1. Gastro-esophageal reflux disease (GERD) in old age.
2. The incidence of gastric and duodenal ulcers and their bleeding complications is increasing in old-aged populations worldwide.
3. H. pylori infection in elderly patients with H. pylori-associated peptic ulcer disease and severe chronic gastritis
4. Almost 40% of GU and 25% of DU in the elderly patients are associated with the use of NSAID(1) and/or aspirin(2).(a)
I. Gastro-esophageal reflux disease (GERD)
Gastroesophageal reflux disease (GERD), also known as gastro-oesophageal reflux disease (GORD), gastric reflux disease, or acid reflux disease, is defined as a chronic condition of liquid stomach acid refluxing back up from the stomach into the esophagus, causing heartburn. According to the study of "Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease." by DeVault KR, Castell DO; American College of Gastroenterology, GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus.
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Symptoms
1. Heartburn
Heart burn is one of common symptom of Gastroesophageal reflux disease (GERD) in adult, as a result of acid reflux cause of burning sensation or pain in the middle of the chest mostly after meal.
2. Regurgitation
In gastroesophageal reflux disease (GERD), regurgitation is the expulsion of a small amount of digested foods to the mouth from esophagus. frequent or prolonged regurgitation can lead to acid-induced erosion of the teeth, bad breath or damage to the esophagus.
3. Trouble swallowing
It is caused by damage of the muscles and tissues that must flex for swallowing, as a result of prolonged period of acid reflux that has left untreated.
It is one of uncommon of Gastroesophageal Reflux Disease (GERD), but is is associated to some people with the disease.
5. Pain when swallow
It may be caused by the damage or infection of the esophagus.
6. Asthma
In a study of The association between gastro-oesophageal reflux disease and asthma: a systematic review" by B D Havemann, C A Henderson, H B El-Serag, posted in a international journal of gastroenteroloy and hepatology, researchers found that this systematic review indicates that there is a significant association between GORD and asthma, but a paucity of data on the direction of causality.
7. Etc.
Complication
In some severe cases as a result of frequent acid reflux.
1. Ulcers
Damage of the esophagus can lead to result of ulcers as a result of inflammation forming of scar.
2. Esophageal strictures
Prolonged period and frequent acid reflux, if keft untreated can lead to inflammation cause of narrowing of the esophagus
3. Barrett's esophagus
In a study of . "Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett's esophagus" by Kenneth K. Wang, M.D. and Richard E. Sampliner, M.D.
The Practice Parameters Committee of the American College of Gastroenterology, researchers wrote that screening for Barrett’s esophagus remains controversial because of the lack of documented impact on mortality from EAC. The large number of patients that lack reflux symptoms but have Barrett’s esophagus provides a diagnosis challenge. The highest yield for Barrett’s is in older (age 50 or more) Caucasian males with longstanding heartburn.
4. Esophageal adenocarcinoma
In GICS 2009: EGF Genetic Variant Increases Risk for GERD-Associated Esophageal Adenocarcinoma " by Roxanne Nelson posted by Medscape Newa Today, the author wrote that January 16, 2009 (San Francisco, California) — Specific mutations in the epidermal growth factor (EGF) gene appear to increase the risk for esophageal cancer in patients with gastroesophageal reflux disease (GERD), according to research presented here at the 2009 Gastrointestinal Cancers Symposium. Compared with the EGF wild-type A/A genotype, presence of the G/G variant was associated with an odds ratio (OR) of 1.90 for esophageal cancer, but the correlation between the G/G genotype and esophageal cancer risk was evident only among patients who also had GERD.
5. Etc.
Causes
1. Slower in emptying of the stomach after eating
Most uncommon causes of Gastroesophageal reflux disease (GERD) is due to the distention of the stomach with food over prolonged period of time that can lead to reflux. Approximately 20% of Gastroesophageal reflux disease (GERD) are caused the reason above.
2. Cardia
Cardia is the area between the part of the stomach and the esophagus. It is angle where the esophagus enters the stomach and acts as a valve to prevent foods and others to reflux back to the esophagus. If the cardia is not functioning well, it can cause Gastroesophageal reflux disease (GERD with burning sensation of the esophagus.
3. Esophageal contractile defection
If the esophageal contraction fails to performed its function of proper swallowing food, it may not generate enough waves of contractions to push the foods down to the stomach after swallowing and the acid back into the stomach.
4. Hiatal hernia
Hiatal hernia is a condition of a portion of the stomach protrudes upward into the chest, through a tear or weakness in the diaphragm. According to the study of Nocturnal Reflux Episodes Following the Administration of a Standardized Meal. Does Timing Matter?Michael Piesman, M.D.; Inku Hwang, M.D.; Corinne Maydonovitch, B.S.; Roy K.H. Wong, M.D, posted in Medscape news Today, researchers found that GERD patients consuming a late-evening meal had significantly greater supine acid reflux compared to when they consumed an early meal, especially in overweight patients, and in patients with esophagitis or HH. These findings support the recommendations to our GERD patients to eat dinner early and to lose weight.
5. Obesity
Obesity increase the risk of Gastroesophageal reflux disease (GERD). In a sudy of "The association between gastroesophageal reflux disease and obesity." by Friedenberg FK, Xanthopoulos M, Foster GD, Richter JE., the authors wrote that weight loss, through caloric restriction and behavioral modification, has been studied infrequently as a means of improving reflux. Bariatric surgery and its effects on a number of obesity-related disorders have been studied more extensively. Roux-en-Y gastric bypass (RYGB) has been consistently associated with improvement in the symptoms and findings of GERD.
6. Esophageal mucosa
In a study of "Halimeter ppb Levels as the Predictor of Erosive Gastroesophageal Reflux Disease." by Kim JG, Kim YJ, Yoo SH, Lee SJ, Chung JW, Kim MH, Park DK, Hahm KB. posted in US National Library of Medicine National Institutes of Health, researchers found that Erosive changes in the esophageal mucosa were strongly associated with VSC levels, supporting the hypothesis that halitosis can be a potential biomarker for the discrimination between ERD and NERD, reflecting the presence of erosive change in the lower esophagogastric junction.
7. Medication
The use of medication such as prednisolone acetate ophthalmic suspension, an adrenocortical steroid product can increase the risk of Gastroesophageal reflux disease (GERD).
8. Chronic diseases
Chronic diseases, including cough, pulmonary fibrosis, earache, and asthma are also associated with the higher risk of develop Gastroesophageal reflux disease (GERD)
9. Infection
Infection caused by H. pylori can increase the risk of Gastroesophageal reflux disease (GERD). According to the study of "Helicobacter pylori infection and chronic gastric acid hyposecretion" by EM El-Omar, K Oien, A El-Nujumi, D Gillen, A Wirz, S Dahill, C Williams, JE Ardill, KE McColl posted in Gastroenterology, researchers concluded that in some subjects, chronic H. pylori infection produces a body-predominant gastritis and profound suppression of gastric acid secretion that is partially reversible with eradication therapy. (Gastroenterology 1997 Jul;113(1):15-24).
10. Etc.
If you are experience some of the above symptoms, after recording your family history and physical exam, the following test may be recommended by your doctor
1. Esophagogastroduodenoscopy (EGD)
Esophagogastroduodenoscopy (EGD) also known as upper gastrointestinal endoscopy is a diagnosis procedure allowing your doctor to check for any abnormality in the lining of the esophagus, stomach, and upper duodenum after a flexible endoscope inserted down the throat.
If any abnormality is found, your doctor order further examinations.
2. Barium swallow
Barium swallow is a medical imaging procedure which allows your doctor to examine the upper GI (gastrointestinal) tract, to exam the lining of the esophagus and the stomach, after you have drunk a suspension of barium sulfate.
3. Chest X-rays
A chest x-ray is an x-ray of the chest that allows your doctor to examine the lining of the esophagus, stomach, and upper duodenum.
4. Biopsy
A biopsy is a test of removal sample of cells or tissues for examination and determination of the grade and type of the tumors by examining them under a microscope by a pathologist or chemically, if the location of the tumor allows the test to be done without major risk to the patient.
4. Esophageal manometry
Esophageal manometry is a test with the use of a pressure-sensitive tube-like thin instrument passed through your mouth or nose and into your stomach to allow your doctor to examine the motor function of the Upper Esophageal Sphincter (UES), Esophageal body and Lower Esophageal Sphincter (LES).
5. Etc.
Prevention
A. GERD Diet
According to the The GERD Diet (Gastroesophageal Reflux Disease) in McKinley Health Center of The university of Illinois at Urbana-Champaign
Dietary modifications are recommended to lessen the likelihood of reflux and to avoid irritation of sensitive or inflamed esophageal tissue. Listed below are several recommendations that may help to manage GERD:
1. Decrease total fat intake - High fat meals and fried foods tend to decrease LES pressure and delay
2. Avoid large meals - Large meals increase the likelihood of increased gastric (stomach) pressure and reflux.
3. Decrease total caloric intake if weight loss is desired - Since obesity may promote reflux, weight loss
may be suggested by your healthcare provider to control reflux. Reducing both total fat and caloric intake will aid in weight loss.
4. Avoid chocolate - Chocolate contains methylxanthine, which has been shown to reduce LES pressure by causing relaxation of smooth muscle.
5. Avoid coffee depending on individual tolerance - Coffee, with or without caffeine, may promote gastroesophageal reflux. Coffee may be consumed if it is well tolerated.
6. Avoid other known irritants - Alcohol, mint, carbonated beverages, citrus juices, and tomato products all may aggravate GERD. These products may be consumed depending on individual tolerance.
B. Other modifications for treating GERD
7. Maintain upright posture during and after eating.
8. Stop smoking.
9. Avoid clothing that is tight in the abdominal area.
10. Avoid eating within 3 hours before bedtime.
11. Lose weight if you are overweight.
12. Sleep on your left side.
13. Chew non-mint gum which will increase saliva production and decrease acid in the esophagus.
14. Elevate the head of your bed 4-6 inches by placing bricks under the headboard. (Source)
Treatments
A. Conventional medicine
A.1. Medication
1. Proton-pump inhibitors
Proton-pump inhibitors including omeprazole, esomeprazole, pantoprazole, are used to reduce the production of gastric acid in the stomach.
2. H2 receptor blockers
H2 receptor blockers include ranitidine, famotidine, cimetidine, etc.. In a study of " Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease therapies." by Tran T, Lowry AM, El-Serag HB., posted in US National Library of Medicine National Institutes of Health , researchers found that Over-the-counter medications are effective in treating symptomatic gastro-oesophageal reflux disease. Compared with the placebo response, which ranged between 37% and 64%, the relative benefit increase was up to 41% with histamine-2 receptor antagonists, 60% with alginate/antacid combinations, and 11% with antacids.
3. 5HT4 agonist
According to the study of "The effect of mosapride, a novel prokinetic, on acid reflux variables in patients with gastro-oesophageal reflux disease." by Ruth M, Hamelin B, Röhss K, Lundell L., posted in US National Library of Medicine National Institutes of Health, researchers found that
Mosapride 40 mg q.d.s. is effective in decreasing acid reflux in the oesophagus in patients with GERD and therefore has the potential to be effective in the treatment of this disease.
4. GABA-B Receptor Agonists
In an article of "Medical Management of GERD" From Medscape Gastroenterology by Ronnie Fass, MD, FACP, FACG., the author wrote that Richard Holloway from Adelaide, Australia, reviewed the current studies assessing the role of baclofen, a GABA-B agonist, in the treatment of patients with GERD. He emphasized that the drug inhibits 34% to 60% of the TLESRs and improves basal lower esophageal sphincter pressure.
Antacids are oral medicine used to relieve symptom of heartburn of gastroesophageal reflux disease (GERB).
4. Promotility Agents
Promotility Agents are used to improve GERD symptoms for patients with slow gastric emptying by stimulating the muscles of the gastrointestinal tract to reduce acid reflux into the esophagus.
5. Etc.
A.2. Surgery
1. Fundoplication Surgery
The aim of the sugery is to reduce heartburn caused by acid reflux, in severe case of inflammation, hiatal hernia, damage of esophagus, etc.. Fundoplication surgery is the procedure to treat Gastroesophageal Reflux Disease (GERD) by strengthening the valve between the esophagus and stomach as the upper curve of the stomach is wrapped and satured around the lower end of the esophagus to prevent acid from backing up into the esophagus with a laparoscopic with a small tunnel made from the stomach muscle to allow foods of the lower part of the esophagus to pass through. The sugery is also by times for the esophagus to heal. Acccording to the artilce of "Barrett's esophagus: the role of laparoscopic fundoplication" by Abbas E. Abbas MD, Claude Deschamps MD, Stephen D. Cassivi MD, Mark S. Allen MD, Francis C. Nichols, III MD, Daniel L. Miller MD and Peter C. Pairolero MD, posted in ScienceDirect, researcher found that laparoscopic fundoplication is effective in controlling symptoms in the majority of patients with BE. While disappearance of BE may occur in some patients, the possibility of developing esophageal adenocarcinoma is not eliminated by laparoscopic fundoplication. Therefore, endoscopic surveillance should continue.
1. Deglycyrrhizinated licorice
Deglycyrrhizinated licorice has been used by people with gastric and peptic ulcers for nearly a hundred years. in a study of "Secretin as a potential mediator of antiulcer actions of mucosal protective agents." by Takeuchi T, Shiratori K, Watanabe S, Chang JH, Moriyoshi Y, Shimizu K., posted in US National Library of Medicine National Institutes of Health, researcher found that the three antiulcer agents FM 100, plaunotol, and teprenon have been shown to increase the content of endogenous prostaglandins in the gastric mucosa, endogenous secretin released by these agents may play a significant role in their mucosal protective action. It is concluded that the antiulcer effect of these drugs could in part be attributable to their unique ability to release endogenous secretin, and that secretin is a potential mediator of the antiulcer actions of mucosal protective agents
2. Aloe Vera
According to the article of "Effect Of Orally Consumed Aloe Vera Juice On Gastrointestinal Function In Normal Humans, excerpts By Jeffrey Bland, Ph.D. (Linus Pauling Institute of Science & Medicine) involved ten healthy subjects - five men (median age: 42; standard deviation: 14 years), and five women (median age: 32; standard deviation: 5 years) - engaged in a semicontrolled Aloe vera juice oral supplementation study protocol., researchers found that The function of Aloe vera juice in promoting, proper gastrointestinal function, based upon the
information from this preliminary study, may be to regulate gastrointestinal pH while improving
gastrointestinal motility, increasing stool specific gravity, and reducing populations of certain fecal micro-organisms, including yeast.
3. Mastic gum
According to the article of Strategies to Protect Against Potential Bone-Destroying Effects"By Chris D. Meletis, ND, the aithor wrote that While much of the research on mastic gum revolves around its ability to support the health of patients with ulcers and its ability to inhibit the bacteria H. pylori, clinically it has been equally useful in patients with GERD and acid reflux.
4. Ginger
Ginger has been used for thousands of years to enhance the function of digestive system and treat stomach distress including nausea, vomiting, diarrhea and in digestion, acid reflux, motion sickness, dyspepsia, etc. due to its due to its anti-inflammatory, antimicrobial and analgesic properties. According to the study of " Ginger (Zingiber officinale Roscoe) and the gingerols inhibit the growth of Cag A+ strains of Helicobacter pylori." by Mahady GB, Pendland SL, Yun GS, Lu ZZ, Stoia A., researchers found that The methanol extract of ginger rhizome inhibited the growth of all 19 strains in vitro with a minimum inhibitory concentration range of 6.25-50 micrograms/ml. One fraction of the crude extract, containing the gingerols, was active and inhibited the growth of all HP strains with an MIC range of 0.78 to 12.5 micrograms/ml and with significant activity against the CagA+ strains.
5. Peppermint
According to the study of A review of the bioactivity and potential health benefits of peppermint tea (Mentha piperita L.)." by McKay DL, Blumberg JB. posted in , researchers wrote that In vitro, peppermint has significant antimicrobial and antiviral activities, strong antioxidant and antitumor actions, and some antiallergenic potential. Animal model studies demonstrate a relaxation effect on gastrointestinal (GI) tissue, analgesic and anesthetic effects in the central and peripheral nervous system... However, human studies of peppermint leaf are limited and clinical trials of peppermint tea are absent. Adverse reactions to peppermint tea have not been reported, although caution has been urged for peppermint oil therapy in patients with GI reflux, hiatal hernia or kidney stones.
6. Etc.
C. Traditional Chinese medicine
a. Ban Xia Xie Xin Wan, also known as "Pinellia Drain Epigastrium Pills" was recorded in classic texts around 210 C.E. Though often referred to as heartburn in classical Chinese medical literature, has been used in TCM to treat various gastrointestinal disorders such as gastritis, enteritis, gastric ulcer, gastralgia. In a study of "The effects of hange-shashin-to on gastric function in comparison with sho-saiko-to." by , , , , researchers suggested that suggest that TJ-14 exhibits an anti-ulcer action (probably based on its ability to protect the gastric mucosa), improvement of gastric emptying and an anti-emetic action. TJ-9 also showed anti-ulcer effects, probably based on its ability to suppress gastric secretion and to protect the gastric mucosa. Thus, the present study demonstrated the effectiveness of TJ-14 and TJ-9 against gastric disease, and provided basic data which explain the differences in clinical application between these two kampo medicines.
b. Ingredients
b.1. Ban Xia (Pinellia Tuber)
Main use: Dries Dampness, Transforms Phlegm, Stops vomiting, Resolves masses, Disperses nodules....
b.2. Huang Qin (Skullcap Root)
Main use: Clears Heat, Dries Dampness, Expels toxins, Stops bleeding...
b.3. Dang Shen (Codonopsis Root)
Main use: Tonifies the Middle Burner, Strengthens Qi, Promotes generation of Body Fluids, Nourishes Blood....
b.4. Gan Cao ( Licorice Root)
Main use: Tonifies the Spleen, Benefits the Qi, Moistens the Lungs, Calms cough...
b.5. Huang Lian (Coptis Rhizome)
Main use: Clears Heat, Dries Dampness, Expels toxins...
b.6. Bai Shao
Main use: Nourishes Blood, Preserves the Yin, Nourishes the Liver, Calms pain....
b.7. Chen Pi
Main use: Regulates the Qi, Regulates the Middle, Dries Dampness, Transforms Phlegm...
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Sources
(a) http://www.ncbi.nlm.nih.gov/pubmed/15588798
(1) http://www.ncbi.nlm.nih.gov/pubmed/16001646
(2) http://www.ncbi.nlm.nih.gov/pubmed/22542157
II. Gastric ulcers
Gastric ulcer, a type of peptic ulcer is defined as a condition of a localized tissue erosion in the lining the stomach.
A. Symptoms
1. Abdominal pain, bloating, septic shock and blood type O positive
In a clinical, retrospective, cross-sectional and descriptive study of patients who were treated at the General Hospital of Mexico with a diagnosis of perforated peptic ulcer from January 2006 to December 2008 of 30 patients with an average age of 57.07 years (± 14.2 years). The male:female ratio was 2:1, found that the risk of developing postoperative complications was 66.7% and is significantly influenced by time of onset of abdominal pain prior to admission, bloating, septic shock and blood type O positive. Mortality was 16.7% and was correlated with the presence of septic shock on admission. The surgical procedure performed was primary closure with Graham patch in 86.6%. Average hospital stay was 12.8 days(1).
2. Dyspepsia
Dyspepsia, may be the first symptom of peptic ulcer disease (an ulcer of the stomach or duodenum), is the medical term for difficult digestion. It consists of various symptoms in the upper abdomen, such as fullness, discomfort, early satiation, bloating, heartburn, belching, nausea, vomiting, or pain. Organic causes of dyspepsia are peptic ulcer, gastroesophageal reflux disease, gastric or esophageal cancer, pancreatic or biliary disorders, intolerance to food or drugs, and other infectious or systemic diseases(2).
3. Blood in stool
As a result of upper gastrointestinal bleeding
4. Nausea and vomiting
there is a report on a 78-year-old female patient, who presented to the emergency department with nausea and vomiting. Investigations: Endoscopy of the upper gastrointestinal tract revealed gastric erosions and duodenal ulcers(3).
5. Bleeding
There is a report of a 50-year-old female was admitted to our hospital with dizziness and tarry stools. Upper gastrointestinal endoscopy revealed bleeding from a gastric ulcer, and endoscopic hemostasis by endoscopic clipping was carried out(4)
5. Unintentional weight loss
Benign gastro-colic fistula is a rare occurrence in modern surgery due to the progress in medical management of gastric ulcer disease. There is a report of an 84-year-old woman of Caucasian background presented with 12 months of worsening abdominal pain, nausea, vomiting, diarrhea and weight loss on a background of known gastric ulcer disease(5).
6. Mood disorders
In the study used data collected in the Canadian Community Health Survey, cycle 3.1 (2005) to examine factors associated with comorbid mood disorders and to assess their association with the quality of life of individuals living in Ontario, indicate that individuals with chronic fatigue syndrome, fibromyalgia, bowel disorder or stomach or intestinal ulcers had the highest rates of mood disorders(6).
7. Etc.
B. Causes and Risk factors
B.1. Causes
1. Imbalance between stomach acid and upper GI tract mucosa
Imbalance between stomach acid is the lead cause of Gastric ulcer is caused by the imbalance between stomach acid and upper GI tract mucosa. Acid-related disorders are common conditions that negatively impact quality of life for a significant number of people nationwide. The pathology of these conditions involves an imbalance between acid secretion by gastric parietal cells and the ability of upper GI tract mucosa to defend against the effects of the acid(7).
2. Medication
Medication such as aapirin and Non-steroidal anti-inflammatory drugs (NSAIDs) may adversely cause damage throughout the gastrointestinal tract and aggravate pre-existing disease. OTC NSAIDs should be taken on a fasting stomach, not with food as commonly advocated. Epidemiological studies show an association between NSAID intake and serious events. Ibuprofen is consistently at the lower end of toxicity rankings, whereas ketorolac and azapropazone are the worst. The risk of bleeding is increased with advancing age, presence of HP, previous history of bleeding, anticoagulant use, etc.(9).
3. Helicobacter pylori and chronic gastritis
Helicobacter pylori is a Gram-negative, microaerophilic bacterium found in the stomach. In developed countries, the prevalence of this infection has decreased, although it continues to be high. The prevalence in Spain is high (50%) and does not seem to be decreasing. There is an increase in antibiotic resistance, which is correlated with the frequency of prior antibiotic prescription. H. pylori eradication improves the symptoms of "epigastric pain syndrome" in functional dyspepsia. The frequency of idiopathic peptic ulcers seems to be increasing(10). Other study indicated that the GU series differed from the controls in having a higher degree of HP colonisation in gastric mucosa. The relative risks (RR) in predicting high GU connected with high HP colonisation were significantly elevated, both in the antrum (RR = 6.0-4.8) and in the corpus (RR 5.0-4.4), and still higher when combined HP colonisation values were used (RR 9.5-7.1). The persistence of active ulcer (GU+) was associated with a very high level of HP colonisation, with absence of corpus atrophic gastritis at the first examination and with young patients. The presence of HP infection as well as the level of HP colonisation are of importance in both the development and chronicity of peptic GU disease(11).
4. Etc.
B.2. Risk factors
1. Periodontal disease
In the analyzed study of the eligible 28 765 subjects, peptic ulcer was present in 397 (1.4%). The results of bivariate analyses showed that a significantly higher proportion of subjects with peptic ulcer reported that they lost five or more teeth (35.3 vs. 17.4%, p<0.001) or that they were told they had periodontitis (33.5 vs. 20.7%, p<0.001)(8).
2. Aging
In the study by Osaka City University Graduate School of Medicine, indicated that he total number of elderly persons with gastric ulcers in Japan is increasing with an improvement in the average life expectancy. So far, gastric ulcer in elderly persons is considered proximal gastric ulcer due to corpus-predominant atrophic gastritis(12).
3. Smoking
In the study by University of Hong Kong found that cigarette smoking increases xanthine oxidase activity, leukotrienes, and nitric oxide production and also neutrophil infiltration in the gastric mucosa. On the other hand, it reduces blood flow, prostaglandin production, epithelial cell proliferation, and formation of blood vessels in the tissue(13).
4. Mechanical ventilation
Mechanical ventilation increases risk for bleeding in the upper part of the gastrointestinal tract. In the study to compare the effectiveness of famotidine (a histamine(2) antagonist) and pantoprazole (a proton pump inhibitor) in preventing stress ulcers in critically ill patients receiving mechanical ventilation, showed that in a total of 522 patients who received famotidine and 95 who received pantoprazole were included. Bleeding in the upper part of the gastrointestinal tract was more common in patients receiving pantoprazole than in patients receiving famotidine (0.38% vs 3.2%, P= .03)(14).
5. Critical illness
Critical illness such as ischemia can lead to back-diffusion of H+ ions through increased membrane permeability. Impaired mucosal buffering then leads to intramural acidosis and cell death(15).
8. Etc.
C. Complications
1. Death
In a study of 701 patients with gastric ulcers admitted to hospital within the period 1955-64, 180 died within a five-year period calculated from the time of admission. Causes of death were established at autopsy in 66%, and otherwise were derived from death certificates. Mortality was significantly higher than expected in both men and women, particularly high in the first year after actual admission, but falling thereafter to about the same level as the expected mortality(16),
2. Peptic ulcer bleeding
Peptic ulcer bleeding is a frequent and dramatic event with both a high mortality rate and a substantial cost for healthcare systems worldwide. It has been found that age is an independent predisposing factor for gastrointestinal bleeding, with the risk increasing significantly in individuals aged>65 years and increasing further in those aged>75 years. Indeed, bleeding incidence and mortality are distinctly higher in elderly patients, especially in those with co-morbidities(17)
3. Perforative hole
In the study of Diagnosis and the results of surgical treatment of perforated gastroduodenal ulcers, showed that the excellent and good long-term results after closure of a perforative hole were noted in 11.7% of the patients, after vagotomy--in 91.6% after gastric resection--in 88%(18).
4. Others
In the study to evaluate their relative risks of ulcer complications between 1984 and 1989, 62 patients with giant ulcers (greater than or equal to 3 cm) and to compare with 476 benign gastric ulcer patients, researchers at the Department of Pharmacology, Ataturk University, showed that giant ulcers are more prone to severe hemorrhage (44% versus 27%; chi 2 test: p less than 0.009) but not more prone to free perforation. Penetration into contiguous organs occurred more frequently with giant gastric ulcers (45% versus 10%; chi 2 test: p less than 0.0001). The risk of the presence of microscopic malignancy in the macroscopically benign-looking giant ulcer is significantly greater than in the nongiant type (13% versus 3%; Fisher's exact test: p = 0.0013(19). Other study of 1470 patients over 65-year-old who were treated for various diseases, 50 had gastric ulcer and 10 had duodenal ulcer. About half the gastric ulcers were located in the body and fundus (n = 24, 48.0%). One third of the patients with gastric or duodenal ulcers had as their chief complaints hematemesis and hematochezia (n = 20, 33.3%), and a greater number had atypical gastrointestinal complaints (general malaise, fever etc, n = 25, 41.7%). Complications of gastric and duodenal ulcers were hematemesis and hematochezia (n = 20, 33.3%), and perforation (n = 2, 3.3%)(20).
D. Preventions
D.1. The do and do not's list
1. Dietary phytosterols and phospholipids
Experiments using animal peptic ulcer models showed that the lipid fraction in foods from the staple diets of low prevalence areas gave protection against both gastric and duodenal ulceration, including ulceration due to non-steroidal anti-inflammatory drugs (NSAIDs), and also promoted healing of ulceration. The protective activity was found to lie in the phospholipid, sterol and sterol ester fractions of the lipid. Amongst individual phospholipids present in the phospholipid fraction, phosphatidyl ethanolamine (cephalin) and phosphatidyl choline (Lecithin) predominated. The sterol fraction showing activity contained β-sitosterol, stigmasterol and an unidentified isomer of β-sitosterol. The evidence shows that dietary phytosterols and phospholipids, both individually and in combination, have a protective effect on gastroduodenal mucosa. These findings may prove to be important in the prevention and management of duodenal and gastric ulceration including ulceration due to NSAIDs(21).
2. Reduce intake of NSAID
As NSAID has been proven to cause gastric Ulcer(9), by by inhibiting the body's production of prostaglandins, hormones that protect the stomach lining.
3. Smoking
Cigarette smoking increases xanthine oxidase activity, leukotrienes, and nitric oxide production and also neutrophil infiltration in the gastric mucosa(13).
4. Don't miss your dental appoinment
Study showed that a significantly higher proportion of subjects with peptic ulcer reported that they lost five or more teeth (35.3 vs. 17.4%, p<0.001) or that they were told they had periodontitis (33.5 vs. 20.7%, p<0.001)(8).
5. Reduce stress
In t5he study to investigate Peptic ulcers after the Great East Japan earthquake and tsunami: possible existence of psychosocial stress ulcers in humans, showed that the incidence of all types of peptic ulcers was 1.5-fold increased after the earthquake, and in particular, the incidence of hemorrhagic ulcers was 2.2-fold increased; the gastric ulcer/duodenal ulcer ratio in hemorrhagic ulcers was also significantly increased (p < 0.05). Regarding the etiology of the peptic ulcers, the proportion of non-H. pylori and non-NSAID ulcers was significantly increased, from 13 % in 2010 to 24 % in 2011 after the earthquake (p < 0.05)(22).
6. Excessive hard liquor drinking can damage the lining of stomach and worsen ulcers and aggravate pain.
7. According to the article of Good Foods / Bad Foods For Peptic Ulcers By Sharon Gillson, she suggested the below
- Restrict or avoid those foods that may cause irritation to the digestive system
- Reduce excessive acid production
- Prevent unpleasant side effects, such as heartburn.
- Eat 5 to 6 small meals a day instead of 3 larger meals. It is important that you avoid overeating. Frequent, smaller meals will be more comfortable and easier on the stomach than two or three large meals a day.
- Eat a diet rich in fiber, especially from fruits and vegetables
- Rest and relax a few minutes before and after each meal, as well as remaining relaxed during meals.
- Eat slowly and chew you food well
- Avoid eating within 3 hours before bedtime
- Eat foods that are low fat
- Avoid foods that are fried
- Avoid foods that are spicy
- Cut down on the following foods:
- Coffee
- Decaffeinated coffee
- Tea
- Cola drinks
- Carbonated beverages
- Citrus fruits
- Tomato-based products
- Chocolate(23)
1. Honey
In the study of Gastric ulceration was induced using 1.5ml acid-alcohol prepared from equivolume of 0.1NHCl and 70% methanol introduced into the stomach via a portex cannula tied and left in place following an incision made on the antral-pyloric junction of the stomach, showed that honey significantly reduced ulcer scores as well as caused scanty haemorrhage in the test group compared with increased ulcer scores and multiple haemorrhage in the control group. It is therefore concluded that honey intake offered cytoprotection on the gastric mucosa of albino rats23).
2. Apple
In the study to investigate whether apple polyphenol extract (APE) reduced aspirin-induced injury to the rat gastric mucosa, showed that APE reduced aspirin-induced mRNA and protein over-expression of COX-2 and HB-EGF; aspirin significantly increased gastric MDA and this effect was counteracted by APE pre-treatment. APE did not significantly affect gastric acid secretion. In conclusion, APE reduces aspirin-induced gastric injury independently of acid inhibition. We speculate that APE might be of therapeutic use in the prophylaxis of aspirin-related gastropathy(24).
3. Probiotics
Helicobacter pylori infection, a highly prevalent pathogen, is a major cause of chronic gastritis and peptic ulcer and a risk factor for gastric malignancies. Animal studies demonstrated that probiotic treatment is effective in reducing H. pylori-associated gastric inflammation. Seven of 9 human studies showed an improvement of H. pylori gastritis and decrease in H. pylori density after administration of probiotics. The addition of probiotics to standard antibiotic treatment improved H. pylori eradication rates (81% vs. 71%, with combination treatment vs. H. pylori-eradication treatment alone; chi(2)test: P=0.03). Probiotic treatment reduced H. pylori therapy-associated side effects (incidence of side effects: 23% vs. 46%, with combination therapy vs. H. pylori-eradication treatment alone; chi(2)test: P=0.04)(25).
4. Oat
Oat has been chosen as a substrate for fermentation because it contains 100 times more of membrane lipids (surfactants) than any other food, has a favorable amino acid pattern (rich in glutamine), and is rich in water-soluble, fermentable-fiber beta-glucans. More than 1000 isolates of human-specific lactobacilli have been studied. Some strains, especially those of plantarum type, have proven effective in colonizing the colonic mucosa, suppressing the potentially pathogenetic flora, and may have other probiotic effects as well(26).
5. Onion
According to the study by The National Onion Association, Onions functions as an antioxidant, deactivating molecules that are injurious to cells inthe body. Research studies have shown quercetin to promote healing of stomach ulcers(27)
D.3. Phytochemcals to prevent gastric ulcer
Plants and phytoconstituents are better choice to treat diseases than the allopathic drugs. Most of the drugs used in primitive medicine were originated from plants and are the earliest and principal natural source of medicines. The drugs from plants are fairly innocuous and relatively free from toxic effects(28).
1. Fructans
Fructans found abundantly in onion, are small carbohydrate molecules that help maintain gastrointestinal health by sustaining beneficial bacteria(27).
2. Phenols
Polyphenols display a number of pharmacological properties in the GIT area, acting as antisecretory, cytoprotective, and antioxidant agents. The antioxidant properties of phenolic compounds have been widely studied, but it has become clear that their mechanisms of action go beyond the modulation of oxidative stress. Various polyphenolic compounds have been reported for their anti-ulcerogenic activity with a good level of gastric protection(29). Other indicated that the antimicrobial activity was greater in extract mixtures than in individual extracts of each species. The results also indicate that the synergistic contribution of oregano and cranberry phenolics may be more important for inhibition than any species-specific phenolic concentration(30).
3. Anthocyanins
Edible berries, a potential source of natural anthocyanin antioxidants, have demonstrated a broad spectrum of biomedical functions. In the study by InterHealth Research Center, showed that OptiBerry exhibits high antioxidant efficacy as shown by its high oxygen radical absorbance capacity (ORAC) values, novel antiangiogenic and antiatherosclerotic activities, and potential cytotoxicity towards Helicobacter pylori, a noxious pathogen responsible for various gastrointestinal disorders including duodenal ulcer and gastric cancer, as compared to individual berry extracts. OptiBerry also significantly inhibited basal MCP-1 and inducible NF-kappabeta transcriptions as well as the inflammatory biomarker IL-8, and significantly reduced the ability to form hemangioma and markedly decreased EOMA cell-induced tumor growth in an in vivo model(31).
4. Triterpenes
In study of the extracted isolation of Eugenia umbelliflora Berg. (Myrtaceae): taraxerol, alpha-amyrin, beta-amyrin, betulin and betulinic acid from the leaves, as well as trimethoxy ellagic acid from the fruitshe extracts of Eugenia umbelliflora Berg. (Myrtaceae), found that E. umbelliflora leaves display gastro-protective activity, as demonstrated by significant inhibition of ulcer formation in the different models. The results suggest that the gastroprotective activity may be attributed, at least in part, to the triterpenes(32).
5. Oleuropein
In the study to assess the antioxidant abilities of oleuropein in comparison with ranitidine in ethanol-induced gastric damages via evaluation of ulcer index inhibition, antioxidant enzyme activities, and lipid peroxidation level, found that oleuropein has beneficial antioxidant properties against ethanol-induced gastric damages in the rat. Therefore, it seems that a combination regimen including both antioxidant and antisecretory drugs may be beneficial in prevention of ethanol-mediated gastric mucosal damages(33).
6. Etc.
F. Diagnosis
If you are experience the symptoms of gastric ulcer as mentioned above, a complete physical examination (rectal exam) and and medical (weight loss or fatigue, present and past medication use including chronic use of NSAID) and family history( If your family has a history of gastric ulcer) should be recorded to rule out other diseases with the same symptoms (Gallstones, heart condiction, GERB, etc.)
F1. Non invasive testing
1. Blood test (Complete blood count)
The aim of the test is to check for the abnormally high or low counts which may be an indication of infection
2. Fecal occult blood test (FOBT)
This is a test tocheck for hidden (occult) blood in the stool (feces) with an aim to detect subtle blood loss in the gastrointestinal tract,
3. Screen for Helicobacter pylori test
If your doctor suspects that you have gastric ulcer due to infection, screen for Helicobacter pylori test may be ordered, including Blood antibody test, Stool antigen test, Urea breath test, etc.)
4. Endoscopy
Endoscopy is a procedure for your doctor look inside your body with an endoscope, (a long, thin tube equipped with a tiny video camera) to detect any abnormality including the presence of peptic ulcers, bleeding, stomach cancer, etc.
5. Biopsy
In biopsy, a sampling of tissues is withdrawn for examination.
6. Etc.
F. Treatments
F1. In conventional medicine perspective
1. Antibiotics
Antibiotics for gastric ulcer caused by H. pylori. Unfortunately, monoresistant strains were prevalent with rates of 89% for metronidazole, 36% for clarithromycin, 37% for amoxicillin, 18.5% for ofloxacin and 12% for tetracycline. Furthermore, clarithromycin resistance was on the rise from 2005 to 2008 (32% vs 38%, P = 0.004) and it is significantly observed in non ulcerative dyspeptic patients compared to gastritis, gastric ulcer and duodenal ulcer cases (53% vs 20%, 18% and 19%, P = 0.000). On the contrary, metronidazole and ofloxacin resistance were more common in gastritis and gastric ulcer cases. Distribution analysis and frequencies of resistant mutants in vitro correlated with the absence of cagA gene with metronidazole and ofloxacin resistance, according to the study to determine antibiotic resistance of Helicobacter pylori (H. pylori) in Pakistan and its correlation with host and pathogen associated factors(34).
2. Sequential therapy
In the study to compare the effectiveness of sequential therapy for Helicobacter pylori (H. pylori) infection with that of triple therapy of varying durations, showed that he overall eradication rate was 81.0%, and eradication rates were 75.7% for 7-d conventional triple therapy, 81.9% for 10-d conventional triple therapy, 84.4% for 14-d conventional triple therapy, and 82.0% for 10-d sequential therapy. Neither intention-to-treat analysis nor per protocol analysis showed significant differences in eradication rates using sequential therapy or the standard triple therapy (P = 0.416 and P = 0.405, respectively)(35).
3. Endoscopy
Endoscopy in most cases is used to control ulcer bleeding, but according to the study of evaluation in a retrospective manner by reviewing all gastric ulcers that were followed with serial endoscopy and all gastric cancers diagnosed at the University of Alabama at Birmingham, found that if either the endoscopic impression or the biopsy and cytology is suspicious for malignancy, then follow-up endoscopy until healing should be done. On the other hand, if, at the initial examination, the ulcer appears benign and biopsy plus cytology are negative, then serial endoscopy has a low benefit relative to its cost(36).
4. Probiotic therapy
In the study to investigate the influence of fungal colonization and probiotic treatment on the course of gastric ulcer (GU) and ulcerative colitis (UC), showed that
1) Fungal colonization delays process of ulcer and inflammation healing of GI tract mucosa. That effect was attenuated by probiotic therapy.
2) Probiotic therapy seems to be effective in treatment of fungal colonization of GI tract.
3) Lactobacillus acidophilus therapy shortens the duration of fungal colonization of mucosa (enhanced Candida clearance is associated with IL-4, INF-gamma response)(37).
3. Surgery
Surgery will always be the last resources in treating gastric ulcer, and only be performed if patients do not respond to medicines or endoscopy
1.Vagotomy
The aim of the surgery is to control the secretion of stomach acid by cutting of the vagus nerve.
2. Pyloroplasty
Pyloroplasty is a surgical procedure to widen the opening in the lower part of the stomach (pylorus), allowing stomach contents to empty more quickly into the intestine.
3. Partial gastrectomy
Partial gastrectomy is a surgical procedure in the removal part of the stomach.
But according to the Progress report in Vagotomy for gastric ulcer, Vagotomy and pyloroplasty has not yet been established as a routine treatment for all gastric ulcers. The attraction of a potentially lower mortality rate, especially when high lesser curve ulcers have to betreated by surgeons not widely experienced in gastric resection, cannot be gainsaid. However, an ulcer in this situation gives rise to technical difficulties if it has to be exposed through a separate gastrotomy incision, to permit a full inspection and an adequate biopsy. The lower morbidity of vagotomy and pyloroplasty has to be balanced against the two factors: first, recurrent
ulceration is not less than after Billroth I gastrectomy and may be more: secondly, the risk of leaving a gastric cancer in situ. This small, but definite, risk must be avoided. The surgeon must ensure that this operative diagnosis is correct. Short of excision of the ulcer, this requires a biopsy of all the edge
of the lesion and not just of four quadrants. The results reported to date do not justify the abandonment of partial gastrectomy in the treatment of benign gastric ulcer(38).
F,2, In Herbal medicine perspective
Despite a number of reports on the toxicity of herbs and spices, they are generally accepted as safer alternatives to conventional therapy against gastric ulcers. But excessive consumption of spices may favor the pathogenesis of gastric and duodenal ulcer and some studies have substantiated this common perception(39).
1. Korean red ginseng
In the study to assess the effects of a KRG-containing drug (KRGCD) on gastric ulcer models in mice, found that KRGCD (100 and 300 mg/kg, p.o.) significantly decreased ethanol- and indomethacin-induced gastric ulcer compared with the vehicle-treated (control) group. KRGCD (100 and 300 mg/kg) also decreased the level of thiobarbituric acid reactive substance (TBARS) and increased gastric mucosal blood flow compared with the control group(40).
2. Alchornea triplinervia
Alchornea triplinervia is a medicinal plant commonly used by people living in the Cerrado region of Brazil to treat gastrointestinal ulcers. According to the study by Departamentos de Fisiologia, São Paulo State University, ME displayed antibacterial activity against H. pylori. Liquid-liquid separation of ME indicated that active constituents responsible for the gastroprotective action are concentrated in the ethyl acetate fraction (EAF) (50% protection) rather than in the aqueous fraction, which did not induce significant gastroprotection at the same dose (100 mg/kg). EAF induced an increase of gastric mucosa prostaglandin (PG) E(2) levels, which remained high even after previous administration of indomethacin. The phytochemical profile of ME revealed that EAF contains mainly flavonoids. In conclusion, all these results suggest that ME did not show acute toxicity, but exhibited an antisecretory property, anti-H. pylori effect, and gastroprotective action(41).
3. Davilla elliptica and Davilla nitida
Davilla elliptica and Davilla nitida are species commonly found in the Brazilian Cerrado biome. In the study to evaluate the gastroprotective action of both extracts in rodent experimental models (HCl/ethanol, ethanol or NSAID), researchers at the São Paulo State University, found that EDE and EDN (500 mg/kg) were able to protect gastric mucosa against HCl/ethanol solution (EDE 63%; EDN 59%), absolute ethanol (EDE 95%; EDN 88%), and also against injurious effect of NSAID (EDE 77%; EDN 67%). When EDE and EDN were challenged with sulfhydryl depleter compound, the gastroprotective action of both extracts was completely abolished. EDE had gastroprotective effect related to increase of glutathione bioavailability and stimulated higher levels of NO, H2O2 and TNF-alpha production(42).
4. Oxalis corniculata
In the study to investigate the antiulcer activity of methanol extract of Oxalis corniculata (whole plant) using pylorus ligation and indomethacin-induced gastric ulceration in Wistar rats, found that pretreatment of test extract significantly (p<0.05) decreased the gastric volume, total acidity, free acidity and increase in the pH of the gastric fluid in pylorus-ligated rats. It also showed significant (p<0.05) decrease in number of ulcers, ulcers score and ulcer index in pylorus ligated and indomethacin treated rats(43).
5. Cedrus deodara (Roxb.) Loud
Cedrus deodara (Roxb.) Loud. is used in Ayurvedic medicine to treat peptic ulcer. In the study to evaluate the gastric antisecretory and antiulcer activity of Cedrus deodara, researchers at the Shobhit University, showed that he volatile oil showed significant antisecretory activity as evidenced by decreased gastric fluid volume, total acidity, free acidity and increase in the pH of the gastric fluid in pylorus-ligated rats. Pretreatment with Cedrus deodara significantly reduced the number of ulcer, ulcer score and ulcer index in pylorus-ligated and ethanol treated rats. The antiulcer activity of Cedrus deodara is further supported by histopathological study which showed protection of mucosal layer from ulceration and inflammation(44).
6. Hyptis spicigera Lam. (Lamiaceae)
Hyptis Jacq. (Lamiaceae) is being used in traditional medicine to treat fever, inflammation and gastric disturbances. Hyptis spicigera Lam. is a native plant distributed across the central region of Brazil. In the study to assess the effects of the essential oil obtained from the aerial parts of Hyptis spicigera (OEH) for their gastroprotective and healing activities, showed that the efficacy and safety of Hyptis spicigera in combating and healing gastric ulcer. Considering the results, it is suggested that the OEH could probably be a good therapeutic agent for the development of new phytotherapeutic medicine for the treatment of gastric ulcer(45).
7. Achyrocline satureoides (Lam.) DC (Asteraceae) (Marcela)
In the study to evaluate and contribute to validating the antiulcer activity of hydroalcoholic extract of inflorescences of Achyrocline satureoides, found that hydroalcoholic extract of Achyrocline satureoides displays antiulcer activity, as demonstrated by the significant inhibition of the formation of ulcers induced using different models. However, this activity appears not be related to the antisecretor mechanisms. Moreover, this work suggests that preparations obtained from Achyrocline satureoides could be used for the development of new phytotherapic drugs for the treatment of gastric ulcer(46).
8. Etc.
F.3. In traditional Chinese medicine perspective
1. Acupuncture and moxibustion
Chief physician YANG Mei-liang is a famous doctor of TCM in China. He emphasizes general diagnosis and treatment, and he is good at applying spleen and stomach theory to clinical acupuncture and moxibustion treatment, accurate and proper prescription association and acupoint selection, so as to attain multi-effects of one acupoint, and special and strong results. His unique treatment style achieves excellent effect in treatment. The present paper introduces YANG's clinical successful samples in acupuncture and moxibustion treatment of insomnia, ophthalmopathy, intestinal obstruction, gastric ulcer, metrorrhagia and metrostaxis, etc(47).
2. Adlay seeds
Adlay (Coix lachryma-jobi L. var. ma-yuen Stapf) seeds have long been used to treat warts, chapped skin, rheumatism, and neuralgia in traditional Chinese medicine (TCM). According to th study by National Taiwan University, ABE showed better antiproliferative activity, and 19 compounds were purified from AB in a further phenolic-compound-guided separation. Among the isolated compounds, caffeic and chlorogenic acids significantly suppressed the growth of AGS cells. In addition, the antiulcer activity of DA was examined in an indomethacin-induced gastric lesion model. The ulcer index (UI) and oxidative biomarkers in animals decreased, while the non-protein sulfhydryl (NPSH) groups were elevated when given DA(48).
3. Qifang Weitong Powder and omeprazole
In the study to observe the histological changes of gastric mucosa in patients with active gastric ulcer before and after treatment by Qifang Weitong Powder combined with omeprazole (QWP-Op), showed that QWP-Op therapy can improve the histological quality of ulcer healing and restore the morphological structure of gastric mucosa in patients with active gastric ulcer(49).
4. Kangyanling and Omeprazole
The study of the curative effects of combined therapy with Kangyanling (KYL, a Chinese herbal preparation) and Omeprazole on post-burn digestive dysfunction, including 18 with acute stress gastrointestinal mucosal hemorrhagic lesion and 14 with toxic enteroparalysis, were treated by KYL plus Omeprazole, and the 20 patients in the control group, 11 with acute stress gastrointestinal mucosal hemorrhagic lesion and 9 with toxic enteroparalysis were treated with Omeprazole alone, showed that the pH value in gastric mucosa of both groups before therapy were all lower than the normal range, it raised after treatment in the treated group (P < 0.05), approaching to the normal range, but with no significant change in the control group. The total hemostatic rate and the anti-paralysis rate was 77.8% and 85.7% respectively in the treated group, and 45.5% and 0% in the control group, all shown statistical significance between groups (P < 0.05)(50).
5. Jian pi qing re hua yu recipe
In the study to investigate the effects of Jianpi Qingre Huayu Recipe in curing gastric ulcer and to preliminarily probe into its pathogenic mechanism, including fifty patients with gastric ulcer of Pi -insufficiency and stasis-heat syndrome type were assigned to the treated group (30 patients) and the control group (20 patients). showed that Comparison of the total effective rate on gastroscopic figure in the treated group and the control group (86.7% vs 80.0%) showed insignificant difference, but the cure rate and markedly effective rate in the former (50.0% and 20.0%) was higher than that in the latter (40.0% and 15.0%) respectively. Comparison of the total effective rate on TCM syndrome in the treated group and in the control group (96.7% vs 70.0%) showed insignificant difference, but the cure rate and markedly effective rate in the former (63.3% and 23.3%) was higher than that in the latter (50.0% and 20.0%) respectively. Serum levels of CD3+, CD4+, CD8+ got restored to normal range in the treated group after treatment but it was not so in the control group. IL-8 level in gastric mucosa was improved in both groups but the improvement in the treated group was better(51).
6. Jianwei Yuyang Granule
According to the study by Institute of Integrative Traditional Chinese and Western Medicine, Xiangya Hospital of Central South University, indicated that JYG, with its good clinical compliance, has favorable effects in relieving clinical symptoms, promoting endoscopic ulcer healing and HP clearance, decreasing the expression of IL-1beta mRNA and increasing the expression of bFGF, therefore, it could promote the recovering of gastric ulcer(52).
7. Other Chinese herbs include Abrus cantoniensis (Fabaceae), Saussurea lappa (Asteraceae) and Eugenia caryophyllata (Myrtaceae) were strongly inhibitory to all test strains (MICs: approximately 40 microg/ml), and Hippophae rhamnoides (Elaeagnaceae), Fritillaria thunbergii (Liliaceae), Magnolia officinalis and Schisandra chinensis (Magnoliaceae), Corydalis yanhusuo (Papaveraceae), Citrus reticulata (Rutaceae), Bupleurum chinense and Ligusticum chuanxiong (Apiaceae)(53).
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C. Duodenal ulcers
Duodenal ulcers, a type of peptic ulcer is defined as a condition of a localized tissue erosion in the lining the duodenum as a result of bacteria Helicobacter pylori (H pylori) in most cases. According to the study by Department of Research, University Hospital, Basel, fasting gastrin and pepsinogen-I and -II concentrations were significantly higher in H pylori positive compared with H pylori negative subjects. Neither age nor sex affected basal gastrin and pepsinogen concentrations in H pylori negative subjects. Fasting gastrin, pepsinogen-I and -II concentrations in serum samples were similar in H pylori positive persons with no symptoms and those with duodenal ulcers suggesting that similar mechanisms are involved in increasing plasma concentrations of these variables in both populations. Hypergastrinaemia and hyperpepsinogenaemia are therefore probably secondary to active H pylori infection(1).
A. Symptoms
1. Dyspepsia
Dyspepsia, may be the first symptom of peptic ulcer disease (an ulcer of the stomach or duodenum), is defined by persistence of pain, burning or discomfort localised to the upper abdomen; some authors include in dyspepsia symptoms such as belching, bloating, alitosis, nausea, postprandial repletion, vomiting and regurgitation, etc. as a result of the infection of Helicobacter pylori (Hp)(2).
2. Functional disorders
Functional disorders mainly occur in young, anxious hyperactive, sometimes obsessional patients and involve all parts of digestive tract: feeling of obstruction the upper oesophagus or dysphagia; aerophagia related to a slow gastric emptying or gastric fullness relieved by eructation. Although psychologic profiles have been associated with gastro-duodenal ulcer, these are not necessary for the development of the disease(3).
3. Loss of appetite
It may be result of slow gastric emptying.
4. Unexplained weight loss
It nay be cause by malnutrition due to Upper gastrointestinal disorders.
6. Bloody stool (blood may be red, black)
The color of blood depends to the location of bleeding
7. Vomiting blood
As a result of upper gastrointestinal bleeding
8. Etc.
B. Causes and Risk factors
B.1. Causes
1. Congenital causes
There is a report of seven cases of congenital anomalies in adults, duodenal obstruction and peptic ulcer disease developed. There were two cases of congenital duodenal web, two of hypertrophic pyloric stenosis, two of annular pancreas,according to the study by Dr. Naylor RG and Dr. Juler GL Fortunately, treatment should be directed toward relief of the duodenal obstruction and the reduction of basal acid secretion by truncal vagotomy in all such cases(4).
2. Inflammation
In the study of the causes of the incompetence of stump sutures in resection of the stomach observed in 90 out of 3479 patients with chronic duodenal ulcers, showed that most patients have a combination of general and local factors. Among the local factors the leading one was appearance of a large inflammatory infiltration around the "active" ulcers(5).
3. Medication
Medication such as aapirin and Non-steroidal anti-inflammatory drugs (NSAIDs) may adversely cause damage throughout the gastrointestinal tract and aggravate pre-existing disease. OTC NSAIDs should be taken on a fasting stomach, not with food as commonly advocated. Epidemiological studies show an association between NSAID intake and serious events. Ibuprofen is consistently at the lower end of toxicity rankings, whereas ketorolac and azapropazone are the worst. The risk of bleeding is increased with advancing age, presence of HP, previous history of bleeding, anticoagulant use, etc.(6).
4. Helicobacter pylori and chronic gastritis
Helicobacter pylori is a Gram-negative, microaerophilic bacterium found in the stomach. In developed countries, the prevalence of this infection has decreased, although it continues to be high. The prevalence in Spain is high (50%) and does not seem to be decreasing. There is an increase in antibiotic resistance, which is correlated with the frequency of prior antibiotic prescription. H. pylori eradication improves the symptoms of "epigastric pain syndrome" in functional dyspepsia. The frequency of idiopathic peptic ulcers seems to be increasing(7). Other study indicated that the GU series differed from the controls in having a higher degree of HP colonisation in gastric mucosa. The relative risks (RR) in predicting high GU connected with high HP colonisation were significantly elevated, both in the antrum (RR = 6.0-4.8) and in the corpus (RR 5.0-4.4), and still higher when combined HP colonisation values were used (RR 9.5-7.1). The persistence of active ulcer (GU+) was associated with a very high level of HP colonisation, with absence of corpus atrophic gastritis at the first examination and with young patients. The presence of HP infection as well as the level of HP colonisation are of importance in both the development and chronicity of peptic GU disease(8).
5. Etc.
B.2. Risk factors
1. Psychosomatic factors
Life stress may modulate these impulses and in this way cause two types of gastrointestinal reactions. Psychophysiological reactions involve accentuations, inhibition or distortion of the pattern of function of gastrointestinal organs without changes in their structure. Psychosomatic reactions lead to morphological changes in the end organ, e.g. activation of peptic ulcer or ulcerative colitis(9).
2. Genetic predisposition, incorrect diet and unbalanced lifestyle, e.g. increased stress level, cigarette smoking
According to the study of The origins of gastric hyperacidity, gastric and duodenal ulcer appearance includes genetic predisposition, incorrect diet and unbalanced lifestyle, e.g. increased stress level, cigarette smoking(10).
3. Mechanical ventilation
Mechanical ventilation increases risk for bleeding in the upper part of the gastrointestinal tract. In the study to compare the effectiveness of famotidine (a histamine(2) antagonist) and pantoprazole (a proton pump inhibitor) in preventing stress ulcers in critically ill patients receiving mechanical ventilation, showed that in a total of 522 patients who received famotidine and 95 who received pantoprazole were included. Bleeding in the upper part of the gastrointestinal tract was more common in patients receiving pantoprazole than in patients receiving famotidine (0.38% vs 3.2%, P= .03)(11).
4. Excessive Alcohol drinking
Too much alcohol can irritate and erode the mucous lining of your stomach, in some case prolonged period of excessive drinking can cause upper gastrointestinal bleeding, if damage of stomach limning is left untreated.
5. Etc.
C. Complications
1. Peptic ulcer bleeding
Peptic ulcer bleeding is a frequent and dramatic event with both a high mortality rate and a substantial cost for healthcare systems worldwide. It has been found that age is an independent predisposing factor for gastrointestinal bleeding, with the risk increasing significantly in individuals aged>65 years and increasing further in those aged>75 years. Indeed, bleeding incidence and mortality are distinctly higher in elderly patients, especially in those with co-morbidities(12).
2. Perforative hole
In the study of Diagnosis and the results of surgical treatment of perforated gastroduodenal ulcers, showed that the excellent and good long-term results after closure of a perforative hole were noted in 11.7% of the patients, after vagotomy--in 91.6% after gastric resection--in 88%(13). Other indicated that
Complications of gastric and duodenal ulcers were hematemesis and hematochezia (n = 20, 33.3%), and perforation (n = 2, 3.3%)(14).
3. Ulcer scars
Scar tissue produced by peptic ulcers can block passage of food through the digestive tract. There is a study of 181 patients with a gastroduodenal ulcer or ulcer scar (102 with a gastric lesion, 60 with a duodenal lesion, and 19 with both sites involved), specimens were cultured for H. pylori and TTV infection was sought in serum by a polymerase chain reaction(15).
4. Etc.
D. Preventions
D.1. The do and do not's list
1. Dietary phytosterols and phospholipids
Experiments using animal peptic ulcer models showed that the lipid fraction in foods from the staple diets of low prevalence areas gave protection against both gastric and duodenal ulceration, including ulceration due to non-steroidal anti-inflammatory drugs (NSAIDs), and also promoted healing of ulceration. The protective activity was found to lie in the phospholipid, sterol and sterol ester fractions of the lipid. Amongst individual phospholipids present in the phospholipid fraction, phosphatidyl ethanolamine (cephalin) and phosphatidyl choline (Lecithin) predominated. The sterol fraction showing activity contained β-sitosterol, stigmasterol and an unidentified isomer of β-sitosterol. The evidence shows that dietary phytosterols and phospholipids, both individually and in combination, have a protective effect on gastroduodenal mucosa. These findings may prove to be important in the prevention and management of duodenal and gastric ulceration including ulceration due to NSAIDs(16).
2. Reduce stress
In t5he study to investigate Peptic ulcers after the Great East Japan earthquake and tsunami: possible existence of psychosocial stress ulcers in humans, showed that the incidence of all types of peptic ulcers was 1.5-fold increased after the earthquake, and in particular, the incidence of hemorrhagic ulcers was 2.2-fold increased; the gastric ulcer/duodenal ulcer ratio in hemorrhagic ulcers was also significantly increased (p < 0.05). Regarding the etiology of the peptic ulcers, the proportion of non-H. pylori and non-NSAID ulcers was significantly increased, from 13 % in 2010 to 24 % in 2011 after the earthquake (p < 0.05)(17).
3. Quit smoking and reduced intake of alcohol
As cigarette smoking and excessive alcohol drinking can cause damage to the stomach lining of that can lead peptic ulcer.
4. Others, According to the article of Good Foods / Bad Foods For Peptic Ulcers By Sharon Gillson, she suggested the below
- Restrict or avoid those foods that may cause irritation to the digestive system
- Reduce excessive acid production
- Prevent unpleasant side effects, such as heartburn.
- Eat 5 to 6 small meals a day instead of 3 larger meals. It is important that you avoid overeating. Frequent, smaller meals will be more comfortable and easier on the stomach than two or three large meals a day.
- Eat a diet rich in fiber, especially from fruits and vegetables
- Rest and relax a few minutes before and after each meal, as well as remaining relaxed during meals.
- Eat slowly and chew you food well
- Avoid eating within 3 hours before bedtime
- Eat foods that are low fat
- Avoid foods that are fried
- Avoid foods that are spicy
- Cut down on the following foods:
- Coffee
- Decaffeinated coffee
- Tea
- Cola drinks
- Carbonated beverages
- Citrus fruits
- Tomato-based products
- Chocolate(17)
1. Honey
In the study to assess the antibacterial potential of various brands of honey sold in Muscat area on some isolates of H. pylori and to determine if there is any synergy between honey and amoxycillin or clarithromycin used in the treatment of H. pylori gastritis and duodenal ulcer, found that all honey samples produced growth inhibition zones with H. pylori no at dilution of honey but had different zone sizes at 1:2-1:8 dilutions. Black Forest honey had the highest antibacterial activity followed by Langnese honey. None of the honeys had a synergistic effect with either clarithromycin or amoxycillin(
D.3. Phytochemicals to prevent Duodenal ulcers(18).
2. Probiotics
Helicobacter pylori infection, a highly prevalent pathogen, is a major cause of chronic gastritis and peptic ulcer and a risk factor for gastric malignancies. Animal studies demonstrated that probiotic treatment is effective in reducing H. pylori-associated gastric inflammation. Seven of 9 human studies showed an improvement of H. pylori gastritis and decrease in H. pylori density after administration of probiotics. The addition of probiotics to standard antibiotic treatment improved H. pylori eradication rates (81% vs. 71%, with combination treatment vs. H. pylori-eradication treatment alone; chi(2)test: P=0.03). Probiotic treatment reduced H. pylori therapy-associated side effects (incidence of side effects: 23% vs. 46%, with combination therapy vs. H. pylori-eradication treatment alone; chi(2)test: P=0.04)(19).
3. Oat
Oat has been chosen as a substrate for fermentation because it contains 100 times more of membrane lipids (surfactants) than any other food, has a favorable amino acid pattern (rich in glutamine), and is rich in water-soluble, fermentable-fiber beta-glucans. More than 1000 isolates of human-specific lactobacilli have been studied. Some strains, especially those of plantarum type, have proven effective in colonizing the colonic mucosa, suppressing the potentially pathogenetic flora, and may have other probiotic effects as well(20).
4. Onion
According to the study by The National Onion Association, Onions functions as an antioxidant, deactivating molecules that are injurious to cells inthe body. Research studies have shown quercetin to promote healing of stomach ulcers(21).
5. Etc.
D.3. Phytochemicals to prevent Duodenal ulcers
Plants and phytoconstituents are the better choice to treat diseases than the allopathic drugs. Most of the drugs used in primitive medicine were originated from plants and are the earliest and principal natural source of medicines. The drugs from plants are fairly innocuous and relatively free from toxic effects(22).
1. Fructans
Fructans found abundantly in onion, are small carbohydrate molecules that help maintain gastrointestinal health by sustaining beneficial bacteria(23).
2. Phenols
Polyphenols display a number of pharmacological properties in the GIT area, acting as antisecretory, cytoprotective, and antioxidant agents. The antioxidant properties of phenolic compounds have been widely studied, but it has become clear that their mechanisms of action go beyond the modulation of oxidative stress. Various polyphenolic compounds have been reported for their anti-ulcerogenic activity with a good level of gastric protection(24). Other indicated that the antimicrobial activity was greater in extract mixtures than in individual extracts of each species. The results also indicate that the synergistic contribution of oregano and cranberry phenolics may be more important for inhibition than any species-specific phenolic concentration(25).
3. Anthocyanins
Edible berries, a potential source of natural anthocyanin antioxidants, have demonstrated a broad spectrum of biomedical functions. In the study by InterHealth Research Center, showed that OptiBerry exhibits high antioxidant efficacy as shown by its high oxygen radical absorbance capacity (ORAC) values, novel antiangiogenic and antiatherosclerotic activities, and potential cytotoxicity towards Helicobacter pylori, a noxious pathogen responsible for various gastrointestinal disorders including duodenal ulcer and gastric cancer, as compared to individual berry extracts. OptiBerry also significantly inhibited basal MCP-1 and inducible NF-kappabeta transcriptions as well as the inflammatory biomarker IL-8, and significantly reduced the ability to form hemangioma and markedly decreased EOMA cell-induced tumor growth in an in vivo model(26).
4. Triterpenes
In study of the extracted isolation of Eugenia umbelliflora Berg. (Myrtaceae): taraxerol, alpha-amyrin, beta-amyrin, betulin and betulinic acid from the leaves, as well as trimethoxy ellagic acid from the fruitshe extracts of Eugenia umbelliflora Berg. (Myrtaceae), found that E. umbelliflora leaves display gastro-protective activity, as demonstrated by significant inhibition of ulcer formation in the different models. The results suggest that the gastroprotective activity may be attributed, at least in part, to the triterpenes(27).
5. Etc.
E. Diagnosis
If you are experience the symptoms of Duodenal ulcers as mentioned above, a complete physical examination (rectal exam) and and medical (weight loss or fatigue, present and past medication use including chronic use of NSAID) and family history( If your family has a history of Duodenal ulcers) should be recorded to rule out other diseases with the same symptoms (Gallstones, heart condiction, GERB, etc.)
F1. Non invasive testing
1. Blood test (Complete blood count)
The aim of the test is to check for the abnormally high or low counts which may be an indication of infection
2. Fecal occult blood test (FOBT)
This is a test tocheck for hidden (occult) blood in the stool (feces) with an aim to detect subtle blood loss in the gastrointestinal tract,
3. Screen for Helicobacter pylori test
If your doctor suspects that you have Duodenal ulcersdue to infection, screen for Helicobacter pylori test may be ordered, including Blood antibody test, Stool antigen test, Urea breath test, etc.)
4. Endoscopy
Endoscopy is a procedure for your doctor look inside your body with an endoscope, (a long, thin tube equipped with a tiny video camera) to detect any abnormality including the presence of peptic ulcers, bleeding, stomach cancer, etc.
5. Biopsy
In biopsy, a sampling of tissues is withdrawn for examination.
6. Etc.
Others in the study to determine the benefit of post-treatment assessment of H. pylori eradication in patients with uncomplicated duodenal ulcer, found that in patients with uncomplicated duodenal ulcer, evaluation of eradication after H. pylori treatment markedly increases costs with no clear improvement in results and therefore should not be performed routinely(28).
F. Treatments
F.1. In conventional medicine perspective
1. Non invasive treatments
a. Low-dose triple therapy (omeprazole, clarithromycin and metronidazole)
In the study to test the hypothesis that 1-week low-dose triple therapy for H. pylori is sufficient for relief from dyspeptic symptoms and healing of duodenal ulcers.One-week, found that low-dose triple therapy consisting of omeprazole, clarithromycin and metronidazole is a highly effective and well-tolerated approach to the cure of H. pylori infection in patients with a duodenal ulcer. Our data suggest that continuation of antisecretory drug therapy beyond anti-H. pylori therapy is actually excessive regarding relief from dyspeptic symptoms and healing of duodenal ulcers(29).
b. Antibiotics
In the study to evaluate the primary objective of the present study was to evaluate the efficacy of 30 and 60 mg of lansoprazole administered in combination with two antibiotics for 7 or 10 days in eradicating Helicobacter pylori in duodenal ulcer patients, found that the double dose of lansoprazole optimizes H. pylori eradication rates. The highest eradication rates were obtained after 10 days of therapy. Additional studies should be carried out to determine the optimal duration of triple therapy for eradicating H. pylori(30).
c. Probiotics
A comparison of the clinical strains isolated from patients from St. Petersburg, Russia and patients from Dushanbe, Tajikistan showed that cagA gene was more prevalent in the strains from St. Petersburg. These findings demonstrate the necessity of implementation of molecular genetic identification of H. pylori in the clinical diagnostics practice reflecting the virulent genes profile of the strain. Addition of probiotics to the standard eradication therapy of H. pylori significantly improves the results of this therapy, according to the study by North-West State Medical University(31).
d. Endoscopy
In the article of The role of endoscopy in the management of patients with peptic ulcer disease, indicated that When a duodenal ulcer is detected either on endoscopy or a radiologic study, surveillance endoscopy has a low yield if symptoms resolve after a course of acid suppression together with eradication therapy for H Pylori (when present) and discontinuation of NSAIDs. More than 90% of duodenal ulcers heal with 4 weeks of proton pump inhibitor therapy.18,19 Surveillance endoscopy should be considered in patients with duodenal ulceration who experience persistent symptoms despite an appropriate course of therapy, specifically to rule out refractory peptic ulcers and ulcers with nonpeptic etiologies(32).
5. Etc.
2. Surgery
Surgery will always be the last resources in treating gastric ulcer, and only be performed if patients do not respond to medicines or endoscopy
a.Vagotomy
The aim of the surgery is to control the secretion of stomach acid by cutting of the vagus nerve.
b. Pyloroplasty
Pyloroplasty is a surgical procedure to widen the opening in the lower part of the stomach (pylorus), allowing stomach contents to empty more quickly into the intestine.
c. Partial gastrectomy
Partial gastrectomy is a surgical procedure in the removal part of the stomach.
d. Gastrectomy
In the study to analyze outcomes of patients who underwent emergency gastrectomy for complicated peptic ulcer disease in regional hospital in Hong Kong, showed that emergency gastrectomy should be considered seriously as the primary treatment option in appropriately selected elderly patients, instead of salvage procedures to repair a perforation or control bleeding by plication(33).
F,2, In Herbal medicine perspective
Herbal drugs have been proved to be very effective in treatment of hyperacidity, gastric and duodenal ulcer, include mucus: Lini semen, Psylli semen, Foenugraeci semen, Althaeae radix/folium, Sinapis albae semen; antiphlogistic volatile-oils: Chamomillae anthodium, Millefolii herba, moreover Glycyrrhizae radix, Aloe gel, according to the study of [Herbs and herbal preparations applied in the treatment of gastric hyperacidity, gastric and duodenal ulcer in cigarette smokers(34)].
2. Peloidin (Reloidinum).
Oral administration and electrophoresis of peloidin, extract from the silt mud are beneficial in the lesions of the gastric and duodenal mucosa. Plants infusions per os combined with the exposure to sinusoidal modulated currents can be recommended in the disease aggravations, scarry ulcerative deformities(35).
3. Spices, herbal xenobiotics
Despite a number of reports on the toxicity of herbs and spices, they are generally accepted as safer alternatives to conventional therapy against gastric ulcers. But excessive consumption of spices may favor the pathogenesis of gastric and duodenal ulcer and some studies have substantiated this common perception, according to the study of "Spices, herbal xenobiotics and the stomach: friends or foes"(36).
4. Etc.
F.3. In traditional Chinese medicine perspective
In the study to investigate whether the tongue inspection technique in Traditional Chinese Medicine (TCM) can be used as a noninvasive auxiliary diagnostic tool to differentiate the subtypes of peptic ulcer disease (PUD) and as an indicator of therapeutic efficacy, found that the color of the tongue body did not change in the cured patients; however, tongue fur was markedly thinner with a color change to white (p<0.05), while sublingual veins with engorgement (p<0.05) and blood stasis (p<0.01) improved after the ulcer healed and Hp was eradicated and concluded that TCM tongue inspection can be potentially used as a noninvasive auxiliary diagnostic method and as an indicator for clinical outcomes for patients with PUD(37).
1. Hai Gui Yu Yang capsule
In the study to assess the efficacy and safety of haiguiyuyang capsule in the treatment of duodenal ulcer (also diagnosed as weiwan pain and hanrecuoza syndrome according to the theory of TCM), researchers found that the efficacy of haiguiyuyang capsule in treating duodenal ulcer is similar to that of ranitidine. No obvious adverse effect of it was observed in this trial(38).
2. Kang Wei Granules
Kang Wei Granules, a granular preparation for strengthening the spleen and replenishing Qi and for clearing away heat and resolving dampness, was used in the treatment of 288 cases of gastropathy related to Helicobacter pylori infection. The effects were compared with De Nol triple therapy in the control group of 74 cases. The therapeutic results showed that Kang Wei Granules was superior to the western drugs in improving the principal symptoms of deficiency of the spleen and stomach, and retention of damp-heat in the interior (P < 0.05), according to the study by Beijing TCM Institute(39).
3. Yu Yang powder
In the study of two hundreds patients of peptic ulcer diagnosed by fiber-gastroscope treated with Yuyang powder (YYP) and to compare with patient treated with cimetidine for control, showed that the curative rate of YYP on peptic ulcer was 88.1%, the total effective rate was 96%, similar to that of cimetidine. But the difference of recurrence rate (19.1% for YYP and 46% for control) between the two groups was very significant. Animal experiment revealed that the protective action of YYP with high dosis on gastric mucosa in peptic ulcer and gastritis was superior to that of cimetidine, its has the double effect of both strengthening protective factors and weakening aggressive factors of gastric mucosa(40).
4. Bushen kangkui decoction
The clinical controlled study of Bushen Kangkui Decoction (BSKKD) on 150 peptic ulcer patients showed that it had a similar effect to injectio cimetidine, and had a lower rate of relapse. And the long-term therapeutic effect was better than that of injectio cimetidine, according to the study by Yichun People's Hospital(41).
5. Wei Yang An (easing peptic-ulcer) capsule)
Tthe effects of the two are similar, but the long-term effect of Wei Yang An was better. Wei Yang An was also good for most cimetidine resistant ulcers, with few side effect. Animal experiment showed that Wei Yang An inhibited the ulcers, according to the study by Hunan Institute of Gerontology(42).
6. Etc.
Sources
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(2) http://www.ncbi.nlm.nih.gov/pubmed/10367546
(3) http://www.ncbi.nlm.nih.gov/pubmed/8281896
(4) http://www.ncbi.nlm.nih.gov/pubmed/1275697
(5) http://www.ncbi.nlm.nih.gov/pubmed/8992723
(6) http://www.ncbi.nlm.nih.gov/pubmed/23163547
(7) http://www.ncbi.nlm.nih.gov/pubmed/23018004.
(8) http://www.ncbi.nlm.nih.gov/pubmed/1759132
(9) http://www.ncbi.nlm.nih.gov/pubmed/3477993
(10) http://www.ncbi.nlm.nih.gov/pubmed/16521987
(11) http://www.ncbi.nlm.nih.gov/pubmed/18310651
(12) http://www.ncbi.nlm.nih.gov/pubmed/17896831
(13) http://www.ncbi.nlm.nih.gov/pubmed/1881067
(14) http://www.ncbi.nlm.nih.gov/pubmed/9059054
(15) http://www.ncbi.nlm.nih.gov/pubmed/11192317
(16) http://www.ncbi.nlm.nih.gov/pubmed/23097339
(17) http://www.ncbi.nlm.nih.gov/pubmed/23053423
(18) http://heartburn.about.com/od/pepticulcers/a/ulcer_diet.htm
(19) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3074916/
(20) http://www.ncbi.nlm.nih.gov/pubmed/17311980
(21) http://www.ncbi.nlm.nih.gov/pubmed/8577022
(22) http://onions-usa.org/img/site_specific/uploads/phytochemical_brochure.pdf
(23) http://onions-usa.org/img/site_specific/uploads/phytochemical_brochure.pdf
(24) http://www.ncbi.nlm.nih.gov/pubmed/21966156
(25) http://www.ncbi.nlm.nih.gov/pubmed/16332847
(26) http://www.ncbi.nlm.nih.gov/pubmed/17533652
(27) http://www.ncbi.nlm.nih.gov/pubmed/19731591
(28) http://www.ncbi.nlm.nih.gov/pubmed/10759623
(29) http://www.ncbi.nlm.nih.gov/pubmed/9042978
(30) http://www.ncbi.nlm.nih.gov/pubmed/10891736
(31) http://www.ncbi.nlm.nih.gov/pubmed/22683837
(32) http://www.asge.org/uploadedFiles/Publications_and_Products/Practice_Guidelines/The%20role%20of%20endoscopy%20in%20the%20management%20of%20patientswith%
20peptic%20ulcer%20disease.pdf
(33) http://www.ncbi.nlm.nih.gov/pubmed/22865172
(34) http://www.ncbi.nlm.nih.gov/pubmed/16521987
(35) http://www.ncbi.nlm.nih.gov/pubmed/1792722
(36) http://www.ncbi.nlm.nih.gov/pubmed/20533590
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(38) http://www.ncbi.nlm.nih.gov/pubmed/15807275
(39) http://www.ncbi.nlm.nih.gov/pubmed/12747192
(40) http://www.ncbi.nlm.nih.gov/pubmed/8762418
(41) http://www.ncbi.nlm.nih.gov/pubmed/8704420
(42) http://www.ncbi.nlm.nih.gov/pubmed/1861510
D. Upper gastrointestinal bleeding
Upper gastrointestinal bleeding (UGIB) is defined as hemorrhaging derived from a source proximal to the ligament of Treitz. It is life threatening and considered as medical emergency, which is followed by high mortality rate, ranging from 6 to 15% in spite of modern diagnostic methods and treatment.
J.1. Causes and risk factors
1. Causes
1.1. Esophageal causes of Upper gastrointestinal bleeding
Espophagus or gullet, an organ in vertebrates, is the tube that lead foods from the pharynx to the stomach.
a. Esophageal varices
In the study to investigate the effects of splenectomy and ligature of the left gastric vein on risk factors for bleeding of esophagogastric varices in patients with schistosomiasis mansoni, hepatosplenic form, with a history of upper gastrointestinal bleeding, showed that the variceal pressure has fallen from 22.3+/-2.6 mmHg before surgery to 16.0+/-3.0 mmHg in the immediate postoperative period (p<0.001), reaching 13.3+/- 2.6 mmHg in the sixth month of follow-up. A significant reduction of the frequency of the parameters associated with a greater risk of hemorrhage was observed between the preoperative period and six-month follow-up, when the proportion of large esophageal varices (p<0.05), varices extending to the upper esophagus (p<0.05), bluish varices (p<0.01), varices with red signs (p<0.01) and gastropathy (p<0.05) decreased(1)
b. Esophagitis
there is a report of a case of recurrent, severe upper gastrointestinal bleeding due to hemorrhagic candidal esophagitis in a man with renal failure is described. Dysphagia, odynophagia, and retrosternal chest discomfort were all absent. Oral thrush was present only at the outset. Standard therapy for massive bleeding with blood products alone was not successful. Intravenous amphotericin eventually resulted in resolution, according to the study by University of Manitoba, Canada(2).
c. Esophageal cancer
Esophageal cancer is not very uncommon and caused by malignant of the esophagus due to abnormal cell growth as a result of the DNA alternation of the cells that line the upper part of the esophagus or glandular cells that are present at the lower part of the esophagus that connected with the stomach.
The esophageal cancer tend to spread if it left untreated and starts from the lining of esophagus, then later penetrate in the the wall of the esophagus and spread to the lumph node around the bottom of the esophagus, stomach and the chest, then to the distant parts of the body. for more information, please visit
http://medicaladvisorjournals.blogspot.ca/2011/06/cancers-from-b-to-t-most-common-types_07.html
d. Esophageal ulcers
there is a report of five cases in the upper GI tract due to insufflating large amounts of air through the endoscopes. All 5 patients needed an emergency upper endoscopy for acute presumed upper GI bleeding. In two cases both esophageal variceal bleeding and ulcer bleeding were detected; the fifth case presented with a bleeding due to gastric cancer(3).
e. Other causes
Other causes of UGI bleeding include Dieulafoy's lesion, Mallory-Weiss syndrome, and portal hypertensive enteropathy. The most common non-variceal endoscopic findings reported in patients with lower gastrointestinal bleeding are portal hypertensive colopathy and hemorrhoids(4).
1.2. Gastric causes of Upper gastrointestinal bleedinga
a. Gastric ulcer
There is a report iIn 16 patients (mean age, 59.4 years) with acute bleeding ulcers (13 gastric ulcers, 2 duodenal ulcers, 1 malignant ulcer), a metallic clip was placed via gastroscopy and this had been preceded by routine endoscopic treatment, according to the study of Chonbuk National University Medical School(5).
b. Gastric cancer
Bleeding from the upper gastrointestinal system may be caused by gastrointestinal stromal tumors of the stomach, which are mainly characterized by occult bleeding, while profuse bleeding rarely occurs accompanied by hemorrhagic shock. Gastrointestinal stromal tumors of stomach are the most common mesenchimal tumors of the gastrointestinal tract(1). For more information of Stomach Cancer/Gastric Cancer, please visit http://medicaladvisorjournals.blogspot.ca/2011/06/cancers-from-b-to-t-most-common-types_30.html
c. Gastritis
In a material of 4560 panendoscopic investigations carried out in an endoscopy laboratory haemorrhages from the upper gastrointestinal tract were found in 201 cases. In 49 cases the cause of blood loss was acute haemorrhagic gastritis. Among them males accounted for 41% (mean age 35.6 years) and females for 59% (mean age 41.8 years)(6).
d. Gastric varices
Although most portal hypertensive bleeds result from the ruptured distal esophageal varices, bleeding from other sources such gastric varices, portal hypertensive gastropathy, and ectopic varices can lead to clinically significant bleeding. Variceal bleeding typically presents as massive gastrointestinal (GI) bleeding with hematemesis, melena or hematochezia(7).
e. Gastric antral vascular ectasia
Gastric antral vascular ectasia (GAVE) syndrome, also known as watermelon stomach is a significant cause of acute or chronic gastrointestinal blood loss in the elderly. is characterized endoscopically by "watermelon stripes." Without cirrhosis, patients are 71% female, average age 73, presenting with occult blood loss leading to transfusion-dependent chronic iron-deficiency anemia, severe acute upper gastrointestinal bleeding, and nondescript abdominal pain(8).
f. Dieulafoy's lesions
Dieulafoy's lesions are considered uncommon causes of gastrointestinal bleeding and occur from pinpoint non-ulcerated arterial lesions(9).
g. Etc.
1.3. Duodenal causes of Upper gastrointestinal bleeding
The duodenum represents second place in frequency for the presence of diverticula in the digestive tract after the colon. Duodenal diverticulum as a cause of hemorrhage of the upper gastrointestinal (GI) tract has been described as an infrequent complication, although it must be considered in patients with digestive hemorrhage without evident cause at the esophagogastric level(10).
1.4. Etc.
2. Risk factors
a. Medication
Medication such as aspirin, NSAIDs, warfarin, corticosteroids and SSRIs are associated with increase risk of upper gastrointestinal bleeding. In the study assess the impact of increased use of low-dose aspirin, other non-steroidal anti-inflammatory drugs (NSAIDs), warfarin, corticosteroids and selective serotonin re-uptake inhibitors (SSRIs) on the site and outcome of non-variceal gastrointestinal (GI) bleeds, researchers at the Lund University, Lund, Sweden, found that aspirin, warfarin and SSRI users tended to suffer more severe GI bleeds than non-users of these drugs. When comparing non-ulcer GI bleeds with PUBs, aspirin (OR 0.56, 95% CI 0.38-0.82) was more strongly associated with PUBs, whereas SSRIs (OR 3.71, 95% CI 1.39-12.9) and corticosteroids (OR 2.8, 95% CI 1.28-6.82) were more associated with non-ulcer GI bleeds after adjusting for age, gender and co-morbidity(11).
b. Acid reflux disease
Gastrointestinal (GI) complaints are common among athletes with rates in the range of 30% to 70%. Both the intensity of sport and the type of sporting activity have been shown to be contributing factors in the development of GI symptoms. Three important factors have been postulated as contributing to the pathophysiology of GI complaints in athletes: mechanical forces, altered GI blood flow, and neuroendocrine changes. As a result of those factors, gastroesophageal reflux disease (GERD), nausea, vomiting, gastritis, peptic ulcers, GI bleeding, or exercise-related transient abdominal pain (ETAP) may develop(12). For more information of gastroesophageal reflux disease (GERD), please visit
http://medicaladvisorjournals.blogspot.ca/2011/09/gastroesophageal-reflux-disease-gerd.html
c. Age
Upper GI bleeding was significantly correlated with age younger than 50 (P = .01) and male gender (P = .01; odds ratio, 3.13)(13).
d. Coagulopathy
Coagulopathy was prevalent in 16% of patients after nonvariceal upper gastrointestinal bleeding (NVUGIB). and independently associated with more than a fivefold increase in the odds of in-hospital mortality. Wide variation in plasma use exists indicates clinical uncertainty regarding optimal practice(14).
e. Etc.
J.2. Symptoms
Acccordfing to the study of a total of 124 patients were eligible for inclusion, 71 (57%) of whom were male. A total of 63 (51%) presented with blood in stool and 53 (43%) with bloody emesis; 8 (6%) had blood in both emesis and stool. A total of 31 (25%) patients had a lower GI bleed, 88 (70%) had an upper, and 5 (4%) had both upper and lower bleeding sources. The mean BUN level was 24 mg/dL, the mean Cr level 1.03 mg/dL, and the mean BUN/Cr ratio was 24. The mean hemoglobin (Hb) level was 11.3 g/dL, the mean Hct was 32 g/dL, and 51% required transfusion. Upper GI bleeding was significantly correlated with age younger than 50 (P = .01) and male gender (P = .01; odds ratio, 3.13)(15).
1. Blood vomiting looks like coffee grounds(15).
2. Blood in stool
3. Light head, Fatigue, Generalized weakness and fainting as a result of massive blood loss
4. Abdominal pain
5. Constipation
6. Diarrhea
7. Gastroesophageal reflux disease (GERD)
8. Etc.
J.3. Diagnosis
According to the study by Georgia Health Sciences University, Rapid assessment and resuscitation of upper gastrointestinal bleeding should precede the diagnostic evaluation in unstable patients with severe bleeding. Risk stratification is based on clinical assessment and endoscopic findings. Early upper endoscopy (within 24 hours of presentation) is recommended in most patients because it confirms the diagnosis and allows for targeted endoscopic treatment, including epinephrine injection, thermocoagulation, application of clips, and banding. Endoscopic therapy results in reduced morbidity, hospital stays, risk of recurrent bleeding, and need for surgery. Although administration of proton pump inhibitors does not decrease mortality, risk of rebleeding, or need for surgery, it reduces stigmata of recent hemorrhage and the need for endoscopic therapy(16).
J.4. Prevention
1. Reduce stress
Stress-damage of upper gastro-intestinal tract (GIT) mucous membrane and gastro-intestinal hemorrhage (GIH)(17).
2. Cardiac surgery
GI bleeding events occurred approximately 10 days after cardiac surgery in patients with a complicated postoperative course. Improving the heart function is the best way to reduced risk of Upper gastrointestinal bleeding(18).
3. Drugs, alcohol and smoking
Chronic moderate alcohol consumption by itself does not seem to increase the liability to peptic ulceration. With highly concentrated alcoholic beverages, gastric bleeding from acute lesions may, however, be occasionally precipitated under certain circumstances, such as when unbuffered ASA is taken concomitantly. Smoking of cigarettes is associated, and perhaps causally related, with an increased incidence of gastric and duodenal ulcerations, impaired ulcer healing, and more frequent ulcer recurrences(19).
4. Avoid prolonged period intake of aspirin and medication which can induce Upper gastrointestinal bleeding (UGIB), such as Ibuprofen (Motrin, Advil)Naproxen (Anaprox, Naprosyn, Aleve)Ketoprofen (Orudis).
5. No extreme exercise
Gastrointestinal (GI) complaints are common among athletes with rates in the range of 30% to 70%. Both the intensity of sport and the type of sporting activity have been shown to be contributing factors in the development of GI symptoms. Three important factors have been postulated as contributing to the pathophysiology of GI complaints in athletes: mechanical forces, altered GI blood flow, and neuroendocrine changes. As a result of those factors, gastroesophageal reflux disease (GERD), nausea, vomiting, gastritis, peptic ulcers, GI bleeding, or exercise-related transient abdominal pain (ETAP) may develop(20).
6. Etc.
J.5. Treatments
1. In conventional medicine perspective
Some researchers suggested that despite successful endoscopic therapy, rebleeding can occur in 10 to 20 percent of patients; a second attempt at endoscopic therapy is recommended in these patients. Arteriography with embolization or surgery may be needed if there is persistent and severe bleeding(16). Others indicated that Pre-endoscopic management (including use of scoring scales, nasogastric tube placement and blood pressure stabilization) is crucial for triage and optimal resuscitation of patients, and should include a multidisciplinary approach at an early stage. Unless the patient has specific comorbidities, transfusion should only be considered if their hemoglobin level is ≤70 g/l. Endoscopic therapy, the cornerstone of therapeutic management of high-risk lesions, should not be delayed for more than 24 h following admission. Several endoscopic techniques, mostly using clips or thermal methods, are available and new approaches are emerging. When endoscopy fails, surgery or arterial embolization should be considered. Although the efficacy of prokinetics and high-dose intravenous PPI prior to endoscopy is controversial, the use of an intravenous PPI following endoscopy is strongly recommended. Antiplatelet therapy should be suspended and resumed in 3-5 days. Finally, all patients should be tested for Helicobacter pylori by serology in the acute setting(21).
2. In herbal medicine perspective
a. Rhubarb is a small flower grouped with large compound leafy in the the genus Rheum, belonging to the family Polygonaceae. The herb has been used in traditional medicine as laxative agent, reduce inflammation and treat diarrhea, dysentery blood clots, tumor red and painful eyes abdominal-distention and/or pain blood in stool hemorrhoidal bleeding urination: burning sensation, absence of menses, etc. In the study of the effect of rhubarb on gastrointestinal (GI) perfusion in critical illness and hemorrhagic shocked rats, showed that in clinical study: The pH in septic patients was much lower than that in the control, whereas rhubarb could obviously elevate GI pH (P < 0.01). In addition, rhubarb also had a good effect on gastric hemorrhage caused by stress ulcer, the effectiveness was 73.4%. Animal study: Although the shocked rats were resuscitated completely, their GI perfusion was much lower than that in the control. Rhubarb could significantly improve the mucous membrane of GI and mesenterium perfusion (P < 0.01)(22).
b. Liquorice
Liquorice or liquorice roots has been used in traditional Chinese medicine over 4000 years as anti allergy, anti inflammation, anti ulcer, anti convulsion and to treat stomach weakness, tired and lack of strength, palpitation and short of breath, cough with abundance of phlegm, stomach and solar plexus pain, etc,. some studies indicated that gastric mucosal damage induced by giving 60 mg aspirin orally to rats was reduced by simultaneous administration of 100-500 mg deglycyrrhizinated liquorice. Human faecal blood loss induced by 975 mg aspirin orally three times a day was less when 350 mg deglycyrrhizinated liquorice was given with each dose of aspirin(23).
c. Etc.
3. In traditional Chinese medicine perspective
a. Wen She decoction (WSD)
Wen She decoction (WSD), a Chinese herbal formula, consists of Codonopsis pilosulae, Atractylodes macrocephala, Poria cocos, Glycyrrhiza uralensis, Zingiber officinale, Os sepiae Halloysitum rubrum and Astragalus membranaceus. In a clinical study to investigate the effects of Wen She decoction (WSD)ion treatment of acute upper digestive tract hemorrhage, found that the effective rate of WSD of the stool OB (+) becoming (-) within 5 days was more than 95%. . It is effective in stopping bleeding by warming the Spleen and tonifying Qi(24)
b. Rheum officinale Baill, Rheum palmatum L, and Rheum tanguticum Maxim ex Balf
Evidences incated that Rheum officinale Baill, Rheum palmatum L, and Rheum tanguticum Maxim ex Balf have an efective rate of 90.7%, 93.7%, and 92.8% respectively in treating upper digestive tract bleeding, according to the 10 years study by Shanghai Xiang Shan TCM Hospital(25).
c. Etc.
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Sources
(1a) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1065003/table/T1/
(1) http://www.ncbi.nlm.nih.gov/pubmed/22569978
(2) http://www.ncbi.nlm.nih.gov/pubmed/8202782
(3) http://www.ncbi.nlm.nih.gov/pubmed/22649332
(4) http://www.ncbi.nlm.nih.gov/pubmed/22661272
(5) http://www.ncbi.nlm.nih.gov/pubmed/21852908
(6) http://www.ncbi.nlm.nih.gov/pubmed/2623868
(7) http://www.ncbi.nlm.nih.gov/pubmed/22514572
(8) http://www.ncbi.nlm.nih.gov/pubmed/20740102
(9) http://www.ncbi.nlm.nih.gov/pubmed/20514835
(10) http://www.ncbi.nlm.nih.gov/pubmed/18492423
(11) http://www.ncbi.nlm.nih.gov/pubmed/20695720
(12) http://www.ncbi.nlm.nih.gov/pubmed/22897615
(13) http://www.ncbi.nlm.nih.gov/pubmed/9928705
(14) http://www.ncbi.nlm.nih.gov/pubmed/22897615
(15) http://www.ncbi.nlm.nih.gov/pubmed/9928705
(16) http://www.ncbi.nlm.nih.gov/pubmed/22534226
(17) http://www.ncbi.nlm.nih.gov/pubmed/22834289
(18) http://www.ncbi.nlm.nih.gov/pubmed/22720275
(19) http://www.ncbi.nlm.nih.gov/pubmed/6378444
(20) http://www.ncbi.nlm.nih.gov/pubmed/22410703
(21) http://www.ncbi.nlm.nih.gov/pubmed/22230903
(22) http://www.ncbi.nlm.nih.gov/pubmed/11789209
(23) http://www.ncbi.nlm.nih.gov/pubmed/493863
(24) http://www.ncbi.nlm.nih.gov/pubmed/2766422
(25) http://www.ncbi.nlm.nih.gov/pubmed/2379297
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