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Monday, 23 February 2015

(!st edited) Most Common Diseases of Ages of Elders: Upper gastrointestinal disorders: Gastric ulcers - Preventions, Treatments and Management



 Gastric ulcer, a type of peptic ulcer is a condition of a localized tissue erosion in the lining the stomach.

A. Symptoms
1. Abdominal pain, bloating, septic shock
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), most common symptoms include
1. Abdominal pain prior to admission,
2. Bloating,
3. Septic shock(1).

2. Dyspepsia
Dyspepsia, may be the first symptoms of peptic ulcer disease (an ulcer of the stomach or duodenum), is the medical term for difficult digestion, including  various symptoms in the upper abdomen, such as fullness, discomfort, early satiation, bloating, heartburn, belching, nausea, vomiting, or pain(2).

3. Blood in stool
As a result of upper gastrointestinal bleeding(4).

4. Nausea and vomiting
Upper gastrointestinal tract with gastric erosions and duodenal ulcers in most cases can cause nausea and vomiting(3).

5. Dizziness and tarry stools
Patients with bleeding from a gastric ulcer, and endoscopic hemostasis may consist symptoms of  with dizziness and tarry stools, depending to amounts of blood loss(4)

5. Unintentional weight loss
Benign gastro-colic fistula with symptoms of worsening abdominal pain, nausea, vomiting, diarrhea and weight loss, is a rare occurrence  due to the progress in medical management of gastric ulcer disease(5).

6. Mood disorders
 Individuals with chronic fatigue syndrome, fibromyalgia, bowel disorder or stomach or intestinal ulcers had the highest risk 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, a common conditions impacted quality of life for a significant number of people nationwide. is the leading cause of  Gastric ulcer, due to an abnormal secretion by gastric parietal cells and the ability of upper GI tract mucosa(7).

2. Medication
Medication such as aspirin and Non-steroidal anti-inflammatory drugs (NSAIDs) may cause damage of the gastrointestinal tract and aggravate pre-existing diseases. Risk of bleeding is increased with advancing age, presence of Helicobacter pylori(HP), previous history of bleeding, anticoagulant use, etc.(9).

3. Helicobacter pylori and chronic gastritis 
Helicobacter pylori, a Gram-negative, microaerophilic bacterium found in the stomach, has shown to be a leading cause of idiopathic peptic ulcers in developed countries, especially, the bacterial now exhibited an increase in antibiotic resistance(10).
 Higher degree of HP colonisation in gastric mucosa showed to associate to the persistence of active ulcer (GU+) and its infection is a leading cause of the development and chronicity of peptic GU disease(11).
4. Etc.

B.2. Risk factors
1. Periodontal disease
according to the study of eligible 28 765 subjects, the rate of periodontitis  in people with peptic ulcer(1.4%) is 20% plus(8).

2. Aging 
According Osaka City University Graduate School of Medicine, risk of gastric ulcer, especially corpus-predominant atrophic gastritis increases proportionally with increased  life expectancy(12).

3. Smoking
 Cigarette smoking increases xanthine oxidase activity, leukotrienes, and nitric oxide production and also neutrophil infiltration in the gastric mucosa(13).

4. Mechanical ventilation
Mechanical ventilation increases risk for bleeding in the upper part of the gastrointestinal tract. Patients recieved pantoprazole and famotidine are associated to bleeding in the upper part of the gastrointestinal tract14).

5. Critical illness
Critical illness such as ischemia can lead to back-diffusion of H+ ions may impair mucosal buffering that can lead to intramural acidosis and cell death(15).

8. Etc.

C. Complications
1. Death 

according to 701 patients with gastric ulcers admitted to hospital within the period 1955-64, 180 died within a five-year period with causes of death of autopsy of 66%(16).

2. Peptic ulcer bleeding 
Peptic ulcer bleeding is a frequent and dramatic event with both a high mortality rate associated to increased risk of in individuals aged>65 years and increasing further in those aged>75 years, especially in those with co-morbidities(17).

3. Perforative hole
 Perforated gastroduodenal ulcers, in many cases, can lead to perforative hole in 11.7% of the patients(18).

4. Others
According to, Ataturk University
4.1.  Giant ulcers are more prone to severe hemorrhage and malignancy
4.2. Giant gastric ulcers are more prone to free perforation(19).
Other complications may include
4.3. Hematemesis, hematochezia and perforation(20).


D. The do and do not’s list
1. Dietary phytosterols and phospholipids

Experiments using animal peptic ulcer models showed that intake of lipid fraction in foods from the staple diets not only  reduced risk if adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs in both gastric and duodenal ulceration patients, but also promoted healing of ulceration.
due to phospholipid, sterol and sterol ester fractions of the lipid present in the diets. including   phosphatidyl ethanolamine (cephalin) and phosphatidyl choline (Lecithin), β-sitosterol, etc.(21).

2. Reduce intake of NSAID if possible
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 induce gastric ulcer due to the presence of increased xanthine oxidase activity, leukotrienes, and nitric oxide production and neutrophil infiltration in the gastric mucosa(13).

4.  Don’t miss your dental appointment
 Periodontitis is more frequently occurred in elder patients. Risk of gastric ulcer increases proportionally with existence of teeth loss and bad oral hygiene(8).

5. Reduce stress
The risk of gastrointestinal diseases has found to increase with psychosocial stress by 1.5 times, including hemorrhagic ulcers,  gastric ulcer/duodenal ulcer, non-H. pylori and non-NSAID ulcers etc.(22).

6. Excessive hard liquor drinking can damage the lining of stomach and worsen ulcers and induced pain, through its interference of gastric acid secretion and  activity of the muscles surrounding the stomach.(22a).

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)
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)
The aim of  test to check 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
Although antibiotics have shown to be best treatment  for gastric ulcer caused by H. pylori, unfortunately, monoresistant strains are prevalent with high  rates(34).

2. Sequential and Conventional triple therapies
Most frequently used in treatment of gastric ulcer, Sequential and Conventional triple therapies
showed overall eradication rate of 81.0%, and 75.7%(35).

3. Endoscopy
Endoscopy in most cases is used to control ulcer bleeding, but has low benefits for patients with benign ulcer in comparison to its cost(36).

4. Probiotic therapy
Probiotic treatment with an aim to reduce fungal colonization and  on patients with gastric ulcer (GU) and ulcerative colitis (UC), showed effectively in delay process of fungal colonization, reduced inflammation and promoted healing of GI tract(37).

3. Surgery 
Surgery will always be the last resources for treatment 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 used to widen the opening in the lower part of the stomach (pylorus), to allow stomach contents to empty more quickly into the intestine.

3. Partial gastrectomy
Partial gastrectomy is a surgical procedure removed parts of the stomach, but vagotomy( a surgical procedure involved resection of the vagus nerve) and pyloroplasty(a surgical procedure involved removal of  lower portion of the stomach,) have not yet been established as a routine treatment for all gastric ulcers(38).

B. Herbs
1. Deglycyrrhizinated licorice

B. Herbs
1. Deglycyrrhizinated licorice
Deglycyrrhizinated licorice used to treat people with gastric and peptic ulcers for nearly a hundred years, showed to increase the content of endogenous prostaglandins in the gastric mucosa, due to endogenous secretin released by its antiulcer agents, namely FM 100, plaunotol, and teprenon(39)(40).

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., aloe vera juice promoted proper gastrointestinal function, probably through its regulated gastrointestinal pH,  improved
gastrointestinal motility, increased stool specific gravity, and reduced populations of certain fecal micro-organisms activities(41).

3. Mastic gum
According to the article of "Strategies to Protect Against Potential Bone-Destroying Effects”By Chris D. Meletis, ND, the author, mastic gum only supports the health of patients with ulcers and also inhibits the bacteria H. pylori(42).

4. Ginger
Ginger used for thousands of years to enhance the function of digestive system to treat stomach distress including nausea, vomiting, diarrhea and in digestion, acid reflux, motion sickness, dyspepsia, etc., its methanol extract showed to inhibit the growth of all 19 strains in vitro, probably through its anti-inflammatory, antimicrobial and analgesic activities(43) 

5. Peppermint
 In vitro, has significant  Animal model studies, peppermint demonstrate a relaxation effect on gastrointestinal (GI) tissue, probably through its antimicrobial and antiviral activities, strong antioxidant and antitumor actions, and some antiallergenic potential.analgesic and anesthetic effects, but caution is necessary for the use of peppermint therapy  due to absent and limited clinical trials(44).
6. Etc.

F.3. In traditional Chinese medicine perspective
1. Acupuncture and moxibustion 

 According to chief physician YANG Mei-liang, a famous doctor of TCM in China, applying spleen and stomach theory with the use of acupuncture and moxibustion together with accurate and proper prescription association and acupuncture point selection, is the most effective way in treating patients with insomnia, ophthalmopathy, intestinal obstruction, gastric ulcer, etc.(45).

2. Adlay seeds
Adlay seeds used to treat warts, chapped skin, rheumatism, and neuralgia in traditional Chinese medicine (TCM), showed to inhibit antiulcer activity, probably through anti oxidative and inflammatory properties(46).

3. Qifang Weitong Powder and omeprazole
Qifang Weitong Powder combined with omeprazole (QWP-Op), showed to improve the histological quality of ulcer healing and restore the morphological structure of gastric mucosa in patients with active gastric ulcer(47).

4. Kangyanling and Omeprazole 
 Combined therapy with Kangyanling (KYL, a Chinese herbal preparation) and Omeprazole on post-burn digestive dysfunction, showed to restore normal pH value in gastric mucosa(48)

5. Jianpi Qingre Huayu Recipe
Jianpi Qingre Huayu Recipe showed to cure gastric ulcer up to 86.7% in 30 patients with gastric ulcer of Pi -insufficiency and stasis-heat syndrome type(49).

6. Jianwei Yuyang Granule
According to the study by Institute of Integrative Traditional Chinese and Western Medicine, Xiangya Hospital of Central South University, Jianwei Yuyang Granule with its good clinical compliance, has favorable effects in relieving clinical symptoms, promoting endoscopic ulcer healing and HP clearance, etc.(50).


References
(1) http://www.ncbi.nlm.nih.gov/pubmed/21631975
(2) http://www.ncbi.nlm.nih.gov/pubmed/22327302
(3) http://www.ncbi.nlm.nih.gov/pubmed/23152072
(4) http://www.ncbi.nlm.nih.gov/pubmed/22187712
(5) http://www.ncbi.nlm.nih.gov/pubmed/21756322
(6) http://www.ncbi.nlm.nih.gov/pubmed/18625088 
(7) http://www.ncbi.nlm.nih.gov/pubmed/11729446.
(8) http://www.ncbi.nlm.nih.gov/pubmed/22980150
(9) http://www.ncbi.nlm.nih.gov/pubmed/23163547
(10) http://www.ncbi.nlm.nih.gov/pubmed/23018004.
(11) http://www.ncbi.nlm.nih.gov/pubmed/1759132
(12) http://www.ncbi.nlm.nih.gov/pubmed/21061517
(13) http://www.ncbi.nlm.nih.gov/pubmed/9872502
(14) http://www.ncbi.nlm.nih.gov/pubmed/18310651
(15) http://www.ncbi.nlm.nih.gov/pubmed/7495942
(16) http://www.ncbi.nlm.nih.gov/pubmed/1211040
(17) http://www.ncbi.nlm.nih.gov/pubmed/17896831
(18) http://www.ncbi.nlm.nih.gov/pubmed/1881067
(19) http://www.ncbi.nlm.nih.gov/pubmed/1636903
(20) http://www.ncbi.nlm.nih.gov/pubmed/9059054
(34) http://www.ncbi.nlm.nih.gov/pubmed/22611319
(35) http://www.ncbi.nlm.nih.gov/pubmed/22654429
(36) http://www.ncbi.nlm.nih.gov/pubmed/8425440 
(37) http://www.ncbi.nlm.nih.gov/pubmed/17242486 
(38) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1553030/pdf/gut00684-0094.pdf
(39) http://www.ncbi.nlm.nih.gov/pubmed/776752
(40) http://www.ncbi.nlm.nih.gov/pubmed/6588541
(41) http://wholeleaf.com/aloeveraoralconsumption.html
(42) http://www.drmeletis.com/wp-content/uploads/2012/07/Proton-Pump-Inhibitors.pdf
(43) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3761965/
(44) http://onlinelibrary.wiley.com/doi/10.1002/ptr.1936/abstract
(45) http://www.ncbi.nlm.nih.gov/pubmed/18481724
(46) http://www.ncbi.nlm.nih.gov/pubmed/21517098
(47) http://www.ncbi.nlm.nih.gov/pubmed/17717919
(48) http://www.ncbi.nlm.nih.gov/pubmed/18476431
(49) http://www.ncbi.nlm.nih.gov/pubmed/17578313
(50) http://www.ncbi.nlm.nih.gov/pubmed/17717918