Peptic ulcer disease manifests either as a gastric ulcer (a sore that develops in the lining of the stomach) or a duodenal ulcer (a sore that develops in the duodenum, which is the first section of the small intestine). The condition affects 4 to 6 million Americans each year. Older adults are at particular risk because they are more likely to take medications that may contribute to ulcer formation and more likely to carry a specific bacteria that can cause ulcers.

Drugs May Contribute

Many older adults with cardiovascular disease take daily aspirin because the drug has been shown to reduce the risk of heart attack. Older adults also may take ibuprofen (Advil®, Motrin®) or naproxen (Aleve®, Naprosyn ®) to ease arthritis, which causes swelling and pain in the joints. Aspirin, ibuprofen, and naproxen are nonsteroidal anti-inflammatory drugs (NSAIDs). These need to be used with caution in older adults because they are linked to serious side effects, including gastrointestinal bleeding and kidney damage. NSAIDs deactivate an enzyme called cyclooxygenase (COX). “COX contributes to inflammation, but it also has a role in protecting the lining of the stomach from the hydrochloric acid that helps break down the food you consume,” says Mount Sinai gastroenterologist Brijen J. Shah, MD. “Blocking COX relieves pain, but you lose the protective effect in the stomach. This makes the lining of the stomach vulnerable to hydrochloric acid.”

Other drugs that may raise the risk of peptic ulcer disease if used concurrently with NSAIDs include corticosteroids, blood thinners, a class of antidepressants called selective serotonin reuptake inhibitors, and the osteoporosis drugs alendronate (Fosamax®) and risedronate (Actonel®).

Bacteria Connection

Another major underlying cause of peptic ulcer disease is infection with a bacteria called Helicobacter pylori (H. pylori), which accounts for about 90 percent of duodenal ulcers and 70 to 90 percent of gastric ulcers. “The acid in your stomach destroys most harmful bacteria, but H. pylori is able to survive because it secretes an enzyme that neutralizes the acid,” says Dr. Shah. H. pylori burrows deep into the thick layer of mucus that coats the lining of the stomach and protects it from acid. “If the mucus layer is breached by H. pylori, stomach acid can seep through and irritate the sensitive tissue beneath, causing inflammation,” Dr. Shah explains. “Once inflammation occurs, continued irritation from stomach acid can lead to an ulcer.”

Diagnosing a Peptic Ulcer

As well as pain, a peptic ulcer may cause nausea and vomiting, a poor appetite, weight loss, bloating, and excessive burping. If you’ve been troubled by these symptoms, your doctor may refer you for an endoscopy to examine the lining of your stomach. “During the procedure, a long, thin, flexible tube with a light and a tiny camera lens on the end is inserted into your esophagus and down into your stomach, and the images the camera takes are transmitted to a video monitor,” Dr. Shah says. A thin wire with forceps may be passed through the endoscope in order to take biopsies (small samples of tissue) that will be tested for the presence of H. pylori. Stool testing also may be carried out to check for H. pylori.

Peptic Ulcer Treatment

The American College of Gastroenterology recommends 10 to 14 days of quadruple therapy to treat peptic ulcer disease—the regimen consists of a proton pump inhibitor (PPI) to reduce the production of stomach acid; two antibiotics; and bismuth, which kills H. pylori and helps protect the lining of the stomach from acid. “If this is the first time you’ve suffered from peptic ulcer disease, your doctor may recommend triple therapy instead,” Dr. Shah says. “This consists of a PPI, an antibiotic, and bismuth. An alternative is sequential therapy, which involves taking a PPI and antibiotic for five to seven days, followed by another five to seven days of the PPI with a different antibiotic.” It is important to tell your doctor if you have been treated for H. pylori in the past or have recently taken antibiotics, since this will influence which treatment regimen your doctor recommends.

Some peptic ulcer symptoms warrant emergency medical attention because they indicate that the ulcer has caused a hole (perforation) in the stomach or duodenal wall, broken a blood vessel, or blocked food from leaving the stomach and entering the intestine—see What You Can Do.

Preventing Peptic Ulcer Disease

Peptic ulcer disease doesn’t always cause symptoms, so it is important to reduce your risk for developing ulcers. If you regularly take NSAIDs, substitute acetaminophen (Tylenol ®) for pain relief. If you find NSAIDs more effective, discuss with your doctor whether you should take a PPI to protect your stomach while you take NSAIDs. Avoid excessive alcohol consumption, since alcohol can irritate the lining of the stomach as well as increase the production of stomach acid. If you are infected with H. pylori, smoking may further increase your ulcer risk, so consider quitting. Obesity has been linked to peptic ulcer disease, too, so if you are obese, discuss with your doctor how you can shed excess pounds. Help protect yourself against H. pylori by frequently washing your hands with soap and water (and always after using the bathroom and prior to eating).

The post Protect Against Peptic Ulcer Disease appeared first on University Health News.

If you have GI symptoms under stress or when experiencing anxiety, they can make stress worse. Imagine a sudden attack of diarrhea under stress, and then add the stress and anxiety of not being able to get to a bathroom. Learning how to deal with stress can help you avoid this vicious cycle. _[1,2]

The Gut-Brain Connection

Harvard Medical School explains that when GI symptoms are caused by stress or anxiety and not by an infection or disease, it is called a functional GI disorder. Just because it is not caused by infection or disease does not mean it’s not real. _[3]

The part of your brain and nervous system that controls functions like breathing and digestion is called your autonomic nervous system. It is divided into sympathetic and parasympathetic systems. Stress triggers your fight or flight reaction and causes your sympathetic nervous system to slow down digestion. To avoid the damage of long-term stress, your parasympathetic nervous system kicks in to return things to normal. _[3]

Both your sympathetic and parasympathetic nervous systems are connected to your enteric (or gut) nervous system, sometimes called your “second brain.” Your gut’s nervous system uses the same brain chemicals and chemical messengers – called hormones – as your brain. _[3]

In fact, your gut has the largest area of nerves outside your brain. When stress causes your brain to produce stress chemicals and hormones they go into your gut and cause GI symptoms, including diarrhea. _[1] When your GI system is under stress, GI stress chemicals and hormones go to your brain triggering more stress and inhibiting your autonomic nervous system from turning off the stress switch. _[1]

The Gut Bacteria Connection

There are millions upon millions of bacteria living in your gut. A healthy GI system relies on good bacteria outnumbering or balancing bad bacteria. There is a connection between gut bacteria and mental health, so stress or anxiety can upset the balance: _[1,2,5]

• Stress may reduce good gut bacteria and favor bad bacteria.
• Bad bacteria cause GI symptoms.
• Bad bacteria reduce the production of the mood-lifting chemical serotonin. That means less serotonin going to your brain and a depressed or anxious mood.

Possible GI Symptoms Caused by Stress

According to the Anxiety and Depression Association of America, stress-related GI symptoms can include: _[1]

• Upset stomach
• Cramps
• Diarrhea or constipation
• Loss of appetite or hunger cravings

So yes, stress can cause diarrhea, an upset stomach, and other uncomfortable GI issues. One thing that stress does not cause is a stress ulcer. According to the American College of Gastroenterology, emotional stress causing an ulcer is a myth. Ulcers are caused by bacteria, called H. pylori. Although stress does not cause stomach ulcers, it may irritate an existing ulcer and make ulcer symptoms worse. _[5]

How to Avoid Stress-Related GI Symptoms

Stress is a normal part of life. Nobody can avoid stress all the time, but you can learn better ways to cope with it: _[2]

• Don’t try to ignore stress with diversions like eating, drinking alcohol, gambling, or shopping. These diversions end up making stress worse over the long term. _[2]
• Identify your stress triggers and avoid them when you can. _[2]
• Learn techniques that help you deal with stress like deep breathing, guided relaxation, or meditation.
• Exercise regularly. Exercise increases gut and brain chemicals called endorphins that improve your mood. _[1]
• If you are really struggling with stress and stress-related GI symptoms, talk to your health care provider. Talk therapy – called psychotherapy – can often help. _[2]

Harvard Medical School says three types of psychotherapy may be helpful for stress, anxiety and the stomach pain that follows if you’re affected by the gut-brain connection.

• Cognitive-behavioral therapy helps you replace negative thoughts and behaviors with positive ones.
• Relaxation therapy teaches you ways to reduce stress like guided relaxation exercises.
• Gut-directed hypnosis combines deep relaxation with calming thought suggestions.

Sources

1. Anxiety and Depression Association of America, How to Calm an Anxious Stomach: The Brain-Gut Connection | Anxiety and Depression Association of America, ADAA
2. Cleveland Clinic, Is Your Stomach Churning? You May Have ‘Gut Stress’ – Health Essentials from Cleveland Clinic
3. Harvard Health, Stress and the sensitive gut – Harvard Health
4. American Psychological Association, Stress effects on the body (apa.org)
5. American College of gastroenterology, https://gi.org/topics/peptic-ulcer-disease/

The post Can Stress Cause Diarrhea? The Gut-Brain Connection appeared first on University Health News.

With walls made of layers and layers of mucous membrane, connective tissue, and muscle fibers, the stomach is a tough organ. When empty, it takes up about a liter in volume, although this can vary depending on a person’s gender and size. But it has the capability to expand and hold up to four liters of food and liquids.

The stomach’s main job is to prepare food for digestion and absorption. The first step is to mix swallowed food with gastric acid and enzymes. Then the stomach muscles churn the food vigorously, until it breaks down into a smooth pulp-like substance. This pulp is then moved along to the small intestine via a narrowed passage known as the pyloric channel. Given all this activity, it’s no surprise that the stomach is a source of so many painful issues. Everyone has the occasional upset stomach, cramps, and bouts of nausea—however, sometimes these issues can become more severe due to chronic inflammation, infections, and other problems. Here is a closer look at the problems that can occur in the stomach, why they happen, and what you can do about them.

Gastritis

Gastritis is not a single disease, but rather a condition with several possible causes. The term “gastritis” means inflammation of the stomach lining. When the body’s immune system detects injury from infection or other causes, it produces inflammation that triggers the healing process. But if the cause of injury persists, the immune system continues to respond. This results in ongoing inflammation, and healing will not occur.

Some possible causes of gastritis include alcohol abuse, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin), and infection with the Helicobacter pylori (H. pylori.) bacteria. Most people infected with H. pylori do not experience symptoms, because the inflammation is mild. However, certain factors can worsen the inflammation and cause gastritis symptoms. Pernicious anemia, autoimmune disorders, and chronic bile reflux also can cause gastritis.

Gastritis Symptoms

The most common symptoms of gastritis are an upset stomach, indigestion, and pain in the upper abdomen that may radiate to the back. Gastritis also can cause frequent burping, nausea, vomiting, loss of appetite, a feeling of fullness, and a burning sensation in the upper abdomen.

Diagnosing Gastritis

Your doctor may suspect gastritis from your symptoms. However, because the symptoms of gastritis can be similar to those of other gastrointestinal (GI) illnesses, the only sure way to diagnose it is by performing an endoscopy (see Chapter 2) to examine the stomach, and taking a biopsy of the stomach lining.

Treating Gastritis

Treatment for gastritis depends on the cause. If H. pylori is the culprit, antibiotics will be prescribed—research suggests that eradicating H. pylori in people with chronic gastritis may reverse the damage. If the cause of gastritis is prolonged use of NSAIDs, these medications should be discontinued. Similarly, if overuse of alcohol is to blame, the solution is to stop drinking.

For most types of gastritis, drugs to reduce stomach acid—such as H2 blockers or proton pump inhibitors (PPIs)—will be prescribed. Since stomach acid irritates the inflamed tissue in the stomach, reducing acid production can promote healing.

Peptic Ulcer

A peptic ulcer is a sore that forms in the lining of the stomach (gastric ulcer) or the first section of the small intestine (duodenal ulcer). Gastric ulcers can occur anywhere in the stomach, but are most common in the lower part (antrum). Duodenal ulcers occur in the first few inches of the small intestine.

In the past, it was thought that ulcers were caused by stress, spicy foods, or an overabundance of stomach acid. It is now known that one of the main causes is infection with H. pylori. Infection with H. pylori, which usually occurs in childhood, doesn’t always cause ulcers—in fact, most people who carry H. pylori in their GI tracts do not develop ulcers. Older adults are more likely to have ulcers, which may be due to a higher infection rate with H. pylori, or because they use more NSAIDs.

H. pylori bacteria have the ability to survive in the acidic environment of the stomach because they secrete enzymes that neutralize the acid. The bacteria also can burrow deep into the thick layer of mucus that coats the lining of the stomach. This mucus is essential for protecting the layers of tissue underneath from being damaged by stomach acid. If the mucus layer is damaged, acid can irritate the sensitive tissue underneath, causing inflammation. Once inflammation occurs, continued irritation from acid and bacteria can lead to the formation of an ulcer.

Long-term use of NSAIDs also can cause ulcers. People of any age can develop an ulcer from long-term use of NSAIDs, but it is more common in people age 60 and older. A warning sign that NSAID use may lead to an ulcer is an upset stomach or heartburn after taking an NSAID. People with a history of ulcers, and those taking NSAIDs for long periods of time, are particularly at risk.

Older adults are more likely to have conditions that require treatment with blood thinning medications, such as clopidogrel (Plavix) and warfarin (Coumadin). These drugs are associated with a greater risk of GI bleeding in people with ulcers.

Peptic Ulcer Symptoms

The first sign of an ulcer is usually a burning sensation in the upper-to-middle abdomen that occurs within one to two hours after a meal. Other symptoms may include pain that feels like a dull, gnawing ache and is intermittent or constant, lasting for days to weeks at a time before subsiding; and pain that strikes in the middle of the night (or any other time that the stomach is empty) but decreases after you eat. Nausea and vomiting, weight loss, a poor appetite, bloating, and frequent burping also are common symptoms.

Some peptic ulcer symptoms warrant emergency medical attention because they indicate that the ulcer has caused a hole (perforation) in the stomach or duodenal wall, broken a blood vessel, or blocked the path of food leaving the stomach and entering the intestine. If you experience any of the following symptoms, you should immediately seek medical help:

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

Diagnosing a Peptic Ulcer

If you have any of the non-emergency symptoms of an ulcer, see a doctor to get diagnosed. Either an upper GI series or an endoscopy will likely be ordered. If an ulcer is spotted, you will be tested for the presence of H. pylori. The bacteria can be detected non-invasively, with breath or stool tests. If you have undergone an endoscopy, biopsy tissue will be tested for H. pylori.

Treating a Peptic Ulcer

If tests indicate that your ulcer is caused by bacteria, your doctor will prescribe medications to reduce stomach acid and kill the bacteria. This allows the ulcer to heal, and lowers the chance it will recur. The treatment regimen will most likely involve two weeks of triple therapy: antibiotics to destroy the bacteria, a PPI to reduce the production of stomach acid, and medications to protect the lining of the stomach from acid, such as sucralfate (Carafate) and bismuth, which also kills H. pylori. This regimen is effective for 70 to 85 percent of patients, and it is important that it be taken each day as prescribed. An alternative is sequential therapy, which involves taking one or two drugs for a few days, followed by one or more different drugs.

If you have ulcers or ulcer complications and take NSAIDs, you also may need to take a PPI. You can get both with esomeprazole/naproxen (Vimovo), or you may try to substitute acetaminophen (Tylenol) for the NSAID. If acetaminophen does not relieve your pain, your doctor may suggest trying a different over-the-counter NSAID from the one causing the problem. You also can try to reduce the dose or the frequency with which you take the NSAID.

Once a peptic ulcer has healed, there is a low chance that it will return—however, recent research suggests that poor sleep quality may raise the risk (see “Poor Sleep Linked to Peptic Ulcer Recurrence”).

Gastroparesis

Gastroparesis—also known as delayed gastric emptying—is a condition in which the stomach fails to empty its contents properly, but no blockage is present. The condition may manifest daily, or in cycles, and mainly affects young adult women, although about 20 percent of patients are children or men.

Gastroparesis occurs when nerves and muscles in the stomach fail to function properly. Sometimes the nerves don’t signal the muscles to contract, such as in diabetic neuropathy; sometimes the nerves work normally, but the muscles don’t respond. Possible reasons for this include diseases that affect the nerves or muscles (such as multiple sclerosis, muscular dystrophy, Guillain-Barré syndrome, diabetes, or systemic scleroderma), side effects from using opiates, stomach virus after effects, and damage to the vagus nerve during surgery. However, in more than one-third of people, the cause for gastroparesis is never found.

Gastroparesis Symptoms

Symptoms include persistent nausea that worsens after eating and may be accompanied by a burning, gnawing stomach pain. People with the condition usually vomit undigested food a couple of hours after a meal. Gastroparesis can be disabling, as its symptoms can cause depression, anxiety, and other psychological issues that require help from a mental health professional.

Diagnosing Gastroparesis

Gastroparesis can be diagnosed with gastric emptying scintigraphy, a type of x-ray that can help identify issues related to the emptying of the stomach.

Treating Gastroparesis

One of the first treatment strategies for gastroparesis is dietary modification: for example, eating five to six small meals each day instead of fewer large ones, ensuring that meals incorporate small amounts of fats and protein, avoiding all dairy products except for yogurt, and puréeing foods so they are easier to digest. Also make a note of any food triggers and cut them out of your diet. In one clinical trial, orange juice, fried chicken, cabbage, oranges, sausage, pizza, peppers, onions, tomato juice, lettuce, coffee, salsa, broccoli, bacon, and roast beef triggered gastroparesis symptoms. Ginger ale, gluten-free foods, tea, sweet potatoes, pretzels, white fish, clear soup, salmon, potatoes, white rice, popsicles, and applesauce were tolerated without provoking symptoms.

Other nonsurgical treatment options include medications to stimulate gastric emptying and prevent vomiting and intestinal spasms, along with pain-relieving medication as needed. Some patients find relaxation techniques helpful, while others report relief from biofeedback. During a biofeedback session, you’re connected to electrical sensors that pick up body signals and transmit them to a special computer that displays the signals via images or sounds that indicate your stress levels, skin temperature, blood pressure, heart rate, and brain waves. You’re then guided in how to vary your thoughts and emotions so that you see a change in the signal display. The idea is that you learn how to consciously control your body’s responses, including its response to pain.

Gastroparesis affects the intake of nutrients, so liquid vitamins and liquid nutritional supplements may be prescribed to help prevent malnourishment. Alternatively, a feeding tube may be placed directly into the small intestine, bypassing the stomach. These tubes are used for feeding or to vent the gaseous distention from low motility of the stomach. In the severest cases, patients may require intravenous feeding.

In some patients, a gastric pacemaker may be placed laparoscopically. The device emits electrical impulses to stimulate the stomach muscles to contract. In some patients, this may be sufficient to move food through the stomach without symptoms.

Because the entire stomach is affected in gastroparesis, many stomach surgeries have not been effective. Even removal of the entire stomach may not solve chronic nausea. However, early results with a new minimally invasive procedure called gastric peroral endoscopic myotomy (G-POEM) indicate that it may help to normalize gastric emptying. The procedure involves passing an endoscope down the throat into the stomach. A surgical instrument attached to the end of the endoscope tunnels into the lining of the stomach and releases tight muscles, before being withdrawn. In studies, about 85 to 86 percent of people with gastroparesis treated with G-POEM experienced significant improvement in gastric emptying. Complications were minor.

Stomach Cancer

About 27,000 people in the United States—approximately 17,000 men and 10,000 women—were diagnosed with stomach cancer in 2019, according to the American Cancer Society (ACS). There also were about 11,000 deaths due to the disease, likely because it can be difficult to diagnose early enough for successful treatment.

As with many cancers, people age 55 and older are at increased risk of stomach cancer. Men are almost twice as likely as women to develop the disease, and it is more common in African Americans than Caucasians. Having the bacteria H. pylori in the stomach may raise the risk, but prompt treatment to eradicate the bacteria can reduce the risk. A diet high in preserved meats (such as bacon and deli meats) and low in fruits and vegetables may contribute to stomach cancer. Conversely, a healthy diet loaded with fruits, vegetables and whole grains, and low in saturated fat may help decrease the risk of developing the disease, and is particularly important for people infected with H. pylori.

Stomach Cancer Symptoms

Stomach cancer often causes no symptoms at all. When symptoms are present, they are likely to include loss of appetite, nausea and pain, vomiting blood, bloody stools, fatigue, weakness, and weight loss. If you experience any of these symptoms, see your doctor.

Diagnosing Stomach Cancer

One or more diagnostic tests may be needed, such as a fecal occult blood test, an upper GI series, and/or an endoscopy (see Chapter 2). New research has suggested that looking for changes in certain chemicals in the breath could be used to identify both stomach and esophageal cancers.

If cancer is suspected, the doctor will take a small sample of tissue (biopsy) from the wall of the stomach during an endoscopy. The tissue will be examined under a microscope to look for changes in the cells that would indicate cancer. If cancer is diagnosed, the next step is to determine the stage of the cancer, which indicates if it has spread to nearby organs, such as the liver or pancreas. Staging of stomach cancer may be done with a computed tomography scan, standard ultrasound, or endoscopic ultrasound.

Treating Stomach Cancer

Treatment for stomach cancer depends on a number of factors, including the size, location, and extent of the tumor, whether it has spread, and the patient’s general health. Options include surgery, chemotherapy, radiation therapy, and the newest weapon, targeted therapy. According to the ACS, using two or more approaches produces the best outcomes.

Surgery is the most common treatment. If the cancer is in its early stages, the surgery may be performed endoscopically, using instruments that are inserted into the stomach via the throat. If only part of the stomach needs to be removed, the remaining portion will be connected to the esophagus or small intestine, but if the cancer has spread throughout the stomach, the entire stomach may need to be removed (total gastrectomy), along with lymph nodes and other organs. The esophagus is then attached to the small intestine. After this surgery, patients must eat small amounts of food often, and some need a feeding tube for liquid nutrition to ensure they receive sufficient calories.

Targeted therapy may be effective in patients who do not respond to standard chemotherapy. It involves the use of drugs that identify unique aspects of stomach cancer cells and target them for destruction. Options include the monoclonal antibody trastuzumab (Herceptin). Used to treat HER2-positive breast cancer, the drug also is effective in HER2-positive stomach cancer. HER2 is a growth-promoting hormone, and one in five stomach cancer patients have too much of it. Trastuzumab finds this protein on the surface of cancer cells and destroys the cells. It usually is given intravenously every two to three weeks, along with chemotherapy. Another monoclonal antibody, ramucirumab (Cyramza), targets specific proteins that allow cancers to grow and spread by creating new blood vessels. It is given intravenously every two weeks, and generally is reserved for patients with advanced stomach cancer that no longer responds to other drugs.

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In the past, it was thought that ulcers were caused by stress, spicy foods, or an overabundance of stomach acid. It is now known that one of the main causes is infection with H. pylori. Infection with H. pylori, which usually occurs in childhood, doesn’t always cause ulcers—in fact, most people who carry H. pylori in their gastrointestinal tracts do not develop ulcers. Older adults are more likely to have ulcers, which may be due to a higher infection rates with H. pylori, or because they use more NSAIDs.

H. pylori bacteria have the ability to survive in the acidic environment of the stomach because they secrete enzymes that neutralize the acid. The bacteria also can burrow deep into the thick layer of mucus that coats the lining of the stomach. This mucus is essential for protecting the layers of tissue underneath from being damaged by stomach acid. If the mucus layer is damaged, acid can irritate the sensitive tissue underneath, causing inflammation. Once inflammation occurs, continued irritation from acid and bacteria can lead to the formation of an ulcer.

Long-term use of NSAIDs also can cause ulcers. People of any age can develop an ulcer from long-term use of NSAIDs, but it is more common in people aged 60 and older. A warning sign that NSAID use may lead to an ulcer is upset stomach or heartburn after taking an NSAID. People with a history of ulcers, and those taking NSAIDs for long periods of time, are particularly at risk.

Peptic Ulcer Symptoms

The first sign of an ulcer is usually a burning sensation in the upper-to-middle abdomen that occurs within one to two hours after a meal. Other symptoms may include:

• Pain that feels like a dull, gnawing ache
• Pain that is intermittent or constant, lasting for days to weeks at a time before subsiding
• Pain that strikes in the middle of the night, or any other time that the stomach is empty
• Pain that decreases after you eat a meal
• Nausea and vomiting
• Weight loss
• Poor appetite
• Bloating
• Burping

Some symptoms warrant emergency medical attention, because they indicate that the ulcer has caused a hole (perforation) in the stomach or duodenal wall, broken a blood vessel, or blocked the path of food leaving the stomach and entering the intestine. If you experience any of the following symptoms, seek medical help immediately:

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

Diagnosing a Peptic Ulcer

If you have any of the non-emergency symptoms of an ulcer, see a doctor to get diagnosed. Either an upper gastrointestinal (GI) series or an endoscopy will likely be ordered. If an ulcer is spotted, you will be tested for the presence of H. pylori. The bacteria can be detected non-invasively, with breath or stool tests. If you have undergone an endoscopy, biopsy tissue will be tested for H. pylori.

Treating a Peptic Ulcer

If the ulcer is caused by bacteria, medications are given to reduce stomach acid and kill the bacteria. This allows the ulcer to heal, and lowers the chance it will recur. The treatment regimen will most likely involve two weeks of triple therapy: antibiotics to destroy the bacteria, a PPI to reduce the production of stomach acid, and medications to protect the lining of the stomach from acid, such as sucralfate (Carafate) and bismuth, which also kills H. pylori. This regimen is effective for 70 to 85 percent of patients, and it is important that it be taken each day as prescribed. An alternative is sequential therapy, which involves taking one or two drugs for a few days, followed by one or more different drugs.

If you have ulcers or ulcer complications and take NSAIDs, you may also need to take a PPI. You can get both with esomeprazole/naproxen (Vimovo), or you may try to substitute acetaminophen (Tylenol) for the NSAID. If acetaminophen does not relieve your pain, your doctor may suggest trying a different over-the-counter NSAID from the one causing the problem. You also can try to reduce the dose or the frequency with which you take the NSAID.

For more information about ulcers, purchase Digestive Disease & Disorders at www.UniversityHealthNews.com.

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The main job of the stomach is to prepare food for digestion and absorption. First, it mixes the food with gastric acid and en-zymes. Then the muscles churn the food vigorously, until it breaks down into a smooth pulp which is passed on into the small in-testine via a narrowed channel called the pyloric channel.

Everyone experiences harmless bouts of nausea at times. However, the stomach is also the source of a variety of more serious ailments, disorders, and diseases, such as infections, ulcers, and cancers.

Gastritis

Gastritis is not a single disease, but rather a condition with several possible causes. The term “gastritis” means inflammation of the stomach lining. When the body’s immune system detects injury from infection or other cause, it produces inflammation which triggers processes that promote healing. Healing occurs as the inflammatory process abates. If the cause of injury persists, the immune system continues to respond. This results in ongoing inflammation, and healing will not occur.

Some possible causes of gastritis include alcohol abuse, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin), and infection with the Helicobacter pylori (H. pylori. bacteria. Most people infected with H. pylori do not ex-perience symptoms, because the inflammation is mild. However, certain factors can worsen the inflammation and cause gastritis symptoms. Pernicious anemia, autoimmune disorders, and chronic bile reflux also can cause gastritis.

Gastritis Symptoms

The most common symptoms of gastritis are an upset stomach, indigestion, and pain in the upper abdomen that can radiate to the back. Gastritis also can cause belching, nausea, vomiting, loss of appetite, a feeling of fullness, and a burning sensation in the up-per abdomen.

Diagnosing Gastritis

Your doctor may suspect gastritis from the symptoms. However, because the symptoms of gastritis can be similar to those of other gastrointestinal illnesses, the only sure way to diagnose gastritis is by performing an endoscopy (see Chapter 2) to examine the stomach, and taking a biopsy of the stomach lining.

Treating Gastritis

Treatment for gastritis depends on the cause. If H. pylori is the culprit, antibiotics will be prescribed—research suggests that erad-icating H. pylori in people with chronic gastritis may reverse the damage. If the cause of gastritis is prolonged use of NSAIDs, these medications should be discontinued. Similarly, if overuse of alcohol is to blame, the solution is to stop drinking.

For most types of gastritis, drugs to reduce stomach acid—such as H2 blockers or proton pump inhibitors (PPIs)—will be pre-scribed. Since stomach acid irritates the inflamed tissue in the stomach, reducing acid production can promote healing.

Peptic Ulcer

A peptic ulcer is a sore that forms in the lining of the stomach (gastric ulcer) or the first section of the small intestine (duodenal ulcer). Gastric ulcers can occur anywhere in the stomach, but are most common in the lower part (antrum). Duodenal ulcers oc-cur in the first few inches of the small intestine (duodenum).

In the past, it was thought that ulcers were caused by stress, spicy foods, or an overabundance of stomach acid. It is now known that one of the main causes is infection with H. pylori. Infection with H. pylori, which usually occurs in childhood, doesn’t always cause ulcers—in fact, most people who carry H. pylori in their gastrointestinal tracts do not develop ulcers. Older adults are more likely to have ulcers, which may be due to a higher infection rates with H. pylori, or because they use more NSAIDs.

H. pylori bacteria have the ability to survive in the acidic environment of the stomach because they secrete enzymes that neu-tralize the acid. The bacteria also can burrow deep into the thick layer of mucus that coats the lining of the stomach. This mucus is essential for protecting the layers of tissue underneath from being damaged by stomach acid. If the mucus layer is damaged, acid can irritate the sensitive tissue underneath, causing inflammation. Once inflammation occurs, continued irritation from acid and bacteria can lead to the formation of an ulcer.

Long-term use of NSAIDs also can cause ulcers. People of any age can develop an ulcer from long-term use of NSAIDs, but it is more common in people aged 60 and older. A warning sign that NSAID use may lead to an ulcer is upset stomach or heartburn after taking an NSAID. People with a history of ulcers, and those taking NSAIDs for long periods of time, are particularly at risk.

Peptic Ulcer Symptoms

The first sign of an ulcer is usually a burning sensation in the upper-to-middle abdomen that occurs within one to two hours after a meal. Other symptoms may include:

• Pain that feels like a dull, gnawing ache
• Pain that is intermittent or constant, lasting for days to weeks at a time before subsiding
• Pain that strikes in the middle of the night, or any other time that the stomach is empty
• Pain that decreases after you eat a meal
• Nausea and vomiting
• Weight loss
• Poor appetite
• Bloating
• Burping.

Some symptoms warrant emergency medical attention, because they indicate that the ulcer has caused a hole (perforation) in the stomach or duodenal wall, broken a blood vessel, or blocked the path of food leaving the stomach and entering the intestine. If you experience any of the following symptoms, seek medical help immediately:

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

Diagnosing a Peptic Ulcer

If you have any of the non-emergency symptoms of an ulcer, see a doctor to get diagnosed. Either an upper gastrointestinal (GI) series or an endoscopy will likely be ordered. If an ulcer is spotted, you will be tested for the presence of H. pylori. The bacteria can be detected non-invasively, with breath or stool tests. If you have undergone an endoscopy, biopsy tissue will be tested for H. pylori.

Treating a Peptic Ulcer

If the ulcer is caused by bacteria, medications are given to reduce stomach acid and kill the bacteria. This allows the ulcer to heal, and lowers the chance it will recur. The treatment regimen will most likely involve two weeks of triple therapy: antibiotics to de-stroy the bacteria, a PPI to reduce the production of stomach acid, and medications to protect the lining of the stomach from acid, such as sucralfate (Carafate) and bismuth, which also kills H. pylori. This regimen is effective for 70 to 85 percent of patients, and it is important that it be taken each day as prescribed. An alternative is sequential therapy, which involves taking one or two drugs for a few days, followed by one or more different drugs.

If you have ulcers or ulcer complications and take NSAIDs, you may also need to take a PPI. You can get both with esomepra-zole/naproxen (Vimovo), or you may try to substitute acetaminophen (Tylenol) for the NSAID. If acetaminophen does not relieve your pain, your doctor may suggest trying a different over-the-counter NSAID from the one causing the problem. You also can try to reduce the dose or the frequency with which you take the NSAID.

Gastroparesis

Gastroparesis—also known as delayed gastric emptying—is a condition in which the stomach fails to empty its contents properly, but no blockage is present. The condition occurs when nerves and muscles in the stomach fail to function properly. Sometimes the nerves don’t signal the muscles to contract, such as in diabetic neuropathy; sometimes the nerves work normally, but the muscles don’t respond. Possible reasons for this include:

• A disease that affects the nerves or muscles (such as multiple sclerosis, muscular dystrophy, Guillain-Barré syndrome, or systemic scleroderma)
• Side effects from using opiates
• Stomach virus after effects
• Damage to the vagus nerve during surgery.

In more than one-third of patients, the cause for gastroparesis is never found.

Gastroparesis mainly affects young adult women, but about 20 percent of patients are children or men. People with diabetes, particularly when they are insulin-dependent, are at high risk for gastroparesis. The condition may occur daily, or in cycles. Needless to say, gastroparesis can be disabling, and the presence of chronic pain, nausea, and vomiting can cause depression, anxiety, and other psychological issues requiring help from a mental health professional.

Gastroparesis Symptoms

Symptoms include persistent nausea that worsens after eating. Patients usually vomit undigested food a couple hours after eating. Many patients report a burning, gnawing stomach pain that worsens after eating, and may become sharply painful.

Diagnosing Gastroparesis

Gastroparesis can be diagnosed with gastric scintigraphy, a type of x-ray that can help identify issues related to the emptying of the stomach.

Treating Gastroparesis

Nonsurgical treatments may be tried first. One of the first approaches is dietary modification. For example:

• Eat five to six small meals each day, instead of fewer large ones
• Eat meals with small amounts of fats and protein
• Avoid all dairy products except for yogurt
• Purée foods so they are easier to digest.

Avoid Food Triggers

In one clinical trial, orange juice, fried chicken, cabbage, oranges, sausage, pizza, peppers, onions, tomato juice, lettuce, coffee, salsa, broccoli, bacon, and roast beef triggered symptoms. Ginger ale, gluten-free foods, tea, sweet potatoes, pretzels, white fish, clear soup, salmon, potatoes, white rice, popsicles, and applesauce were tolerated without provoking symptoms.

Other nonsurgical options include medications to stimulate gastric emptying, medications to prevent vomiting, medications to prevent intestinal spasms, and pain-relieving medication as needed. Some patients find biofeedback and relaxation techniques helpful.

Gastroparesis affects the intake of nutrients, so liquid vitamins and liquid nutritional supplements may be prescribed. Alternatively, a feeding tube or J tube may be placed directly into the small intestine, bypassing the stomach. These tubes are used for feeding or to vent the gaseous distention from low motility of the stomach. In these severest cases, patients may require intravenous feeding.

In some patients, a gastric pacemaker may be placed laparoscopically. The device emits electrical impulses to stimulate the stomach muscles to contract. In some patients, this may be sufficient to move food through the stomach without symptoms.

Because the entire stomach is affected in gastroparesis, many stomach surgeries have not been effective. Even removal of the entire stomach may not solve chronic nausea. However, early results with a new minimally invasive procedure called gastric peroral endoscopic myotomy (G-POEM) indicate it may help to normalize gastric emptying. The procedure involves passing an endoscope down the throat into the stomach. A knife attached to the end of the endoscope tunnels into the lining of the stomach and releases tight muscles, before being withdrawn. In studies, about 85 to 86 percent of gastroparesis patients treated with G-POEM experienced significant improvement in gastric emptying. Complications were minor.

Stomach Cancer

More than 26,000 people in the United States—approximately 16,000 men and 10,000 women—are diagnosed with stomach cancer every year, according to the American Cancer Society (ACS), and nearly 11,000 die from it. The cancer develops for unknown reasons and can be difficult to diagnose early, because its symptoms mimic those of other gastrointestinal diseases.

As with many cancers, people over age 55 are at increased risk. Men are almost twice as likely as women to get stomach cancer, and it is more common in African-Americans than in whites. Having the bacteria H. pylori in the stomach may raise the risk, but prompt treatment to eradicate the bacteria can reduce the risk. A diet high in preserved meats (such as bacon and deli meats) and low in fruits and vegetables may contribute to stomach cancer. Conversely, a healthy diet loaded with fruits, vegetables and whole grains, and low in saturated fat may help decrease the risk of developing stomach cancer, and is particularly important for people infected with H. pylori.

Stomach Cancer Symptoms

Stomach cancer often causes no symptoms at all. When symptoms are present, they are likely to include:

• Pain or discomfort in the abdomen
• Loss of appetite
• Nausea or vomiting
• Vomiting blood or bloody stools
• Weakness or fatigue
• Weight loss.

If you experience any of these symptoms, see your doctor.

Diagnosing Stomach Cancer

One or more diagnostic tests may be needed, such as a fecal occult blood test, an upper GI series, and/or an endoscopy (see Chapter 2). New research has suggested that looking for changes in certain chemicals in the breath could be used to identify both stomach and esophageal cancers (see “Breath Test Could Help Detect Stomach and Esophageal Cancers”).

If cancer is suspected, the doctor will take a small sample of tissue (biopsy) from the wall of the stomach during an endoscopy. The tissue will be examined under a microscope to look for changes in the cells that would indicate cancer. If stomach cancer is diagnosed, the next step is to determine the stage of the cancer, which indicates how far it has spread, if at all (stomach cancer can spread to nearby organs, such as the liver or pancreas). Staging of stomach cancer may be done with a computed tomography (CT) scan or ultrasound. Endoscopic ultrasound is also very good for this purpose.

Treating Stomach Cancer

Treatment for stomach cancer depends on a number of factors, including the size, location, and extent of the tumor, whether it has spread, and the patient’s general health. Options include surgery, chemotherapy, radiation therapy, and the newest weapon, targeted therapy. According to the ACS, using two or more approaches produces the best outcomes. Surgery is the most common treatment. If the cancer is in its early stages, the surgery may be performed endoscopically, using instruments that are inserted into the stomach via the throat. If only part of the stomach needs to be removed, the remaining portion will be connected to the esophagus or small intestine, but if the cancer has spread throughout the stomach, the entire stomach may need to be removed (total gastrectomy), along with lymph nodes and other organs. The esophagus is then attached to the small intestine. After this surgery, patients must eat small amounts of food often, and some need a feeding tube for liquid nutrition in order to receive sufficient calories.

With targeted therapy, certain drugs identify unique aspects of stomach cancer cells and target them for destruction. This treatment may be effective in patients who do not respond to chemotherapy.

Two types of targeted therapy are now used in stomach cancer. Many people are familiar with the monoclonal antibody trastuzumab (Herceptin) from its use in HER2-positive breast cancer. It also is effective in HER2-positive stomach cancer. HER2 is a growth-promoting hormone, and one in five stomach cancer patients have too much of it. Trastuzumab finds this protein on the surface of cancer cells and destroys the cells. It is usually given intravenously every two to three weeks, along with chemotherapy.

Ramucirumab (Cyramza) is a monoclonal antibody that targets specific proteins that allow cancers to grow and spread by creating new blood vessels. It is given intravenously every two weeks, and is generally reserved for patients with advanced stomach cancer that no longer responds to other drugs.

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“Older adults are at particular risk for peptic ulcers and their complications because they are more likely to take medications that have been implicated in the formation of peptic ulcers,” says Brijen Shah, MD, associate professor of medicine at Mount Sinai. “They also may be more likely to carry a bacteria that can cause ulcers.”

Peptic ulcer disease can take the form of a gastric ulcer (a sore that develops in the lining of the stomach) or a duodenal ulcer (a sore that develops in the first section of the small intestine). Gastric ulcers can occur anywhere in the stomach, but are most common in the lower part, while duodenal ulcers occur in the first few inches of the small intestine (duodenum).

The Role of H. Pylori In the past, it was thought that ulcers were caused by stress, spicy foods, or an overabundance of stomach acid. It’s now known that one of the main causes is infection with a bacteria called Helicobacter pylori (H. pylori). H. pylori bacteria are able to survive in the acidic environment of the stomach because they secrete enzymes that neutralize the acid. The bacteria can also burrow deep into the thick layer of mucus that coats the lining of the stomach. “This mucus layer is essential for protecting the tissue beneath from being damaged by stomach acid,” Dr. Shah notes. “However, if the mucus layer is breached by H. pylori bacteria, stomach acid can seep through and irritate the sensitive tissue underneath, causing inflammation. Once inflammation occurs, continued irritation from acid and bacteria can lead to an ulcer.”

Infection with H. pylori, which usually occurs in childhood, doesn’t always cause ulcers—in fact, most people who carry H. pylori in their gastrointestinal tract don’t develop ulcers. “Why this is so remains a mystery, but it may be related to the type of H. pylori a person is infected with, whether they use certain medications, or their age,” says Dr. Shah.

NSAIDs Link Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) also can cause ulcers. NSAIDs include aspirin, ibuprofen (Advil®, Motrin®), and naproxen (Aleve®, Naprosyn®). The drugs relieve pain by deactivating an enzyme called cyclooxygenase (COX). COX is responsible for generating the products of inflammation that are sensed as pain, but it also has a role in protecting the lining of the stomach. Blocking COX relieves pain, but can also negate the enzyme’s protective effect in the stomach.

Using NSAIDs for short periods of time generally doesn’t cause any problems. But people who take these drugs regularly—for example, to relieve arthritis pain—may develop gastritis (inflammation of the stomach lining) or ulcers over time.
“A warning sign that NSAID use may lead to an ulcer is upset stomach or heartburn after taking the drug,”
Dr. Shah cautions.

Keep in mind that NSAIDs are not the only medication linked to an increased risk for peptic ulcers—others include corticosteroids, osteoporosis drugs such as alendronate (Fosamax®) and risedronate (Actonel®), and potassium chloride (which is used to balance potassium levels when necessary in people who take diuretics).

Peptic Ulcer Symptoms The first sign of an ulcer is usually a burning sensation in the upper-to-middle abdomen that occurs within one to two hours after a meal. “Other symptoms may include intermittent or constant pain that feels like a dull, gnawing ache, and decreases after you eat a meal, and/or pain that strikes in the middle of the night, or any other time that the stomach is empty,” Dr. Shah adds. Less common symptoms include nausea and vomiting, a poor appetite, weight loss, bloating, and excessive burping. Some symptoms warrant emergency medical attention because they indicate that the ulcer has caused a hole (perforation) in the stomach or duodenal wall (see What You Can Do).

Diagnosing and Treating a Peptic ­Ulcer If you have any of the non-emergency symptoms of an ulcer, your doctor may refer you for an endoscopy, which utilizes a long, thin, flexible tube that has a light and a tiny lens on the end (endoscope). “The tube is inserted down the throat and into the esophagus, and the images are transmitted in real time to a video monitor,” Dr. Shah explains. “Air may be blown into your stomach to expand the folds of tissue and allow for a better view.” A thin wire with forceps may be passed through the endoscope in order to take biopsies (small samples of tissue that will be examined under a microscope).

If the ulcer is caused by H. pylori, antibiotics will be prescribed to destroy the bacteria. You’ll also be given a proton-pump inhibitor (PPI)—used to treat gastroesophageal reflux disease, PPIs suppress stomach acid, thereby decreasing the risk for gastritis and ulcers. Medications to protect the lining of your stomach from the acid also are necessary—options include sucralfate (Carafate®) and bismuth (Pepto-Bismol®), which also kills H. pylori. “This triple-therapy regimen is effective for up to 85 percent of patients,” Dr. Shah says. “An alternative is sequential therapy, which involves taking one or two drugs for a few days, followed by one or more different drugs.”

Peptic Ulcer Prevention You may have symptoms from a peptic ulcer or may not show any signs of having one until bleeding occurs. The latter means it is important to reduce your risk for developing ulcers in the first place. If you regularly take NSAIDs, consider substituting acetaminophen (Tylenol®) for pain relief. If you don’t find acetaminophen effective, discuss with your doctor whether you should be taking a PPI to protect your stomach while you are taking NSAIDs.

Excessive alcohol intake raises your risk of ulcers because alcohol can irritate the lining of the stomach as well as increase the production of stomach acid. If you are infected with H. pylori, smoking further increases your ulcer risk, so consider quitting (see our December 2017 issue for strategies to help you quit smoking). You can help protect yourself against infections like H. pylori by frequently washing your hands with soap and water (and always prior to eating, and after using the bathroom).

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An Ulcer-Friendly Diet

It turns out that the frequency of your meals is much less important than what is and isn’t on your plate. Warren says some of your main allies are the disease-fighting antioxidants in a variety of fruits and vegetables. These and other healthy foods may also help protect against an infection by the bacterium Helicobacter pylori (H. pylori)—a primary cause of stomach ulcers.

“The dietary fiber found in vegetables and fruits has been shown to prevent ulcers from re-emerging as well as to help heal existing ulcers. Studies have also shown that certain compounds in foods, such as isothiocyanate sulforaphane in broccoli, allicin in garlic, phenols in olive oil, and fish oils, may have specific, potent antimicrobial activity that helps prevent H. pylori infection,” Warren says. “Probiotics, specifically lactobacillus, and fermented milk products may exert similar effects against H. pylori.”

She adds that a healthy intake of omega-6 and omega-3 fats may have an anti-inflammatory, protective effect, too. “To boost your intake of these healthy fats, eat fish such as salmon and mackerel two to three times per week, along with flaxseed, walnuts, and avocados,” suggests Warren.

Foods to Avoid

Just as it’s important to know what you should eat, it’s crucial to know the foods to avoid with an ulcer. Alcohol is a big no-no, and so is cocoa. Not surprisingly, Warren also recommends against the spicy stuff.

“Spices, such as red and black pepper, can irritate the gastrointestinal tract lining, further exacerbating inflammation,” Warren says. “Coffee, tea, soft drinks, and excessive amounts of milk have been shown to increase stomach acid production, also exacerbating the symptoms.” She also notes that heavy coffee consumption (more than three cups a day) could make you more susceptible to an H. pylori infection.

Recognizing Ulcer Symptoms

In addition to H. pylori, aspirin and certain other painkillers are the top causes of stomach ulcers. They can cause acid in your digestive system to eat away at the inner lining of your stomach, which may create an open sore that can bleed. A burning pain in your stomach is one of the main symptoms of stomach ulcers. Other symptoms include:

Nausea and vomiting

A feeling of fullness or bloating

Heartburn

Intolerance of high-fat foods.

If you have these symptoms, see your doctor. Diagnosing a stomach ulcer can be done with an endoscopy. A thin, flexible device with a tiny camera at one end, called an endoscope, is lowered down your throat through your esophagus, stomach, and small intestine. Your doctor can see the exact location and size of your ulcer. You may also be tested for an H. pylori infection.

Treating Your Ulcer

Once a diagnosis is made, your doctor will explain your treatment options. The goal is to help the ulcer heal and to avoid symptom flare-ups. And, if you have H. pylori, you should be given antibiotics to knock out the infection.

Medications to help the ulcer heal include proton pump inhibitors (PPIs), which interfere with the cells that produce stomach acid. Prolonged use of PPIs can raise your risk for bone fractures and other complications, so discuss the pros and cons of PPIs with your doctor. Other ulcer medications include acid blockers (also known as histamine or H-2 blockers), which reduce the amount of acid produced in the stomach. In milder cases, over-the-counter antacids may also help control symptoms and promote healing. 

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Gastritis

Gastritis is not a single disease, but rather a condition with several possible causes. The term “gastritis” means inflammation of the stomach lining. When the body’s immune system detects injury from infection or other cause, it produces inflammation, which triggers processes that promote healing. Healing occurs as the inflammatory process abates. If the cause of injury persists, the immune system continues to respond, causing ongoing inflammation, and healing will not occur.

Some possible causes of gastritis include alcohol abuse, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin), or infection with the Helicobacter pylori (H pylori) bacteria. Most people infected with H pylori do not experience symptoms, because the inflammation is mild. However, certain factors can worsen the inflammation and cause symptoms of gastritis to appear. Pernicious anemia, autoimmune disorders, and chronic bile reflux can also cause gastritis.

Gastritis Symptoms

The most common symptoms of gastritis are upset stomach, indigestion, and pain in the upper abdomen that can radiate to the back. Gastritis also can cause belching, nausea, vomiting, loss of appetite, a feeling of fullness, and a burning sensation in the upper abdomen.

Diagnosing Gastritis

Your doctor may suspect gastritis from the symptoms. However, because the symptoms of gastritis can be similar to those of other gastrointestinal illnesses, the only sure way to diagnose gastritis is by performing an endoscopy (see Chapter 2) to examine the stomach, and taking a biopsy of the stomach lining.

Treating Gastritis

Treatment for gastritis depends on the cause. If H pylori is the culprit, antibiotics will be prescribed—research suggests that eradicating H pylori in people with chronic gastritis may reverse the damage. If the cause of gastritis is prolonged use of NSAIDs, these medications should be discontinued. Similarly, if overuse of alcohol is to blame, the solution is to stop drinking.

For most types of gastritis, drugs to reduce stomach acid, such as H2 blockers or proton pump inhibitors, will be prescribed. Since stomach acid irritates the inflamed tissue in the stomach, reducing acid production can promote healing.

Peptic Ulcer

A peptic ulcer (see Box 4-1, “Peptic Ulcer”) is a sore that forms in the lining of the stomach (gastric ulcer) or the first section of the small intestine (duodenal ulcer). Gastric ulcers can occur anywhere in the stomach, but are most common in the lower part (antrum). Duodenal ulcers occur in the first few inches of the small intestine (duodenum).

In the past, it was thought that ulcers were caused by stress, spicy foods, or an overabundance of stomach acid. It is now known that one of the main causes is infection with H pylori. Infection with H pylori, which usually occurs in childhood, doesn’t always cause ulcers—in fact, most people who carry H pylori in their gastrointestinal tracts don’t develop ulcers. Why this is so remains a mystery, but it may be related to the type of H pylori the person is infected with, use of certain medications, or age. Older adults are more likely to have ulcers, which may be due to a higher infection rate with H pylori, or because they use more NSAIDs.

H pylori bacteria have the ability to survive in the acidic environment of the stomach because they secrete enzymes that neutralize the acid. The bacteria can also burrow deep into the thick layer of mucus that coats the lining of the stomach, weakening the layer of mucus. This mucus is essential for protecting the layers of tissue underneath from being damaged by stomach acid. When the mucus layer is damaged, acid can irritate the sensitive tissue underneath, causing inflammation. Once inflammation occurs, continued irritation from acid and bacteria can lead to the formation of an ulcer.

Long-term use of NSAIDs also can cause ulcers (see Box 4-2, “Nonsteroidal Anti-Inflammatory Drugs [NSAIDs]”). People of any age can develop an ulcer from long-term use of NSAIDs, but it is more common in people over age 60. A warning sign that NSAID use may lead to an ulcer is upset stomach or heartburn after taking an NSAID. People with a history of ulcer, and those taking NSAIDs for long periods of time, are particularly at risk.

Peptic Ulcer Symptoms

The first sign of an ulcer is usually a burning sensation in the upper-to-middle abdomen that occurs within one to two hours after a meal. Other symptoms may include:

• Pain that feels like a dull, gnawing ache
• Pain that is intermittent or constant, lasting for days to weeks at a time before subsiding
• Pain that strikes in the middle of the night, or any other time that the stomach is empty
• Pain that decreases after you eat a meal
• Nausea and vomiting
• Weight loss
• Poor appetite
• Bloating
• Burping

Some symptoms warrant emergency medical attention, because they indicate that the ulcer has caused a hole (perforation) in the stomach or duodenal wall, broken a blood vessel, or blocked the path of food leaving the stomach and entering the intestine. If you experience any of the following symptoms, seek medical help right away:

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

Diagnosing a Peptic Ulcer

If you have any of the non-emergency symptoms of an ulcer, see a doctor to get diagnosed. Either an upper gastrointestinal (GI) series or an endoscopy will likely be ordered. If an ulcer is spotted, you will be tested for the presence of H pylori. The bacteria can be detected non-invasively, with breath or stool tests. If you have undergone an endoscopy, biopsy tissue will be tested for H pylori.

Treating a Peptic Ulcer

If the ulcer is caused by bacteria, medications are given to reduce stomach acid and kill the bacteria. This allows the ulcer to heal, and lowers the chance it will recur.

The treatment regimen will most likely involve two weeks of triple therapy: antibiotics to destroy the bacteria, a proton pump inhibitor (PPI) to reduce the production of stomach acid, and medications to protect the lining of the stomach from acid, such as sucralfate (Carafate) and bismuth, which also kills H pylori. This regimen is effective for 70 to 85 percent of patients.

An alternative is sequential therapy, which involves taking one or two drugs for a few days, followed by one or more different drugs.

If you have ulcers or ulcer complications and take NSAIDs, you may also need to take a PPI. You can get both with the drug Vimovo, which combines the PPI esomeprazole with the NSAID naproxen, or you may try to substitute acetaminophen (Tylenol) for the NSAID. If it does not relieve your pain, your doctor may suggest trying a different over-the-counter NSAID from the one causing the problem. You also can try to reduce the dose or the frequency with which you take the NSAID.

Gastroparesis

Gastroparesis—also known as delayed gastric emptying—is a condition in which the stomach fails to empty its contents properly, but no blockage is present (see Box 4-3, “Gastroparesis”). The condition occurs when nerves and muscles in the stomach fail to function properly. Sometimes the nerves don’t signal the muscles to contract, such as in diabetic neuropathy; sometimes the nerves work normally, but the muscles don’t respond. Possible reasons for this include:

• A disease that affects the nerves or muscles (such as multiple sclerosis, muscular dystrophy, Guillain-Barré syndrome, or systemic scleroderma)
• Side effects from using narcotics
• Stomach virus after effects
• Damage to the vagus nerve during surgery

In more than one-third of patients, the cause for gastroparesis is never found.

Gastroparesis mainly affects young adult women, but about 20 percent of patients are children or men. People with diabetes, particularly when they are insulin-dependent, and those with acid reflux are at high risk for gastroparesis. The condition may occur daily, or in cycles. Needless to say, gastroparesis can be disabling, and the presence of chronic pain, nausea, and vomiting can cause depression, anxiety, and other psychological issues requiring help from a mental health professional.

Gastroparesis Symptoms

Symptoms include persistent nausea that worsens after eating. Patients usually vomit undigested food a couple hours after eating. Many patients report a burning, gnawing stomach pain that worsens after eating, and may become sharply painful.

Diagnosing Gastroparesis

Gastroparesis can be diagnosed with a gastric emptying breath test (GEBT) given in the doctor’s office. The night before the test, the patient eats a meal that includes scrambled eggs and the protein spirulina platensis, which has been enriched with carbon-13. Several measurements of carbon dioxide in the breath taken over a four-hour period the following day reveals how quickly the stomach is emptying. Patients with certain medical conditions, and those allergic to eggs, milk, wheat, or spirulina, can be tested with gastric scintigraphy, a type of X-ray that can help identify issues related to the emptying of the stomach.

Treating Gastroparesis

Nonsurgical treatments may be tried first. These can include dietary modifications (see Box 4-4, Dietary Changes That May Help Gastroparesis”), medications to stimulate gastric emptying, medications to prevent vomiting, medications to prevent intestinal spasms, and pain-relieving medication as needed. Some patients find biofeedback and relaxation techniques helpful.

Gastroparesis affects the intake of nutrients, so liquid vitamins and liquid nutritional supplements may be prescribed. Alternatively, a feeding tube or J tube may be placed directly into the small intestine, bypassing the stomach. In these severest cases, patients may require intravenous feeding.

In some patients, a gastric pacemaker may be placed laparoscopically. The device emits electrical impulses to stimulate the stomach muscles to contract. In some patients, this may be sufficient to move food through the stomach without symptoms.

Because the entire stomach is affected in gastroparesis, many stomach surgeries have not been effective. Even removal of the entire stomach may not solve chronic nausea. However, early results with a new minimally invasive procedure indicate it may normalize gastric emptying (see Box 4-5, “G-POEM Procedure Producing Positive Results”).

Stomach Cancer

More than 26,000 people in the United States are diagnosed with stomach cancer every year, and nearly 11,000 die from it. The cancer develops for unknown reasons and can be difficult to diagnose early, because its symptoms mimic those of other gastrointestinal diseases.

As with many cancers, people over age 55 are at increased risk. Men are almost twice as likely as women to get stomach cancer, and it is more common in African-Americans than in whites. Having the bacteria H pylori in the stomach may raise the risk, but prompt treatment to eradicate the bacteria can reduce the risk. A diet high in preserved meats (such as bacon and deli meats) and low in fruits and vegetables may contribute to stomach cancer. Conversely, a healthy diet loaded with fruits, vegetables, and whole grains and low in saturated fat may help decrease the risk of developing stomach cancer, and is particularly important for people infected with H pylori.

Stomach Cancer Symptoms

Stomach cancer often causes no symptoms at all. When symptoms are present, they are likely to be:

• Vomiting blood or bloody stools
• Pain or discomfort in the abdomen
• Nausea or vomiting
• Loss of appetite
• Weakness or fatigue
• Weight loss

If you experience any of these symptoms, see your doctor.

Diagnosing Stomach Cancer

One or more diagnostic tests may be needed, such as a fecal occult blood test, an upper GI series, and/or an endoscopy (see Chapter 2).

If cancer is suspected, the doctor will take a small sample of tissue (biopsy) from the wall of the stomach during an endoscopy. The tissue will be examined under a microscope to look for changes in the cells that would indicate cancer. If stomach cancer is diagnosed, the next step is to determine the stage of the cancer (see Box 4-6, “Stages of Stomach Cancer”), which indicates how far it has spread, if at all (stomach cancer can spread to nearby organs, such as the liver or pancreas). Staging of stomach cancer may be done with a computed tomography (CT) scan or ultrasound. Endoscopic ultrasound is also very good for this purpose.

Treating Stomach Cancer

Treatment for stomach cancer depends on a number of factors, including the size, location, and extent of the tumor, whether it has spread, and the patient’s general health. Options include surgery, chemotherapy, radiation therapy, and targeted therapy (see Box 4-7, “Monoclonal Antibodies Target Stomach Cancer Cells”). According to the American Cancer Society, using two or more approaches produces the best outcomes.

Surgery is the most common treatment. If the cancer is in its early stages, the surgery may be performed endoscopically, using instruments that are inserted into the stomach via the throat.

If only part of the stomach needs to be removed, the remaining portion will connected to the esophagus or small intestine. If the cancer has spread throughout the stomach, the entire stomach may need to be removed (total gastrectomy), along with lymph nodes and other organs. The esophagus is then attached to the small intestine. After this surgery, patients must eat small amounts of food often, and some need a feeding tube for liquid nutrition in order to receive sufficient calories.

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Ulcer symptoms may include:

• Pain and/or a burning sensation in your abdominal area between your breastbone (the bone in the center of your chest) and your navel (belly button).
• Pain that begins or worsens after eating.
• Pain that begins or worsens when your stomach is empty, especially at night.
• Pain that comes and goes; it may last an hour, several hours, or a few days, and it may go away, only to recur in a few days or even weeks.

If an ulcer is severe, it may bleed. Symptoms of a bleeding ulcer include vomit that contains blood or looks like coffee grounds, and stools (bowel movements) that contain blood or that look black or tarry.

Ulcer Relief

Taking a medication intended to treat indigestion or heartburn may provide temporary relief of ulcer symptoms. These medications include:

• Over-the-counter (OTC) antacids such as Rolaids, Tums, Maalox, Mylanta, and Pepto-Bismol.
• OTC or prescription drugs that block acid, including Zantac, Tagamet, and Pepcid.
• OTC or prescription drugs that decrease acid production, including Prilosec, Prevacid, Nexium, and Zegerid.

Ulcer symptoms are similar to signs of other problems that may occur in the gastrointestinal system. If you experience any of these symptoms, it’s important to see your doctor so he or she can evaluate the cause. (See also our post “What Is GERD? Dealing with Gastroesophageal Reflux Disease.”)

Types of Ulcers

• An esophageal ulcer is located in the esophagus, the passageway that transports food into the stomach.
• A gastric ulcer is located in the stomach.
• A duodenal ulcer is located in the duodenum, the first part of the small intestine.

Avoid Complications

If you have a peptic ulcer, seek treatment to prevent complications, which can include internal bleeding, an infection in your abdominal cavity (caused by a perforated ulcer that has eaten though the wall of the GI tract), and formation of scar tissue that can prevent food from moving through your digestive tract.

Once your ulcer has been successfully treated, your ulcer symptoms will improve.

For further reading, see these University Health News posts:

• “Conventional vs. Natural Heartburn Remedies—How to Test for Hypochlorhydria to Determine the Best Treatment“
• “4 Causes of Gastritis That You Can Treat on Your Own“
• “Gastritis Relief: The Key Is to Treat the Root Cause“

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For instance, peptic ulcer symptoms start with a sore that forms in the lining of the stomach (gastric ulcer) or the first section of the small intestine (duodenal ulcer). Gastric ulcers can occur anywhere in the stomach; however, they are most common in the lower part of the stomach (called the antrum). Duodenal ulcers occur in the first few inches of the small intestine (the duodenum).

In the past, it was thought that ulcers were caused by stress, spicy foods, or an overabundance of stomach acid. It’s now known that amongst the main causes of ulcers is an infection with the bacterium H. pylori. Long-term use of NSAIDs also can cause ulcers. Older adults are more likely to have ulcers, which may be because they have a higher infection rate with H. pylori or because they use more NSAIDs.

Stomach Ulcer Symptoms: What You’ll Feel

The first stomach ulcer symptom is usually a burning sensation in the upper to middle abdomen within one to two hours after a meal. Other symptoms of an ulcer may include:

• Pain that feels like a dull, gnawing ache.
• Pain that is intermittent or constant, lasting for days to weeks at a time before subsiding.
• Pain that strikes in the middle of the night, or any other time the stomach is empty.
• Pain that decreases after meals.

Some stomach ulcer symptoms warrant emergency medical attention because they indicate that the ulcer has caused a perforation in the stomach or duodenal wall, broken a blood vessel, or blocked the path of food leaving the stomach and entering the intestine.

If you experience bleeding ulcer, characterized by any of the following symptoms, seek medical help right away:

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

Stomach Ulcer Diagnosis

To diagnose an ulcer, the first test performed will probably be either an upper gastrointestinal (GI) series or an endoscopy. An upper GI series is an X-ray of the esophagus, stomach, and duodenum. If there is an ulcer, testing for H. pylori bacteria follows.

Treatments for ulcers are highly effective. The three goals to treat ulcers caused by bacteria are to reduce stomach acid, protect the stomach lining, and kill the bacteria. This triple therapy allows the ulcer to heal and lowers the chance that it will come back. Antibiotics are used to destroy the bacteria. Reducing stomach acid is generally accomplished with a proton pump inhibitor (PPI), and sucralfate and bismuth are typical medications to protect the stomach lining.

Originally published in May 2016 and updated.

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