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Peptic Ulcers – Gastric ulcers & Duodenal ulcers.
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What causes Peptic Ulcers – Gastric ulcers & Duodenal ulcers.
During normal digestion, food moves from the mouth down the esophagus into the stomach. The cells with in
stomach produce hydrochloric acid and an enzyme called pepsin to digest the food. A layer with in the stomach called
mucosa protects the stomach from these powerful acids. With out Mucosa, the digestive acids would eat away the
stomach it self.
With in this highly acidic environment survives a spiral-shaped bacterium called Helicobactor pylori (H.pylori). It is
able to do so by producing an alkaline(opposite of acid – for those who slept off the chemistry classes) enzyme called
urease. This bacterium tends to damage the mucosa layer of the stomach and opens out a wound in the inner surface
of the stomach. Where a wound is opened the stomach acids and pepsin start to burn away the stomach resulting in
sores or ulcers. Also as a reaction of body to the attack of H. pylori is to produce more acid (body trying to eat way the
bacterium?) thus worsening the situation. Usually patients with stomach ulcers tend to have more pain in between
meals, that is when stomach is free of food and the acid leftovers have very little neutralizing substances around.

A class of commonly used medicines called Nonsteroidal anti-inflammatory drugs (NSAIDs) also tend to damage the
mucosa layer of the stomach. Examples of NSAIDs are aspirin, ibuprofen, and naproxen sodium which are present in
many non-prescription medications used to treat fever, headaches, and minor aches and pains. These, as well as
prescription NSAIDs used to treat a variety of arthritic conditions, interfere with the stomach's ability to produce
mucus and bicarbonate and affect blood flow to the stomach and cell repair. They can all cause the stomach's
defense mechanisms to fail, resulting in an increased chance of developing stomach ulcers. In most of these cases
the ulcers tend to disappear after the discontinuation of NSAID use.

As we have seen in How stomach works, from the stomach, food passes into the upper part of the small intestine,
called the duodenum, where digestion and nutrient absorption continue. If there is excessive acid produced (more
than that is necessary to digest the food) the discharge to the duodenum may be more acidic than normal. Excess
stomach acid and other irritating factors can cause inflammation of the upper end of the duodenum, the duodenal
bulb. In some people, over long periods of time, this inflammation results in production of stomach-like cells called
duodenal gastric metaplasia. H.pylori then attacks these cells causing further tissue damage and inflammation, which
may result in an ulcer.
Ulcers in the stomach are called gastric or stomach ulcers. Those in the duodenum are called duodenal ulcers. In
general, ulcers in the stomach and duodenum are referred to as peptic ulcers. Ulcers rarely occur in the esophagus
or in the first portion of the duodenum, the duodenal bulb.

How are Ulcers treated.
The most effective treatment of ulcers caused by H. pylori involve 3 things.

1) Formation of wound protecting layer (a temporary replacement of mucosa function) – Achieved by Bismuth
compounds like Bismuth subsalicylate that has both a protective effect and an antibacterial effect against H. pylori.

2) Powerful antibiotics (many times more powerful doses than used in other cases) to get rid off the H. pylori. A
combination of two antibiotics, tetracycline (e.g., Achromycin or Sumycin) and metronidazole (e.g., Flagyl) is usually
used. In some cases, doctors may substitute amoxicillin (e.g., Amoxil or Trimox) for tetracycline or if they expect
bacterial resistance to metronidazole, other antibiotics such as clarithromycin (Biaxin).

3) Suppression of Acid production (neutralization of acids by Antacids or even better is the suppression of it’s
production by using H2 blockers or Proton Pump Inhibitors).
Some of the common H2 blockers are Ranitidine (Zantac), Famotidine (Pepcid), Cimetidine (Tagamet). One of the PPI is
omeprazole. See section on Acidity for more details.

The stomach tends to repair the wounds and replaces the Mucosa layer during this period. When this is done for a
period of two weeks, this treatment on an average is about 90% effective. On successful elimination of H.pylori in 80%
of cases recurrence is not observed. Though the two weeks is rigorous due to multiple medicines taken through out
the day and the irregularity of the stomach due to chemical interference, the results tend to justify the means.

In Ayurveda
1) Ash of Chabala (a Bismuth compound) and Navsagar (purified Sal ammonic) have been traditionally used to protect
the stomach.

2) Aloe vera, Piper cubeba, Syzygium Aromaticum etc display strong anti-bacterial properties.

3) Terminalia Arjuna and other Alkailine extracts have been used to neutralize the excess stomach acids.

4) Withania Somnifera plays a significant part in treatment of chemical induced ulcers. It also finds it’s use in control
of anxiety neurosis.

5) Holarrhena Antidysenterica finds it`s place as stomachic (Promotes increased contraction of stomach muscles)
thus promoting the better emptying of the stomach.

In most cases, anti-ulcer medicines heal ulcers quickly and effectively. Eradication of H.pylori prevents most ulcers
from recurring. However, people who do not respond to medication or who develop complications may require
surgery. While surgery is usually successful in healing ulcers and preventing their recurrence and future
complications, problems can sometimes result. The common types of surgery for ulcers--vagotomy, pyloroplasty, and
antrectomy are described below:

Vagotomy: A vagotomy involves cutting the vagus nerve, a nerve that transmits messages from the brain to the
stomach. Interrupting the messages sent through the vagus nerve reduces acid secretion. However, the surgery may
also interfere with stomach emptying. The newest variation of the surgery involves cutting only parts of the nerve
that control the acid-secreting cells of the stomach, thereby avoiding the parts that influence stomach emptying.

Antrectomy: Another surgical procedure is the antrectomy. This operation removes the lower part of the stomach
(antrum), which produces a hormone that stimulates the stomach to secrete digestive juices. Sometimes a surgeon
may also remove an adjacent part of the stomach that secretes pepsin and acid. A vagotomy is usually done in
conjunction with an antrectomy.

Pyloroplasty: Pyloroplasty is another surgical procedure that may be performed along with a vagotomy. Pyloroplasty
enlarges the opening into the duodenum and small intestine (pylorus), enabling contents to pass more freely from
the stomach.

What Are the Complications of Ulcers? People with ulcers may experience serious complications if they do not get
treatment. The most common problems include bleeding, perforation of the organ walls, and narrowing and
obstruction of digestive tract passages.