

| By Dr. Ronald Hoffman
Up to 12 percent of Americans have ulcers at some point in life. Peptic ulcers are sores found in the lining of your stomach or of your duodenum, the upper portion of your small intestine. Duodenal ulcers are the more common, accounting for 3/4 of all cases. Ulceration occurs when the stomach’s or duodenum’s mucosal lining cannot withstand the corrosive action of gastric juice, which your stomach’s lining secretes to break down your meals. Gastric juice, which consists of hydrochloric acid and an enzyme, pepsin, which breaks down protein, can digest any living tissue, including your stomach and duodenum. Normally, both your stomach and duodenum are bathed constantly in gastric acid. But protective mechanisms, including the work of prostaglandins, which govern secretion of mucus from your stomach lining, and your food and saliva’s ability to dilute acid, prevent your stomach from digesting itself.
In the past few years, medical thinking about peptic ulcers has changed dramatically: Doctors used to think that having ulcers meant that you produced too much gastric acid. Some people with duodenal ulcers do secrete abnormal amounts of acid, but as many as half do not. And in most cases of gastric or stomach ulcers, acid is normal or even reduced. Now researchers recognize that the causes are more complex and may include a failure of your stomach’s cytoprotection. Other contributing factors may be smoking, alcohol, family predisposition, emotional stress and even bacterial infection or the use of common pain-killing medications such as aspirin.
Peptic ulcers are chronic; they may recur at any time. Ulcers are rarely a prelude to cancer, but some ulcers, especially gastric ulcers, are an erosion of the stomach due to cancer. Even if ulcers are not cancerous, they can be very dangerous. An untreated ulcer can cause intestinal obstruction or rapid bleeding into your intestinal tract, which can be fatal. And like a ruptured appendix, an ulcer that erodes all the way through the wall of your stomach or duodenum can cause peritonitis. If you have an ulcer and any of these complications set in, you may need surgery. Thankfully, because of new drugs, ulcer surgery has become relatively rare. Certainly there are some steps you can take to avoid such a dire solution to ulcers.
Fueling an ulcer’s fire
The first sign of an ulcer may be a good deal of belching and bloating, so that you may think you have a bad case of gas pains. But the pain becomes sharp and constant, and sometimes feels like a “stitch” somewhere between your navel and the base of your breastbone. It may be particularly gnawing between meals or when your stomach is empty; you feel some relief after you eat something–but perplexingly, the reverse also can be true. Even after an ulcer heals you may feel pain in that portion of your gut if you eat or drink anything that irritates your stomach lining. One woman in her early 30s who has had a duodenal ulcer felt this “weak link” act up when she had morning sickness during pregnancy and whenever she drank carbonated beverages, even decaffeinated ones, or alcohol on an empty stomach.
As far as we know, moderate consumption of alcohol and caffeine doesn’t cause ulcers. But alcohol and caffeine do stimulate acid secretion in your stomach, as does decaffeinated coffee. Caffeine also blocks production of prostaglandins, weakening your stomach’s cytoprotection. So any of these ingredients of popular beverages can exacerbate an ulcer you already have. Surprisingly, so can milk, which used to be a mainstay of ulcer patients’ diets. Initially, milk does neutralize stomach acid–but then, acting on the rebound, it prompts the production of even more. Stress may not cause ulcers as frequently as most doctors once thought, but it can increase pain or flare-ups. One Australian study found that duodenal ulcers frequently recur when patients go through marital separation or divorce. Genes and gender also may contribute to ulcers: You’re three times as likely to get an ulcer if any of your relatives have them. Men get twice as many duodenal ulcers, while the rate of gastric ulcers is about the same in both sexes.
Smoking–even chewing nicotine gum–certainly does cause ulcers. In fact, smoking not only doubles your risk of coming down with an ulcer but slows its healing and contributes to recurrence. If you quit smoking and take no medication at all, your ulcer will heal more quickly than if you down drugs conscientiously but continue to smoke. Another sure cause of ulcers is regular use of aspirin and other nonsteroidal anti-inflammatory medications such as Motrin or Advil. Arthritis patients are particularly apt to take these drugs habitually over a long period of time. But aspirin and similar medications inhibit your stomach’s production of prostaglandins, which are the key substances for cytoprotection. Prostaglandins govern mucus secretion and other mechanisms that protect your stomach’s mucosal lining from injury by gastric juice, as well as other chemicals. If you stop taking the offending medications, your ulcers usually clear up. A new ulcer drug, Cytotec, offers your stomach cytoprotection even if you’re obliged to take aspirin or other pain medications. But Cytotec has some side effects, ranging from the annoying (diarrhea) to the downright dangerous (miscarriages).
Many medications prescribed for “acid conditions” actually can add to your misery. Many doctors and patients, assuming that too much stomach acid equals ulcers, rely on antacids. This can make as much sense as putting out a fire while simultaneously relighting it. One popular antacid, Alka-Seltzer, contains aspirin, so large doses can actually cause ulcers. Another common antacid ingredient, calcium carbonate, found in Tums, can constipate you. And three or four hours after you take it, calcium carbonate stimulates increased gastric secretion.
Specific ulcer drugs, such as best-selling Zantac and Tagamet, seem to suppress symptoms without clearing up the problem. Most patients who take them relapse within two years. These drugs work by blocking production of stomach acid. That may relieve your pain dramatically but can be harmful in the long run. A certain level of acid secretion is necessary to digest proteins properly and to absorb vitamins and minerals. So if you’re taking an ulcer drug, you may be setting the stage for malabsorption. Stomach acid also protects you by killing fungi, bacteria and viruses that you cannot help ingesting along with your food. Without gastric acid’s protection, you may be much more susceptible to food poisoning, parasites and other gastrointestinal afflictions–including ulcers.
Can you catch an ulcer?
According to recent medical research, one reason ulcers tend to run in families is that they could be the result of infection with a particular bacterium, Campylobacter pylori, which certainly does cause gastritis. Investigators have noticed that most ulcers occur in the presence of gastric secretion that most people can tolerate easily. And many ulcers heal without any decrease in gastric acid output–a sure sign that gastric secretions are not the primary cause of ulcers and that some other factor is at work.
Dr. Barry J. Marshall, an Australian researcher, is convinced that C. pylori is at the bottom of most cases of duodenal ulcers, as well as 70 percent of gastric ulcers and about half of all cases of dyspepsia without ulcers. Many of Dr. Marshall’s patients infected with C. pylori started with gastritis that developed into dyspepsia or peptic ulcers. In 1984, Dr. Marshall tested his own hypothesis by downing a potion of C. pylori. Sure enough he got gastritis, a common precursor of ulcers. Marshall believes that the bacterium protects itself from hydrochloric acid and also frequently eludes detection by burrowing beneath your stomach’s protective mucosa.
Marshall also has been testing his theory by screening ulcer patients’ families for infection with C. pylori. His team has found that the bacterium often spreads to ulcer patients’ spouses and family members. This transmission, not heredity, may explain why ulcers run in families. Detecting C. pylori involves analyzing a sample of the patient’s stomach lining, which means that he or she has to undergo an endoscopy. I have used a blood test, which is somewhat less reliable, but also less invasive and less expensive.
At this point, there is no perfect antidote to C. pylori infection. Bismuth, a metallic element that is a main ingredient in Pepto-Bismol, does seem to kill off the bug. In Australia, one study reported that 92 percent of duodenal ulcer patients healed after being treated with an antibiotic and a drug containing bismuth. After a year, only 21 percent had relapsed. This is how Dr. Marshall cleared up his self-induced gastritis. Antibiotics can exacerbate gastrointestinal symptoms–so much so that the treatment may be worse than the disease. Marshall would like to find a better solution–perhaps a vaccine.
The Hoffman ulcer diet
For years, ulcer patients had to survive on a bland diet of boiled fish, rice, milk and cream. Now we know that while milk coats your stomach and may relieve your ulcer pain temporarily, it may retard your ulcer’s healing. The calcium in milk can make you feel worse in the long run by stimulating the production of gastric acid. So can fried foods, citrus fruits, alcohol, caffeine in beverages or in chocolate, decaffeinated coffee and smoking. Tea seems to particularly stimulate production of gastric juice. In case your ulcer is due to a food intolerance or allergy, try ferreting offenders out with an elimination diet or ask a doctor who is knowledgeable about nutrition for the appropriate tests. And go through your medicine cabinet and throw out all aspirin and other nonsteroidal analgesics. Here are some other measures to consider:
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