-induced peptic ulcer.

The prevalence of H. pylori bacterial infection is about 30 to 40 percent among the adult population in the United States.

Scientists have identified recently that approximately 80 percent of stomach ulcers and more than 90 percent of the duodenal ulcers are caused by H. pylori alone.

Hence, it is safe to state that a large proportion or even almost all ulcers in the duodenum and stomach can be attributed to an infection caused by the H. pylori bacterium.  

NSAIDs Can Cause Stomach Ulcers

The long-term use of pain-relieving nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen, and some rare types of cancerous and noncancerous lesions in the stomach, duodenum, or pancreas such as the Zollinger-Ellison syndrome (ZES) can also cause stomach ulcers.

If you take NSAIDs every day or multiple times per week, then it is quite likely that you may be at risk of developing an NSAID-induced peptic ulcer – a peptic ulcer caused by the long-term overuse of NSAIDs.

Zollinger–Ellison Syndrome Can Cause Stomach Ulcers

Another cause of peptic ulcers could be Zollinger–Ellison syndrome (ZES).

ZES is essentially a gastrinoma – a neuroendocrine tumor that secretes a hormone called gastrin, which causes the stomach to produce too much acid resulting in peptic ulcers.

However, ZES is a rare digestive disorder because its annual incidence is only 0.5 to 2 per million population.

An Unhealthy Lifestyle Can Worsen Symptoms

Excessive smoking, frequent consumption of alcohol, prolonged stress, and eating very spicy foods can increase your risk of developing ulcers or may exacerbate or worsen your symptoms if you have already been diagnosed with an ulcerous disease.

Stomach Ulcers Can Heal Within 2-3 Months

Typically, uncomplicated stomach ulcers can heal within two to three months with proper treatment, however, if there are some complications associated with the ulcers, the healing time may extend considerably. 

Sometimes, stomach ulcers which are complicated with perforation, bleeding or malignancy, or certain peptic ulcers which are unresponsive to extended drug therapy, might require invasive treatment such as surgery.

There are specific surgical procedures such as gastrectomy or vagotomy, which are performed to deal with stubborn peptic ulcers.

After gastric surgery, you might need to make significant lifestyle adjustments to better cope with the aftermath of an invasive procedure.

Poor Sleep Quality Can Worsen Symptoms

While you are recovering from stomach ulcers or gastric surgery to treat the ulcer, your sleep cycle and sleep pattern may suffer drastic changes.

The link between sleep and stomach ulcers is quite interesting.

On one hand, some researchers say that poor sleeping patterns can aggravate the ulcers, while on the other hand, some researchers say that the pain and discomfort associated with stomach ulcers accounts for the sleep disturbances among patients.

Although it is difficult to establish a cause and effect relationship between sleep and stomach ulcers, one can say with certainty that quality of sleep and stomach ulcers are definitely closely associated variables.

Conclusion: Try Multiple Techniques

To sleep better with a stomach ulcer, start by adjusting your sleep position to find the most comfortable position (consider an adjustable bed to help you) and take the medications prescribed by your doctor.

In addition to this, you should consider making lifestyle changes to your diet and improving your sleep hygiene if appropriate.

Speak to your doctor if your symptoms persist.

Up next: 6 ways to sleep better after ACL surgery.


Sources and References

[1] NHS – Stomach Ulcer. Accessed 28/4/21.

[2] Pub Med – Peptic Ulcer Disease. Accessed 28/4/21.

[3] NCBI – Peptic Ulcer Disease and Helicobacter Pylori Infection. Accessed 28/4/21.

[4] NCBI – An Overview of History, Pathogenesis and Treatment of Perforated Peptic Ulcer Disease with Evaluation of Prognostic Scoring in Adults. Accessed 28/4/21.

[5] PubMed – Sleep Duration, Depression, and Peptic Ulcer Recurrence in Older Patients with Mild Cognitive Impairment. Accessed 28/4/21.

[6] AGS – Effect of Subjective and Objective Sleep Quality on Subsequent Peptic Ulcer Recurrence in Older Adults. Accessed 28/4/21.

Medical Disclaimer

No part of this article or website offers medical advice – always consult with a qualified professional for such guidance.

Image Attribution and Licencing

Main image: ‘Stomach Pain’ by Gpoint Studio – used with permission under the terms of Canva’s One Design Use License Agreement.

Dan is the founder and head content creator at Bedroom Style Reviews.

He has been working as a professional online product reviewer since 2015 and was inspired to start this website when he ended up sleeping on a memory foam mattress that was too soft and gave him backache.

Through in-depth research and analysis, Dan’s goal with this website is to help others avoid such pitfalls by creating the best online resource for helping you find your ideal mattress, bedding, and bedroom furniture.

Dan is a qualified NVQ Level 2 Fitness Instructor with 6 years’ experience helping clients improve their health through diet, exercise, and proper sleep hygiene.

He also holds several college and university-level qualifications in health sciences, psychology, mathematics, art, and digital media creation – which helps him to publish well researched and informative product reviews as well as articles on sleep, health, wellbeing, and home decor.

Dan also has direct personal experience with insomnia, anxiety, misophonia (hypersensitivity to sounds), and pain from both acute and long-standing sporting injuries – he enjoys writing insightful articles around these subjects to help fellow sufferers of such conditions.

Learn more about Dan here.

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5 Signs You May Have an Ulcer: Prima Medicine: Internal Medicine

Did you know that stomach ulcers ― also called peptic ulcers ― affect at least 1 in 10 Americans over the course of their lives? And while stomach ulcers can be treated easily when caught early, lack of medical care can lead to serious complications.  

Understanding the signs of stomach ulcers is important in helping you get the treatment you need. At Prima Medicine in Fairfax and South Riding, Virginia, our care team has the experience and knowledge to diagnose and treat stomach ulcers. We’ve curated this guide to help you recognize the warning signs of an ulcer and understand what you can do about it.   

What are stomach ulcers?

There are two kinds of stomach ulcers: gastric ulcers and duodenal ulcers. Gastric ulcers are sores on the lining of your stomach. Duodenal ulcers are sores on the upper section of your small intestine. 

Your body creates a protective layer of mucus to shield the linings of your stomach and small intestine from the harsh stomach acid required to break down food. When the mucus layer is worn away or doesn’t function properly, the acid begins to damage the lining of the stomach or small intestine, creating an ulcer. Many people believe spicy foods or stress cause ulcers, but while these can exacerbate existing ulcers, they don’t actually cause them.

Ulcers are usually caused by an infection from a common bacteria called helicobacter pylori or from the habitual use of nonsteroidal anti-inflammatory drugs, such as aspirin. Other factors, such as being older than age 50, smoking, genetics, steroid use, and frequent alcohol use, can increase your risk of developing an ulcer.   

What are the signs of an ulcer?

The signs of a stomach ulcer can range from mild to severe. Here are the top five signs you may have an ulcer: 

1. Dull, burning pain

The most common sign of a stomach ulcer is dull, burning pain in the stomach area. This pain typically appears between meals when your stomach is empty. It may last only a few moments, or it could last for hours. 

2. Indigestion or heartburn

Ulcers can increase the feeling of indigestion or heartburn, a burning feeling near your heart or upper stomach that happens when stomach acid flows up into your esophagus. If you notice increased instances of indigestion or heartburn, a stomach ulcer could be to blame.  

3. Nausea or vomiting

Stomach ulcers can make you feel sick to your stomach, especially early in the morning after going for a long time without food. Ulcers trigger an inflammatory response in the stomach, which can cause stomach contractions. If they get strong enough, you may experience vomiting.   

4. Change in stool color

If you notice your stool looks black, which is the color of digested blood, this could be a sign of a bleeding ulcer. Bleeding ulcers are a serious medical condition and require urgent attention. 

5. Unexplained weight loss

Sometimes stomach ulcers create a block in the digestive system due to the inflammation they cause. This can prevent food from moving through your stomach, leading to weight loss and a decrease in appetite. 

How can I be sure it’s an ulcer?

The only way to be sure an ulcer is causing your discomfort is with a medical diagnosis. We will evaluate your medical history and conduct a thorough physical examination. 

To determine the root cause of your ulcer, we may run blood, stool, or breath tests. These tests are designed to look for signs of helicobacter pylori, the bacteria linked to ulcers. 

Depending on your unique symptoms, we may also order an endoscopy. During an endoscopy, we insert a tube with a tiny camera down your throat and into your stomach to take pictures of any potential damage and collect tissue samples for analysis.  

What treatments are there for ulcers?

Your treatment will depend on the cause of your ulcer. For example, if our tests indicate that an infection caused by helicobacter pylori is what created your ulcer, we’ll give you antibiotics to eliminate the bacteria. 

Regardless of the cause, medications that help reduce the level of acid in your stomach can help the ulcer heal. And different lifestyle changes can accelerate healing as well, such as eliminating certain foods, abstaining from alcohol, and practicing stress management. 

In severe cases, surgery may be required. Your provider at Prima Medicine will work with you to create a treatment plan for your situation.  

If you have a stomach ulcer or want to see if you do, we can help. To learn more, book an appointment online or over the phone with Prima Medicine today.

Peptic ulcers: what are the symptoms?

The symptoms of peptic ulcers, which comprise gastric (or stomach) ulcers and duodenal ulcers, can vary from person to person and with the location of the ulcer. You may have an ulcer without experiencing any symptoms, have obvious symptoms, or experience a complication, such as bleeding or perforation.

Common symptoms of peptic ulcers

The following symptoms are commonly associated with peptic ulcers. However, bear in mind that peptic ulcers often cause no symptoms, especially in older people.

Burning or gnawing abdominal pain

Abdominal pain or discomfort is a typical symptom of peptic ulcers (both gastric and duodenal). The pain tends to come and go, and is often worse at night.

You may feel the pain anywhere in the area between your navel and your breastbone. It often occurs when the stomach is empty.

The pain may last from between a few minutes to several hours, and may be relieved by eating, drinking milk or taking antacid medicines. However, sometimes eating can make symptoms worse. In addition, drinking milk may be just a temporary fix. While it can improve symptoms quickly, it may increase acid production later on, making symptoms worse.

The pain or discomfort associated with peptic ulcers is sometimes referred to as ‘dyspepsia’.

Nausea and vomiting

Sometimes you might experience nausea or vomiting. These symptoms are not as common as abdominal pain.

Nausea associated with a peptic ulcer may be relieved by eating.

Loss of appetite and weight

Again these symptoms are less common than abdominal pain, but people with peptic ulcers may suffer from loss of appetite and so lose weight.

More serious symptoms

Sometimes people are not aware they have an ulcer until they experience a serious complication, and some of these may include the following.

Haemorrhage

As an ulcer corrodes the lining of the stomach or duodenum, it may extend into the stomach or duodenal wall. In these cases, blood vessels can also be damaged, which can cause bleeding.

If these blood vessels are small, the blood may slowly seep into the digestive tract, leading to the development of anaemia over time. This may make you feel weak, dizzy or tired.

If larger blood vessels are involved, the bleeding will occur much more rapidly. This is a more dangerous situation. You may feel weak when you stand up, or you may faint or vomit blood. Your stools may be a black or dark red colour (from the blood) and ‘tar-like’ in consistency.

If you have any of these symptoms you should seek medical attention immediately, as you may need treatment to stop the bleeding.

Perforation and penetration

Although rare, ulcers can develop to such an extent that they completely perforate through the stomach or duodenal wall. This can cause the gastric contents, including partially digested food, to leak through this opening into the abdominal cavity, resulting in peritonitis (inflammation of the membrane that lines the abdominal cavity). This can cause sudden, severe abdominal pain that is worsened by any kind of movement.

Sometimes an ulcer may penetrate through the wall of the stomach or duodenum into another abdominal organ, such as the pancreas.

Perforation and penetration of ulcers is a medical emergency that needs immediate treatment in hospital.

Narrowing and obstruction

If your ulcer is located at the end of the stomach where it attaches to the duodenum, the scarring it causes may eventually narrow the opening to the duodenum. This will prevent food from leaving your stomach and moving into the small intestine.

If this happens you may experience nausea and vomiting, as well as worsening abdominal pain and bloating. You may also feel full after eating a small amount of food.

See your doctor about ulcer symptoms

If you are experiencing upper abdominal pain (tummy pain) or any of the other symptoms mentioned above, you should see your doctor. If your doctor suspects you may have a peptic ulcer they will want to confirm the cause and diagnosis and start treatment.

1. BMJ Best Practice. Peptic ulcer disease (updated Jan 2018; reviewed Sep 2018). https://bestpractice.bmj.com/topics/en-gb/80 (accessed Oct 2018).
2. Gastric disorders (published March 2016). In: eTG complete. Melbourne: Therapeutic Guidelines Limited; 2018 Jul. https://tgldcdp.tg.org.au/ (accessed Oct 2018).
3. Mitchell H, Katerlaris P. Epidemiology, clinical impacts and current clinical management of Helicobacter pylori infection. Med J Aust 2016; 204 (10): 376-380. || doi: 10.5694/mja16.00104. https://www.mja.com.au/journal/2016/204/10/epidemiology-clinical-impacts-and-current-clinical-management-helicobacter (accessed Oct 2018).

Do I Have An Ulcer

Even though more than 25 million Americans will suffer from a stomach ulcer at some point during their lifetime, according to the Centers for Disease Control and Prevention, you don’t need to put down the jalapeño poppers just yet. Contrary to popular belief, spicy foods don’t cause stomach ulcers. Neither does stress. (If you already have an ulcer, however, both can make your symptoms worse.)

“The two main causes of ulcers in the U.S. are a bacterial infection called H. pylori, and long-term use of aspirin and NSAID painkillers (ibuprofen and naproxen),” says Shipla Ravella, M.D., gastroenterologist at NewYork-Presbyterian and Columbia University Medical Center.

Basically, there’s a thick layer of mucus that protects your stomach from digestive juices, which are hella acidic. And anytime there’s a mucosal drought, the juices eat away at the tissues that line the stomach, causing an ulcer. Gah.

Think you might have one? The primary symptoms to look out for are pretty non-specific (translation: they can be caused by a variety of conditions besides ulcers), says Ravella, so it’s important to check in with your doc if you ever experience any of the following five issues:

RELATED: 6 Signs You’ve Got A Serious Problem With Your Stomach

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The most common stomach ulcer symptom is, not surprisingly, stomach pain—typically, a dull, burning sensation in the mid-abdominal area. “Because ulcers are literally sores in the lining of the stomach or small bowel, pain classically presents in relation to acid secretion in the intestines,” says Rusha Modi, M.D., gastroenterologist and assistant professor of clinical medicine at Keck Medical Center in California. The pain usually peaks between meals and at night, when acid has been secreted into the stomach but there’s no food to act as a buffer. Taking antacids can temporarily relieve the pain, but odds are it will keep coming back until the ulcer is treated by a professional.

(Kick-start your new, healthy routine with Women’s Health’s 12-Week Total-Body Transformation!)

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Because the ulcer is being perpetually doused in acid, stomach pain can often be paired with chronic heartburn and regurgitation (that icky feeling of acid backing up into your throat). Other symptoms, such as bloating, burping, or feeling perma-full, may not be far behind, says Ravella. If taking an OTC antacid only relieves symptoms temporarily, or they seem to strike no matter what you eat, you may want to discuss this with your physician.

RELATED: What It Means if You Have One of These 7 Types of Stomach Pains

Christine Frapech

“Nausea and vomiting are also due to the inflammatory cascade that occurs as a result of the ulcer’s development,” says Modi. The inflammation of the stomach lining itself causes intermittent contractions (cue nausea)—and if the muscles of the abdominal wall contract with enough force, it can cause full-on vomiting, says Rudolph Bedford, M.D., gastroenterologist at Providence Saint John’s Health Center in Santa Monica, California.

In some cases, these symptoms strike because the ulcer is causing a blockage in the stomach and food isn’t able to pass easily into the small intestine. Your doctor can determine the exact cause of the ulcer and, most likely, treat it with antacid medications—but, if there’s evidence of a blockage, you’ll be admitted to the hospital for further treatment, says Modi.

Find out what you MUST do the next time you go to the doctor:

Christine Frapech

Ulcers can bleed and cause vomiting—particularly, vomiting of blood or material that looks like coffee grounds (which is digested blood that’s been sitting in the stomach), says Sophie Balzora, M.D., gastroenterologist and assistant professor of medicine at NYU Langone Medical Center. Your poop may also become black in color, which, again, can be indicative of digested blood. “Both are signs that require urgent and emergent medical attention,” she says.

RELATED: 4 Reasons Why You Might See Blood in Your Poop

Christine Frapech

Pain from a stomach ulcer can travel, radiating to the back or chest. “If the ulcer has penetrated through the bowel wall, the pain can become more intense, longer in duration, and harder to alleviate,” says Ravella. Ulcers can also cause perforation (where the lining of the stomach splits open), in which case you may experience sudden and severe stomach pain that continually gets worse—and should head to the ER, stat.

If you’re not experiencing symptoms that require urgent medical attention, set up a time to chat with your doctor about the best course of action is. “If there’s a high suspicion for an ulcer, you may be advised to undergo an upper endoscopy to formally diagnose and treat it accordingly,” says Balzora. Ulcers are primarily treated with acid-lowering medications—and, if H. pylori is detected, a round of antibiotics. 

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What are Stomach Ulcers? | Stomach Ulcer Symptoms, Causes, Treatment

Stomach Ulcer Symptoms

Stomach ulcers often have no symptoms. Some people will experience:

  • Burning stomach pain
  • Feeling of fullness, bloating, belching
  • Intolerance to fatty foods
  • Heartburn
  • Nausea

Pain that goes away after taking an antacid, like Tums or Maalox, and then returns may also be a symptom of stomach ulcers. Discomfort and pain are frequently worse at night and between meals.

Occasionally, symptoms will include:

  • Vomiting or vomiting blood
  • Dark blood in stools
  • Stools that are black and tarry
  • Trouble breathing
  • Unexplained weight loss
  • Appetite changes

Stomach ulcer causes

The most common cause of stomach ulcers is an infection with Helicobacter pylori (H. pylori). The transmission of this bacteria is not fully understood. Direct contact with bodily fluids and contaminated food or water may cause infection. Not all people who are infected with H. pylori will get an ulcer.

Long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) is another possible cause of stomach ulcers. NSAIDs include over-the-counter aspirin (Excedrin), ibuprofen (Advil), and naproxen (Aleve). Prescription NSAIDs that are prescribed for diseases like rheumatoid arthritis or other orthopedic conditions can also cause ulcers with long-term use.

When NSAIDs are taken with some other medications, there is a greater risk of getting a stomach ulcer. These medications include:

  • Corticosteroids
  • Anticoagulants
  • Selective serotonin reuptake inhibitors (SSRIs) – antidepressants like Paxil and Zoloft
  • Osteoporosis medications – Actonel and Fosamax

Stress and spicy foods do not cause stomach ulcers. They can, however, make symptoms worse.

Stomach ulcer risk factors

A few risk factors can make it more likely that a peptic ulcer will develop.

  • Smoking – especially in people who are already infected with H. pylori
  • Drinking alcohol
  • Having a family history of ulcers

Additionally, people who take NSAIDs are more likely to develop an ulcer if they:

  • Are over 70 years of age
  • Take high doses of NSAIDs
  • Are female
  • Have a personal history of ulcer disease

Stomach ulcer complications

Blood loss is one of the complications associated with stomach ulcers. It can be slow and lead to anemia over time. If an ulcer starts bleeding suddenly, it can cause severe blood loss that may require a blood transfusion and hospitalization.

Rarely, an ulcer can create a hole in the stomach. This can lead to a severe infection of the abdomen called peritonitis.

Obstructions are also possible due to scarring or inflammation from an ulcer. Symptoms of obstruction may be a feeling of fullness or nausea and vomiting.

Stomach ulcer diagnosis

Stomach ulcers diagnosed are based on medical history and physical examination by a doctor. An upper endoscopy may be performed. This allows the gastroenterologist to view the inside of your stomach with a small camera.

Laboratory testing for H. pylori may also be conducted. It may consist of a blood test, a stool test, or a breath test. (Read more about testing for H. pylori)

Stomach ulcer treatment

Treatment with antibiotics may be necessary when there is an H. pylori infection causing the ulcer.

Medications may also be prescribed for treatment, including:

  • Proton-pump inhibitors: omeprazole (Prilosec), esmeprazole (Nexium)
  • Histamine blockers: famotidine (Pepcid), cimetidine (Tagamet)

Your doctor may also recommend antacids like Tums or Maalox for pain relief. Sucralfate may be recommended as well, which adds a protective layer to the surface of the ulcer while it heals.

Stomach ulcer (Gastric ulcer) | NHS inform

If you have a stomach ulcer, your treatment will depend on what caused it.

With treatment, most ulcers heal in a month or two.

Treating Helicobacter pylori (H. pylori) infection

If your stomach ulcer’s caused by a Helicobacter pylori (H. pylori) bacterial infection, you’ll be given:

  • a course of antibiotics
  • a medication called a proton pump inhibitor (PPI)

This is also recommended if it’s thought your stomach ulcer’s caused by a combination of an H. pylori infection and non-steroidal anti-inflammatory drugs (NSAIDs).

Antibiotics

If you have an H. pylori infection, you’ll usually be prescribed a course of 2 or 3 antibiotics.

The most commonly used antibiotics are:

  • amoxicillin
  • clarithromycin
  • metronidazole

You should take these twice a day for a week.

Side effects

The side effects of these are usually mild, but can include:

  • feeling and being sick
  • diarrhoea
  • a metallic taste in your mouth

Further testing

You’ll be re-tested at least 4 weeks after finishing your antibiotic course to see if there are any H. pylori bacteria left in your stomach. If there are, a further course of eradication therapy using different antibiotics may be given.

Ulcers caused by NSAIDs

If your stomach ulcer’s caused by taking NSAIDs:

  • you’ll be given a course of PPI medication
  • your use of NSAIDs will be reviewed, and you may be advised to use an alternative painkiller

Alternative painkillers

You may be advised to use an alternative painkiller not associated with stomach ulcers, such as paracetamol.

COX-2 inhibitors are sometimes recommended. These are an alternative type of NSAID that’s less likely to cause stomach ulcers.

Low-dose aspirin

If you’re taking low-dose aspirin to reduce your risk of blood clots, your GP will tell you whether you need to keep taking it.

If you do, you may also be prescribed long-term treatment with a PPI or h3-receptor antagonist to prevent further ulcers.

Complications

It’s important to understand the potential risks associated with continued NSAID use.

You’re more likely to develop another stomach ulcer and could experience a serious complication, such as internal bleeding.

Read more about the complications of stomach ulcers

Proton pump inhibitors (PPIs)

PPIs work by reducing the amount of acid your stomach produces. This prevents further damage to the ulcer as it heals naturally.

The most commonly used PPIs are:

  • omeprazole
  • pantoprazole
  • lansoprazole

They’re usually prescribed for 4 to 8 weeks.

Side effects

Side effects of these are usually mild, but can include:

These should pass once treatment has been completed.

h3-receptor antagonists

Sometimes a type of medication called h3-receptor antagonists are used instead of PPIs.

These also reduce the amount of acid your stomach produces.

Ranitidine is the most widely used h3-receptor antagonist for treating stomach ulcers.

Side effects

Side effects are uncommon, but can include:

  • diarrhoea
  • headaches
  • dizziness
  • rashes
  • tiredness

Antacids and alginates

As these treatments can take several hours before they start to work, your GP may recommend taking additional antacid medication.

Antacids:

  • neutralise your stomach acid
  • provide immediate, but short-term, symptom relief
  • should be taken when you experience symptoms or when you expect them, such as after meals or at bedtime

Some antacids also contain a medicine called an alginate, which produces a protective coating on the lining of your stomach. Antacids containing alginates are best taken after meals.

You can buy these medications at pharmacies. Your pharmacist can tell you which is most suitable for you.

Side effects

Side effects of both medications are usually mild, but can include:

Lifestyle changes

There aren’t any special lifestyle measures you need to take during treatment.

However, avoiding stress, alcohol, spicy foods and smoking may reduce your symptoms while your ulcer heals.

H. Pylori & Peptic Ulcer

What is a peptic ulcer?

A peptic ulcer is a sore on the lining of the stomach or duodenum, which is the beginning of the small intestine. Peptic ulcers are common: One in 10 Americans develops an ulcer at some time in his or her life. One cause of peptic ulcer is bacterial infection, but some ulcers are caused by long-term use of nonsteroidal anti-inflammatory agents (NSAIDs), like aspirin and ibuprofen. In a few cases, cancerous tumors in the stomach or pancreas can cause ulcers. Peptic ulcers are not caused by stress or eating spicy food.

What is H. pylori?

Helicobacter pylori (H. pylori) is a type of bacteria. Researchers believe that H. pylori is responsible for the majority of peptic ulcers, as well as chronic gastritis (inflammation of the stomach lining) and potentially gastric cancer.

H. pylori infection is common in the United States: About 20 percent of people under 40 years old and half of those over 60 years have it. Most infected people, however, do not develop ulcers. Why H. pylori does not cause ulcers in every infected person is not known. Most likely, infection depends on characteristics of the infected person, the type of H. pylori, and other factors yet to be discovered.

Researchers are not certain how people contract H. pylori, but they think it may be through food or water.

Researchers have found H. pylori in the saliva of some infected people, so the bacteria may also spread through mouth-to-mouth contact, such as kissing.

How does H. pylori cause a peptic ulcer?

The H. pylori bacteria weakens the protective mucous coating of the stomach and duodenum, thus allowing acid to get through to the sensitive lining beneath. Both the acid and the bacteria irritate the lining and cause a sore, or ulcer.

H. pylori is able to survive in stomach acid because it secretes enzymes that neutralize the acid. This mechanism allows H. pylori to make its way to the “safe” area – the protective mucous lining. Once there, the bacterium’s spiral shape helps it burrow through the lining.

What are the symptoms of an ulcer?

Abdominal discomfort is the most common symptom. This discomfort usually:

  • is a dull, gnawing ache.
  • comes and goes for several days or weeks.
  • occurs 2 to 3 hours after a meal.
  • occurs in the middle of the night (when the stomach is empty).
  • is relieved by eating.
  • is relieved by antacid medications.

Other symptoms include

  • weight loss
  • poor appetite
  • bloating
  • burping
  • nausea
  • vomiting

Some people experience only very mild symptoms or none at all.

Emergency Symptoms

If you have any of these symptoms, call your doctor right away:

  • Sharp, sudden, persistent stomach pain.
  • Bloody or black stools.
  • bloody vomit or vomit that looks like coffee grounds.

They could be signs of a serious problem, such as:

  • Perforation – when the ulcer burrows through the stomach or duodenal wall.
  • Bleeding – when acid or the ulcer breaks a blood vessel.
  • Obstruction – when the ulcer blocks the path of food trying to leave the stomach.

How is an H. pylori-related ulcer diagnosed?

Diagnosing an Ulcer
To see whether symptoms are caused by an ulcer, the doctor may do an upper gastrointestinal (GI) series or an endoscopy.

Upper GI series — An x-ray of the esophagus, stomach, and duodenum. The patient drinks a chalky liquid, called barium, to make these organs and any ulcers show up more clearly on the x-ray.

Endoscopy — An exam that uses an endoscope, a thin, lighted tube with a tiny camera on the end. The patient is lightly sedated, and the doctor carefully eases the endoscope into the mouth and down the throat to the stomach and duodenum. This allows the doctor to see the lining of the esophagus, stomach, and duodenum. The doctor can use the endoscope to take photos of ulcers or remove a tiny piece of tissue to view under a microscope.

Diagnosing H. pylori
If an ulcer is found, the doctor will test the patient for H. pylori. This test is important because treatment for an ulcer caused by H. pylori is different from that for an ulcer caused by NSAIDs.

H. pylori is diagnosed through blood, breath, stool, and tissue tests. Blood tests are most common. They detect antibodies to H. pylori bacteria. Blood is taken at the doctor’s office through a finger stick.

Urea breath tests are an effective diagnostic method for H. pylori. They are also used after treatment to see whether it worked. In the doctor’s office, the patient drinks a urea solution that contains a special carbon atom. If H. pylori is present, it breaks down the urea, releasing the carbon. The blood carries the carbon to the lungs, where the patient exhales it. The breath test is 96 percent to 98 percent accurate.

Stool tests may be used to detect H. pylori infection in the patient’s fecal matter. Studies have shown that this test, called the Helicobacter pylori stool antigen (HpSA) test, is accurate for diagnosing H. pylori.

Tissue tests are usually done using the biopsy sample that is removed with the endoscope. There are three types:

  • The rapid urease test detects the enzyme urease, which is produced by H. pylori.
  • A histology test (or biopsy) allows the doctor to find and examine the actual bacteria.
  • A culture test involves allowing H. pylori to grow in the tissue sample.

In diagnosing H. pylori, blood, breath, and stool tests are often done before tissue tests because they are less invasive. However, blood tests are not used to detect H. pylori following treatment because a patient’s blood can show positive results even after H. pylori has been eliminated.

How are H. pylori peptic ulcers treated?

Drugs Used to Treat H. pylori Peptic Ulcers
Antibiotics: metronidazole, tetracycline, clarithromycin, amoxicillin
h3 blockers: cimetidine, ranitidine, famotidine, nizatidine
Proton pump inhibitors: omeprazole, lansoprazole, rabeprazole, esomeprazole, pantoprozole
Stomach-lining protector: bismuth subsalicylate

H. pylori peptic ulcers are treated with drugs that kill the bacteria, reduce stomach acid, and protect the stomach lining. Antibiotics are used to kill the bacteria. Two types of acid-suppressing drugs might be used: h3 blockers and proton pump inhibitors.

h3 blockers work by blocking histamine, which stimulates acid secretion. They help reduce ulcer pain after a few weeks. Proton pump inhibitors suppress acid production by halting the mechanism that pumps the acid into the stomach. h3 blockers and proton pump inhibitors have been prescribed alone for years as treatments for ulcers. But used alone, these drugs do not eradicate H. pylori and therefore do not cure H. pylori -related ulcers. Bismuth subsalicylate, a component of Pepto-Bismol, is used to protect the stomach lining from acid. It also kills H. pylori.

Treatment usually involves a combination of antibiotics, acid suppressors, and stomach protectors. Antibiotic regimens recommended for patients may differ across regions of the world because different areas have begun to show resistance to particular antibiotics.
The use of only one medication to treat H. pylori is not recommended. At this time, the most proven effective treatment is a 2-week course of treatment called triple therapy. It involves taking two antibiotics to kill the bacteria and either an acid suppressor or stomach-lining shield. Two-week triple therapy reduces ulcer symptoms, kills the bacteria, and prevents ulcer recurrence in more than 90 percent of patients.

Unfortunately, patients may find triple therapy complicated because it involves taking as many as 20 pills a day. Also, the antibiotics used in triple therapy may cause mild side effects such as nausea, vomiting, diarrhea, dark stools, metallic taste in the mouth, dizziness, headache, and yeast infections in women. (Most side effects can be treated with medication withdrawal.) Nevertheless, recent studies show that 2 weeks of triple therapy is ideal.

Early results of studies in other countries suggest that 1 week of triple therapy may be as effective as the 2-week therapy, with fewer side effects.

Another option is 2 weeks of dual therapy. Dual therapy involves two drugs: an antibiotic and an acid suppressor. It is not as effective as triple therapy.

Two weeks of quadruple therapy, which uses two antibiotics, an acid suppressor, and a stomach-lining shield, looks promising in research studies. It is also called bismuth triple therapy.

Can H. pylori infection be prevented?

No one knows for sure how H. pylori spreads, so prevention is difficult. Researchers are trying to develop a vaccine to prevent infection.

Why don’t all doctors automatically check for H. pylori?

Changing medical beliefs and practice takes time. For nearly 100 years, scientists and doctors thought that ulcers were caused by stress, spicy food, and alcohol. Treatment involved bed rest and a bland diet. Later, researchers added stomach acid to the list of causes and began treating ulcers with antacids.

Since H. pylori was discovered in 1982, studies conducted around the world have shown that using antibiotics to destroy H. pylori cures peptic ulcers. The prevalence of H. pylori ulcers is changing. The infection is becoming less common in people born in developed countries. The medical community, however, continues to debate H. pylori role in peptic ulcers. If you have a peptic ulcer and have not been tested for H. pylori infection, talk to your doctor.

Points to Remember

  • A peptic ulcer is a sore in the lining of the stomach or duodenum.
  • The majority of peptic ulcers are caused by the H. pylori bacterium. Many of the other cases are caused by NSAIDs (a class of pain-reliever). None are caused by spicy food or stress.
  • H. pylori can be transmitted from person to person through close contact and exposure to vomit.
  • Always wash your hands after using the bathroom and before eating.
  • A combination of antibiotics and other drugs is the most effective treatment for H. pylori peptic ulcers.

For More Information

To learn more about this topic, please visit:

Cleveland Clinic
WebMD

Clinics Chaika – Chaika.com

Peptic ulcer of the stomach and duodenum is characterized by the formation of an ulcer in the walls of the stomach or duodenum, which eats up the mucous layer and deeper muscle layers.

Peptic ulcer disease is most often manifested by pain or discomfort in the upper abdomen (epigastrium). Sometimes pain can be localized in the upper third of the right and left hypochondrium. Occasionally, pain can radiate to the back, but this is a rare and not very typical symptom.If left untreated, symptoms may persist for several weeks and then be replaced by an asymptomatic period, sometimes lasting several months.

Most often, pain in a duodenal ulcer appears 2–5 hours after eating, and also at night (usually between 23:00 and 2:00).

With stomach ulcers, pain usually occurs during meals. There may be other symptoms: belching after eating, early onset of a feeling of satiety, heaviness in the epigastrium, intolerance to fatty foods, nausea, and sometimes vomiting.

The asymptomatic course is most typical for the elderly and patients who have been receiving NSAID painkillers for a long time (the most commonly used group of painkillers).

Complications of peptic ulcer disease develop regardless of whether it is asymptomatic or accompanied by typical complaints.

Main complications:

  • Bleeding from a peptic ulcer – manifested by nausea, vomiting of the color of coffee grounds or chalk (black feces, its staining occurs due to contact of blood with hydrochloric acid in the stomach).
  • Pyloric stenosis (a decrease in the lumen of the outlet between the stomach and duodenum due to scarring of ulcers) – manifested by a feeling of early satiety, overcrowding after a small amount of food, nausea, sometimes vomiting, weight loss.
  • Ulcer penetration – penetration, “germination” of an ulcer into other organs (loops of the large intestine, pancreas, vessels of the abdominal cavity, etc.). Most often, it is manifested by a change in the nature of complaints, an increase in pain syndrome, the appearance of an unusual irradiation of pain (for example, to the back).The new symptomatology depends on which organ was involved. In this case, antacids (drugs used to relieve pain and get rid of heartburn) stop helping or reduce pain slightly.
  • Perforation – the ulcerative defect completely eats up the wall, and the contents of the stomach or duodenum begins to enter the abdominal cavity. It is characterized by the appearance of a sharp, dagger pain in the epigastrium, and then pain throughout the abdomen.
  • Malignancy – the degeneration of an ulcer into a malignant tumor – cancer.

Clinical analysis.

Vladimir Trofimovich Ivashkin , Academician of the Russian Academy of Medical Sciences, Doctor of Medical Sciences:

– We will really talk with you about simple, mundane things that are often encountered in our daily practice and in the practice of the therapist. I’ll ask for a slide. It will be about two patients with peptic ulcer disease. With these two examples, we will take a little break with you from the intricacies of schemes, knowledge and the need for deep penetration into the renal function, into the renal blood flow and the consequences of disturbances in the blood flow of the renal function.

So let’s talk about the first patient. The patient is 44 years old. He was admitted to the clinic with complaints of epigastric pain, periodic bloating and rumbling in the abdomen. I must say that this patient has been complaining of epigastric pain for a long period of time (about 15 years). And pay attention to the nature of the pain. The pain occurs on an empty stomach and is relieved by eating. I think, based only on this complex (fasting pains that decrease after eating), you can safely suspect that your patient has at least duodenitis, and most likely you will think about the possibility of having a duodenal ulcer.Hunger pains relieved by food. Why does the patient endure so long? The pain is mild and not very intense at night, although there are also night pains.

In August 2012, the patient’s condition worsened, there was a dagger pain. Dagger pain is such a student symptom that immediately makes us suspect a possible perforation of the ulcer. The patient was urgently admitted to a surgical hospital. Perforation of the duodenal bulb was indeed diagnosed.Surgeons, as is now customary, performed suturing of the ulcer. After discharge, the patient received proton pump inhibitors as recommended by doctors. Note the “proton pump inhibitors”. That is, attention to the possibility of our patient having H. pylori infections was not properly drawn.

But on an outpatient basis after that (most likely after a recommendation), the patient found Helicobacter pylori antibodies during an outpatient examination. The titer of these antibodies was higher than the reference values.If the patient does not receive eradication therapy at the previous stages, then the detection of immunoglobulin G directed against Helicobacter pylori antigens is indeed a true test that allows us to speak about the presence of Helicobacter pylori infection in our patient.

The patient’s condition worsened since April 2013, when epigastric pain reappeared. The patient is hospitalized. The condition is relatively satisfactory upon hospitalization. Body mass index 26, he is normostenic.And from the side of other organs and systems, there are no special signs that attract to themselves. Blood pressure within the normal range. Blood counts as well. Normal levels of erythrocytes, hemoglobin, hematocrit – everything is in order. On the part of biochemical indicators, there are also no deviations.

The patient naturally underwent electrogastroduodenoscopy. You see in the left picture a moderate amount of secretion with an admixture of bile, the folds are relief longitudinally arranged, as it should be.The gastric mucosa is irregularly hyperemic. In the antrum, where a single point erosion is visualized, this should attract our attention. We see the classic picture of antral gastritis, not pronounced, but so catarrhally erosive. But if we take into account the fact that for a long time the patient has a duodenal ulcer, the patient has a high level of antibodies Helicobacter pylori and antral gastritis, then we can simply 99% conclude, without even determining Helicobacter pylori, that he has an infection with Helicobacter pylori.Antral gastritis is a kind of receptacle for Helicobacter infection.

Then the endoscope is inserted into the duodenum. You see the duodenum is deformed and the ulcer is covered with fibrin, that is, we are talking about an actively living duodenal ulcer, which also confirms our assumption of the presence of Helicobacter pylori.

In essence, all these facts gave us the basis for conducting eradication therapy for ten days, as it should be according to international recommendations.

Proton pump inhibitors, in particular pariet 20 mg twice a day. Note that in recent years, we have begun to use PPI doses that are higher than those recommended after the initial andomized clinical trials. It’s just that the practice of life has shown that large doses of inhibitors are more effective. And two antibiotics: “Amoxicillin” two grams per day and “Clarithromycin” grams per day. Absorbable antacids after meals and continued PPIs after eradication therapy for four to six weeks.

Thus, during the control gastroscopy of duodenoscopy after three weeks, the patient’s erosions in the antrum of the stomach disappeared and the duodenal ulcer essentially also disappeared. This is a classic example of the classic course of duodenal ulcer disease with a successful outcome due to correctly performed eradication therapy.

Now let’s see the following observation. This is a fifty year old patient. He was admitted with complaints of pain, a feeling of heaviness in the epigastric region.Unlike the first patient, this unpleasant feeling of overflow, heaviness, soreness is what young doctors combine with the general term “discomfort”. Although I believe that such a symptom as “discomfort” does not exist. The discomfort must be deciphered. What does “discomfort” mean? One is uncomfortable that he has a sucking pain in the epigastric region, and the other is uncomfortable because he is experiencing a feeling of rapid overflow (just starting to eat, and he is bursting). Discomfort is something that forms at the level of consciousness, so it is necessary to decipher each time the doctor understands what a particular doctor puts into this word “discomfort”.

In addition, the patient has general weakness, shortness of breath with little exercise and increased fatigue. Pay attention to these symptoms. General weakness and fatigue can be caused by low hemoglobin levels in a peptic ulcer patient if bleeding occurs. But he has no bleeding. Therefore, we must explain the shortness of breath and increased fatigue by some other factor. What are they?

Let’s take a look at our patient’s history. In the epigastric pain he has been disturbed since 1991, he ate chaotically and irregularly.I must say that the regularity of the diet is much more important for any of us than the nature of the diet. Strictly observe the hours of food, breakfast, lunch, dinner, rather than looking for some kind of refined diet and diet. Therefore, when we talk with patients about how he eats, we must first of all ask about the rhythm of eating: rhythmic nutrition or irregular nutrition. Arrhythmia in food is a much more negative factor than, say, a restriction in proteins, fats, carbohydrates, and so on, which are most often ephemeral, we overeat, as a rule, rather than malnourish.But the rhythm is a very important thing, especially in relation to persons with a tendency to develop functional and organic diseases of the gastrointestinal tract.

What is characteristic? He’s a terry smoker. He started smoking at the age of 12 and very quickly the number of cigarettes smoked by his youth reached 40 per day for a long time. He is 50 years old. More than 30 years 40 cigarettes a day. Note. When we ask ourselves the question: where does the patient get weakness, fatigue and shortness of breath? Well, if you smoke 40 cigarettes a day, imagine what happens to the pulmonary blood flow, coronary blood flow, parenchyma, in particular the myocardium, and so on.

Sometimes we forget to analyze very simple things. Smoking is a very simple thing. Find out how much a person smokes, and then try to relate the symptoms that are observed in these patients with the intensity and volume of cigarettes smoked.

So, gastroscopy revealed a duodenal ulcer. Periodically, the patient took antacids, proton pump inhibitors with a positive effect – for a short time his pain in the epigastric region disappeared.But eradication therapy was not carried out for a long time and Helicobacter pylori infection was not determined.

Since 2009, he noted episodes of bloating in the epigastric after eating and vomiting of food eaten – these are already alarming symptoms. This should alert the doctor in terms of the possibility of the patient developing stenosis of the outlet section of the stomach. This all really proved to be true. Vomiting brought relief, and the patient lost 30 kg in weight in three years. This is already a nutritional deficiency. This is a violation of the trophological status.In 2012, under pressure from relatives, he was hospitalized in a surgical hospital, where, according to gastroscopy and X-ray examination, cicatricial stenosis of the pylorus was revealed. Subsequently, the performed operation of pyloroplasty and selective proximal vagotomy after surgery felt an improvement in the form of a decrease in abdominal pain. Vomiting no longer bothered.

However, in November 2012, severe weakness appeared, followed by black stools, melena.He was urgently hospitalized and gastroscopy revealed a large stomach ulcer 6 cm in diameter with signs of bleeding. The surgeons sutured the ulcer defect, that is, it was a sparing operation, there was no resection. And in the patient during this period, there is a rather sharp decrease in hemoglobin to 80 g / l. In all likelihood, blood loss during the operation, before the operation, played a role. After discharge, the patient was recommended to take iron supplements and enveloping medications, but weakness persists and continues to smoke.With physical exertion, again shortness of breath and fatigue.

Of course, this can be explained by 80 g / l of hemoglobin, but gradually hemoglobin is restored, but shortness of breath and weakness remain. Two months later, the patient was hospitalized as planned. Upon hospitalization, we see that he has a secondary education, he is a driver, he drives heavy trucks over long distances. Here are the bad habits: 40 cigarettes for over 25 years. Smoker’s index = 480. Pack / years index = 50. Look at his anamnesis, among other things.The father died at the age of 39 from a stroke; in all likelihood, the father had arterial hypertension. The mother has hypertension. She died at 63. Children are healthy.

This is what our patient looks like. Here is a longitudinal scar along the midline of the abdomen. Notice his penetrated fingers, watch glasses, and drum fingers. What does this mean? This suggests that his lungs are not doing well. He has chronic hypoxemia, which is a consequence of smoking, a consequence of chronic obstructive pulmonary disease, and this disease in such double smokers sometimes occurs without local symptoms, it gives only general symptoms.Shortness of breath, weakness, fatigue – this is a manifestation of chronic obstructive pulmonary disease of a smoker caused by chronic hypoxemia. This is a very important factor, seemingly routine, simple, insignificant, uninteresting and not attracting attention, but this must be remembered.

Biochemical and laboratory research. You see, the blood has recovered relatively so. The color index is still rather low 0.64, that is, there is hypochromia. Hematocrit 30. This indicates that either hemoglobin is not restored after a large blood loss, or it “tweaks” in our country.That is, we can talk about chronic post-hemorrhagic anemia in a patient with a sutured stomach ulcer.

See, the antibodies are normal. Consequently, he does not have H. pylori. Then the question arises: what is the basis of its recurrent ulcer course? We looked at his gastrin just in case. Does he have a gastrinoma? Gastrin 200 picomole, which is four times higher than the norm, but this is not the level of gastrin that would make us think about gastrinoma, about a tumor (…) (00:16:47) This is gastrin, which is observed in patients with chronic hypoxemia …Gastrin, which occurs in patients with atrophic gastritis. Gastrin, which is observed in patients taking inhibitors of gastric secretion for a long time, as a reaction to suppression of gastric secretion, antral G-cells begin to release an increased amount of gastrin. Indeed, iron is low, so we have every reason to think about chronic post-hemorrhagic anemia coupled with chronic obstructive pulmonary disease in a heavy smoker.

Here is an esophagogastroduodenoscopy.You see, there is a lot of mucus in the stomach with an admixture of bile. The gastric mucosa is hyperemic. Gastritis. The middle body of the stomach along the lesser curvature to the anterior wall shows an ulcerative defect up to 3-4 cm in size with swollen dense edges, and visible suture material. The ulcer is sutured for bleeding. The corner of the stomach is deformed. The antrum of the stomach is deformed by post-ulcer scars, the pylorus is deformed, we pass. The duodenal bulb is deformed, the mucous membrane is hyperemic, moderately edematous. Fast urease test is negative.No H. pylori infection. What can we think about? What factor can cause such a reaction in the stomach in the form of a continuously recurrent ulcer with bleeding and so on?

Were taken preparations, and in the preparations the picture of chronic atrophic gastritis II – III stage, activity – 2-3. Areas of necrosis, neutrophilic leukocytes, granulation tissue are determined. Neutrophilic infiltration indicates an active gastritis. The patient is prescribed a proton pump inhibitor, sucralfate, enveloping, iron preparations.Four weeks later, he managed to increase the level of hemoglobin, erythrocytes and slightly increased iron.

With repeated biopsies: in the preparations, the picture of chronic atrophic gastritis is preserved in stages II – III. The same activity. Areas of necrosis, neutrophilic leukocytes are determined. That is, in short, we achieved symptomatic success, laboratory success, but we did not achieve morphological success, we did not receive morphological remission in our patient, therefore, we did not achieve complete remission, only clinical and laboratory remission, not morphological remission.

The patient was transferred to the surgical department. When revising the abdominal cavity, you see, a penetrating stomach ulcer. Here it is visible on the left. The patient underwent a distal gastric resection according to Billroth. On the left is what is on the operating table, and on the right, a huge ulcer is already a drug.

So what remains for us to resolve the question of the cause of such a torpid, therapy-resistant course of gastric ulcer? Helicobacter pylori disappears from us, but the fact that he smokes, that he has a multifactorial effect on the stomach is certainly.

What does nicotine and, in general, the components of cigarettes do with the stomach? First, they potentiate aggressive factors, increase the secretion of hydrochloric acid, the production of pepsinogen, increase the production of vasopressin (the posterior lobe of the pituitary gland) and, as it were, contribute to the colonization of Helicobacter pylori infection in the gastric mucosa. In addition, they weaken the defense mechanisms. Reduced blood flow in the gastric mucosa due to spasm of the supplying arteries, inhibited regeneration of the mucous membrane, largely due to inhibition of the production of epidermal growth factor and gastrin, which are trophological factors of the gastric mucosa.The production of mucus decreases mainly (also indicated here) due to the inhibition of the production of prostaglandin E. The content of the intracellular antioxidant factor glutathione decreases significantly. The reduced oxidized glutathione system is the most powerful intracellular system aimed at arresting the free radical oxidation reaction. Glutathione is also reduced.

Further, nicotine has a direct stimulating effect on parietal cells. By increasing the volume and number of parietal cells, by increasing hydrochloric acid… There are nicotinic receptors on parietal cells. Further, the sensitivity of M1-cholinergic receptors increases, that is, the effectiveness of the action of acetylcholine increases, and this leads to an increase in the basal secretion of hydrochloric acid. Further degranulation of mast cells and stimulation leads to the production of histamine, stimulation of histamine receptors and an increase in basal and stimulated secretion of hydrochloric acid.

You see, there are nicotinic receptors on parietal cells and on the main cells, therefore, under the influence of nicotine, there is an increase in the secretion of pepsinogen, and secretion, and an increase in the number of main cells.Pepsinogen 1 is the most active, most aggressive pepsinogen. Further, nicotine has a stimulating effect on the norepinephrine receptors of the supraoptic nuclei of the hypothalamus, which leads to the activation of the neurohypophysis, an increase in the flow of vasopressins into the blood, vasoconstriction, an increase in platelet aggregation and a decrease in blood flow in the gastric mucosa.

How is the relationship between H. pylori infection and smoking? You see, eradication is more effective in nonsmokers – this is a large group of studies.Smoking accelerates the processes of atrophy and intestinal metaplasia in H. pylori-positive patients. Nicotine is able to increase the activity of the H. pylori vacuolating toxin.

What are the features of the presented, I would say, observation? The first observation was specially made by me for warm-up, everything was done as it should: the diagnosis was made on time, H. pylori eradication was carried out on time. It was possible to achieve clinical, laboratory, and morphological remission – complete remission. In the second case, morphological remission was not achieved.Why? Insofar as malignant smoking in this case was the background and pathogenetic factor of peptic ulcer disease. Further, recurrent ulcers passed with the formation of a giant ulcer and bleeding after selective proximal vagotomy. Vagotomy did not keep the gastric mucosa from further progression of the destructive process. The ulcer defect persisted after the suturing operation against the background of continued smoking.

Finally, what is typical for such situations is the absence of a vivid clinical picture, as a rule, in smokers.Ulcers complicated by penitration, therefore, this factor must, of course, be kept in mind when we deal with persistently recurrent ulcers, especially stomach ulcers, and take this into account in the construction of our preventive work with the patient and medical work. Thank you for your attention.

Duodenal ulcer / Medical reference

Chronic disease caused by the formation of ulcers in the duodenal mucosa. The causes of duodenal ulcer disease can be constant psycho-emotional stress and trauma, dystrophy of the nervous system, hormonal disorders, malnutrition, changes in the duodenal mucosa, chronic gastritis, gastroduodenitis and dystrophies, a decrease in the alkaline component in gastric juice.

Adverse climatic conditions – humidity, temperature, atmospheric pressure – contribute to the disease.

A hallmark of duodenal ulcer is a sharp cramping pain near the stomach or in the projection of the duodenum, which radiates between the shoulder blades and decreases if the patient takes a little food, milk, soda, or when exposed to heat. Improvement of well-being can occur after vomiting of acidic contents.

If an ulcer has formed in the duodenal bulb, hunger pains (i.e. on an empty stomach) and pains at night are characteristic. Other symptoms of peptic ulcer disease include heartburn, frequent constipation, fatigue, irritability, poor sleep, and increased sweating. The patient’s tongue is coated, the abdominal muscles are tense, their palpation causes moderate pain. There may be high blood pressure, slow heartbeat, disorders of the pancreas and colon. Peptic ulcer disease is characterized by a chronic course and a gradual increase in symptoms.The rate of ulcer healing and scar formation differ depending on the size of the ulcer, the duration of its formation, the existing complications and concomitant diseases, and the patient’s age.

To diagnose duodenal ulcer, X-ray and endoscopic examinations, analysis of gastric contents are carried out. Patients with frequent relapses and severe pain are admitted to the hospital for 4-5 weeks, after which outpatient treatment is carried out. Prescribe histamine H2-receptor blockers, anticholinergic drugs, antacids, astringent and enveloping, sedatives, vitamins.

90,000 Stomach and duodenal ulcer

Peptic ulcer and duodenal ulcer

Peptic ulcer of the stomach and duodenum.

Stomach ulcer is a chronic disease, which is based on a recurrent ulcer of the stomach or duodenum.

General information.

As a rule, an ulcer occurs against the background of gastritis (inflammation of the gastric mucosa) or duodenitis (inflammation of the duodenal mucosa) associated with Helicobacter pylori infection.Peptic ulcer disease occurs in people of any age, but most often at the age of 30-40, men get sick 6-7 times more often than women.

Causes of the disease.

Damage to the mucous membrane with the formation of ulcers, erosion and inflammation is associated with the predominance of aggressive factors (hydrochloric acid, pepsin, bile acids) over the protective factors of the mucous membrane. Helicobacter pylori infection plays an important role. These microorganisms can cause inflammation of the mucous membrane, while destroying local defense factors and increasing acidity.Factors contributing to the onset of the disease include:

  • Prolonged neuro-emotional stress;
  • Genetic predisposition;
  • The presence of chronic gastritis or duodenitis;
  • Violation of the diet;
  • Drinking strong alcoholic beverages and smoking;
  • The use of certain drugs (acetylsalicylic acid, indomethacin, etc.)).


Symptoms of ulcerative disease.

The most typical manifestation of peptic ulcer disease is pain in the upper abdomen, which often occurs on an empty stomach, i.e. between meals. Pain can also occur at night, causing the patient to wake up and eat. The pain usually subsides in the first 30 minutes after eating. Less specific, but symptoms encountered in peptic ulcer disease are nausea, heaviness after eating, the feeling of an overcrowded stomach, vomiting, loss of appetite, body weight, heartburn.

Complications.

Ulcer perforation is the formation of an opening in the wall of the stomach or duodenum. This is one of the most dangerous complications of peptic ulcer disease, because it leads to the ingress of the contents of the gastrointestinal tract into the abdominal cavity and to infection of the abdominal cavity.
Bleeding is usually manifested by staining the stool black (blood, passing through the gastrointestinal tract, is oxidized and becomes black).
Malignant transformation of an ulcer into a malignant tumor.
Complications of peptic ulcer disease are a number of life-threatening diseases that any peptic ulcer patient should be aware of. That is why you should never postpone ulcer treatment and interrupt therapy.

What can you do.

The main task of the patient is to adhere to the diet and accurately follow the doctor’s prescriptions. The basis of a therapeutic diet is chemical, mechanical and thermal sparing of the affected organ. Exclude foods that increase gastric secretion (spicy, pickled, pickles, fried, smoked foods, alcoholic beverages, coffee, tea, carbonated drinks, rich broths).You should not eat hot or cold food. The smoker is advised to stop smoking as it makes healing more difficult and increases the risk of ulcer recurrence. Also, the ulcer patient should avoid taking aspirin, a non-steroidal anti-inflammatory drug.

Prevention of peptic ulcer disease.

For prevention purposes it is recommended:

  • measures aimed at reducing nervous tension;
  • cessation of smoking and alcohol consumption;
  • normalization of the diet and the quality composition of food;
  • treatment of chronic gastritis or gastroduodenitis.

ABC-medicine

Ulcerative colitis of the intestine is a chronic gastrointestinal disease that has a recurrent nature. The development of this disease involves inflammation of the mucous membrane of the large intestine, where areas of necrosis and ulcers are formed. The clinical manifestations of ulcerative colitis are bloody diarrhea, arthritis, weight loss, general weakness, and abdominal pain. This disease has been proven to increase the risk of developing colorectal cancer.

Reasons

The etiology of the disease has not yet been clarified, scientists are actively looking for the causes of ulcerative colitis. However, at the moment, the main risk factors for this disease are known.

Genetic factors. If a patient has a family member with ulcerative colitis, the risk of developing this disease is increased.

Influence of infection. The intestine is a place where various microorganisms constantly live, which can lead to inflammatory processes in the mucous membrane.

Autoimmune factors. Inflammation is caused by the mass death of cells with antigens.

Influence of factors of inflammation. This cause is released during the immune response when an antigen-antibody complex is formed.

Symptoms

Bloody diarrhea. One of the main diagnostic symptoms of ulcerative colitis of the intestine is diarrhea with mucus and blood, in rare cases – with pus. The frequency of bowel movements in patients can be different – from 2-3 times a day to 15-20 times in severe cases.Stool especially frequent at night and in the morning.

Pain in the projection of the abdomen. Pains have varying degrees of severity in most patients – from mild to acute, severe, accompanied by significant discomfort. Pains are often localized to the left side of the abdomen. The main symptom of the onset of complications is acute abdominal pain, which cannot be stopped by taking analgesics.

Other signs of body intoxication. Weight loss, weakness, poor appetite, frequent dizziness.Tenesmus is a false urge to defecate. Flatulence. Some patients have fecal incontinence. Sometimes patients have constipation instead of diarrhea, which indicates a pronounced inflammation of the colon mucosa.

Diagnostics

Laboratory diagnostics . CBC results indicate anemia (a decrease in the number of red blood cells and hemoglobin) and leukocytosis. A blood biochemistry test allows you to detect an increase in the blood of C-reactive protein, which is an indicator of inflammatory processes in the human body.In the analysis of feces, pathogenic microflora is sown, and the presence of blood, pus and mucus is also noted.

Instrumental diagnostics. Endoscopy (rectosigmoidoscopy, colonoscopy) reveals a complex of symptoms characteristic of the disease in a patient:

  • edema and hyperemia;
  • 90,017 pseudopolyps;

  • granular character of the mucous membrane;
  • contact bleeding;
  • the presence of blood, mucus and pus in the lumen of the intestine;
  • severe atrophy of the colon mucosa in remission.

Treatment

An etiological treatment capable of eliminating the cause of ulcerative colitis has not yet been developed. Treatment is symptomatic, aimed at eliminating inflammation, maintaining remission and preventing complications. In the event that drug therapy is ineffective, surgery is performed.

Diet therapy. During an exacerbation, the patient should refrain from eating. You can only drink water.When remission occurs, the patient is advised to consume a minimum amount of fat and increase the protein content in food (lean fish and meat, eggs, cottage cheese are suitable). As carbohydrates, you should use honey, cereals, jelly, jelly, fruit and berry compotes, decoctions.

Drug treatment. Prescribed to take NSAIDs and antibiotics. The patient can take pain relievers in accordance with the dosage individually selected by the doctor. During an exacerbation of the disease, antibiotics are recommended.

Surgical intervention . Surgical treatment of ulcerative colitis of the intestine is prescribed when conservative methods are ineffective. The methods of colectomy, proctocolectomy are used.

To enroll in the ABC-Medicine clinic for the diagnosis and treatment of ulcerative colitis of the intestine, call +7 (495) 223-38-83 .

causes and symptoms of gastric ulcer and duodenal ulcer

Stomach ulcers (peptic ulcer) are relatively common in our time.More than 5% of the population suffer from them. Do you often experience stressful situations, do not feel well, abuse alcohol and medications that can damage the stomach lining? Perhaps you are at a potential risk zone for this insidious disease.

Main causes of peptic ulcer

More than 150 years ago, the first known disease of the famous Dr. Cruvelier was described. At one time, he said that the causes of peptic ulcer disease are shrouded in deep darkness.Since then, views on the origin of the disease have changed. The key event was the testimony of J. Warren and B. Marshall, who first described Helicobacter pylori in 1983.

Helicobacter pylori

Helicobacter pylori is a bacterium that causes inflammation in certain parts of the stomach. First of all, the bacterium infects “weak” stomachs.

Helicobacter pylori is a special bacterium. This is an illustrative example of the adaptation of a living organism to extreme living conditions.Since this bacterium lives in a very acidic environment, infection with it is the most common infection in humanity. It is reported that in developing countries it affects up to 90% of the population.

Interestingly, however, not everyone can get peptic ulcer disease. One of the possible explanations is the presence of special aggressive strains that resist the ulcer. A higher incidence of ulcers was also observed in patients with blood group 2.

What are the other causes of ulcers

Although Helicobacter pylori is a key cause of ulcers, there are others.The influence of various drugs (acetylsalicylic acid, non-steroidal, anti-inflammatory drugs) is also important. They change the chemical composition of the stomach mucus, which protects the stomach lining from the action of hydrochloric acid.

Another cause of ulcers is the harmful effect of the contents of the duodenum on the gastric mucosa.

Also, the harmful effects of smoking are attributed to the causes of peptic ulcer disease, although not fully investigated.

And finally, the last, but often the most popular cause (or a kind of “trigger” mechanism) of peptic ulcer disease is stress.

How peptic ulcer disease manifests itself

This peptic ulcer disease most commonly affects people between 20 and 40 years of age. Its frequency is the same for men and women.

Main symptoms

A significant symptom for this disease is pain in the middle abdominal line or to the right of it, most often occurring 2 hours or more after eating. She can even wake up the sick at night. This pain usually subsides with food and medication.In this case, it is not uncommon for patients to come to the doctor with suspected gallbladder problems.

Other symptoms include heartburn, bruising, constipation, or vomiting. Fear of illness develops and this can lead to overeating and subsequent obesity. Some patients, on the other hand, do not eat or lose weight due to pain. Drowsiness and fatigue can also be a secondary symptom of this disease.

If you cannot cope with the disease on your own – seek help from the doctors of the DIALINE multidisciplinary clinic.After passing a full examination, the specialist will give professional recommendations for maintaining health, and, if necessary, the most optimal and effective treatment plan will be prescribed.

Peptic ulcer and duodenal ulcer

Nowadays, 7-10% of the population can find peptic ulcer disease. The ratio of duodenal ulcers and stomach ulcers is 4: 1, and in middle and old age, the frequency of stomach ulcers increases, and in young people, the duodenal localization of ulcers is predominantly noted.The development of stomach ulcers is more common in women, and duodenal ulcers – in men. Among the child population, the disease occurs from 0.7 to 6% and in almost the same ratio in both boys and girls.

Peptic ulcer disease develops over the years, slowly undermining the health of its owner. Most often, the ulcer reminds of itself in the spring-autumn period. Periods of exacerbation are replaced by deceptive calm. This suggests that this disease is characterized by a chronic course and cyclicity.

Peptic ulcer of the stomach and duodenum (PUD) is a chronic disease of the gastrointestinal tract, the main manifestation of which is the formation of a sufficiently persistent ulcer defect in the stomach and / or duodenum (Duodenum).

Clinical manifestations of peptic ulcer disease

Clinical manifestations of peptic ulcer disease depend on the patient’s age, ulcer localization, stage of the disease, individual and gender characteristics of the patient.

1.Pain syndrome is the leading clinical syndrome. During the period of exacerbation of duodenal ulcer, patients complain of pain in the epigastrium, pyloroduodenal zone. The nature of the pain is paroxysmal, or aching. The pain occurs on an empty stomach or 2-3 hours after eating (the so-called late pain). Almost half of patients complain of night pains.

The classic Moiningan rhythm: hunger> pain> food intake> relief we had to observe relatively rarely, mainly in older children.

Irradiation of pain in the back or in the lower back is characteristic of complications from the pancreas. Palpation in the period of exacerbation of ulcer prevails soreness in the epigastrium, where a positive Mendel’s symptom, local muscle tension is often found. A little less often, these symptoms are found in the pyloroduodenal zone.

Cutaneous hyperesthesia in the Zakharyin-Ged zones is almost not detected in pediatric practice.

2. Dyspeptic syndrome includes heartburn (the leading symptom), nausea, sour belching, vomiting.To a certain extent, a tendency to constipation can also be attributed to dyspeptic syndrome, which is often observed in patients with hyperacidity of gastric juice during an exacerbation of the disease.

Pain and dyspeptic syndromes are seasonal in nature (worse in autumn and spring).

3. Syndrome of nonspecific intoxication and neurocirculatory dystonia: emotional lability, astheno-neurotic syndrome, autonomic disorders, headache, sleep disturbances, sweating.

The above clinical manifestations are characteristic of the period of exacerbation of the disease.With the onset of epithelialization of the ulcer, as a rule, the intensity of pain decreases, which acquire a slightly intense aching character, the irradiation of pain disappears. Vomiting gradually disappears and the intensity of heartburn decreases, although late pain persists for a long time. With superficial palpation, pain is significantly reduced or disappears, although local muscle tension may persist.