A Gut Feeling:

Is the food you’re eating giving you an ulcer?

Like many modern health issues, our understanding of ulcers has evolved over time.

For the better part of a century, the cause of ulcers was hotly debated, with infections and excess stomach acid most frequently thought to be triggers. Other factors, such as diet and lifestyle, were also considered. Interestingly, in some circles, a stomach ulcer was thought to be a “badge of success” or an occupational hazard related to dealing with big decisions.

Everything changed in 1983, when Australian doctors J. Robin Warren and Barry Marshall isolated Helicobacter pylori, a bacterium later determined to be the primary cause of peptic ulcer disease. While many scientists were slow to accept this discovery, today most doctors regard ulcer management as greatly improved thanks to Marshall and Warren’s discovery.

Ulcers — more specifically called peptic ulcers — are open sores that may develop on the interior lining of your stomach and the upper portion of your small intestine. They include gastric ulcers found on the inside of the stomach and duodenal ulcers found on the inside of the upper portion of your small intestine (the duodenum).

The most common symptom of a peptic ulcer is abdominal pain. But how do you determine the difference between the commonly experienced pain of an upset stomach from a large or spicy meal, and the pain of an ulcer?

While peptic ulcers can sometimes produce no symptoms, a burning pain is the most common. This pain is aggravated by stomach acid coming in contact with the ulcerated area. The pain may be felt anywhere from your navel up to your breastbone. It can be worse when your stomach is empty and is often temporarily relieved by eating certain foods that buffer your stomach acid (or by taking an acid-reducing medication). This pain can disappear and then return for a few days or weeks, and it often flares up at night.

Other symptoms may include nausea, vomiting or vomiting of blood, dark blood in stools, or stools that are black or tarry, as well as appetite changes or unexplained weight loss. These symptoms may also underlie other conditions, some even more serious, so it is important to obtain a medical evaluation for them.

Your digestive tract is coated with a layer of mucus that normally protects against stomach acid. But if the amount of acid is increased or the amount of mucus is decreased, you could develop an ulcer. Again, Helicobacter pylori is the primary cause of peptic ulcers. Usually this infection causes no problems, but it can cause inflammation of the stomach’s inner layer, leading to an ulcer.

It’s not yet clear how Helicobacter pylori spreads. It may be transmitted from person to person by close contact, such as kissing. People may also contract it through food and water.

Another common cause of peptic ulcers is regular use of certain pain relievers used to reduce inflammation (commonly known as “nonsteroidal anti-inflammatory drugs” or NSAIDs), which can irritate the lining of your stomach and small intestine. These medications include aspirin, ibuprofen (such as Motrin or Advil), naproxen (Aleve) and many other anti-inflammatory medications often used to treat pain and arthritis. There are prescription medications and other health conditions that can also lead to ulcers, but these are much less common.

Nutrition and ulcers

For decades, doctors recommended dietary changes to prevent or treat ulcers. Common suggestions included avoiding spicy foods, coffee and alcohol, or eating bland foods and drinking milk. Some of these suggestions have not stood up well when tested in controlled trials. For example, drinking milk tends to produce more acid. Also, spices such as black pepper, chili powder and red pepper may cause indigestion, but they have not been shown to cause or contribute to ulcers.

Recent studies have made connections between diet and ulcers. They include:

• High-fiber diets — A Harvard School of Public Health study found that high-fiber diets were associated with a reduced risk of developing ulcers. Over a six-year period, the risk was 45 percent lower for those with the highest fiber intake, compared to those with the lowest. Foods with soluble fiber were most protective, lowering the risk by 60 percent. However, dietary fiber from wheat bran had no effect on ulcer recurrence, and high-fiber diets appeared to have no benefit on ulcer healing rates.

• Avoiding alcohol — Chronic alcohol abuse aids Helicobacter pylori infection and also slows the healing of existing ulcers.

• Avoiding coffee — Coffee (caffeinated or caffeine-free) stimulates acid production. Some studies have suggested a close association between coffee intake and symptoms. However, it is unclear whether consuming coffee increases or decreases the risk of Helicobacter pylori infection.

• Green tea — Some studies show that regularly drinking green tea can reduce the risk of gastritis by 40 to 50 percent. The chemistry of green tea may act as antioxidant and antibacterial to suppress the Helicobacter pylori bacterium.

• Probiotics — Probiotics, such as the live culture Lactobacillus caseii found in many yogurts, are microorganisms believed to provide health benefits. They may interfere with Helicobacter pylori growth. Some studies have shown that probiotics also increase the effectiveness of antibiotic treatment for this bacterium and may reduce the side effects of treatment. However, further study is necessary before probiotics can be recommended to prevent or treat ulcers.

Testing and diagnosis

Your doctor may recommend tests to determine whether you have this bacterium in your body. These tests may use your blood, breath or stool sample. Your doctor may also recommend an endoscopy or X-ray.

In an endoscopy, your doctor passes a hollow tube equipped with a lens (an endoscope) down your throat and into your esophagus, stomach and small intestine to look for ulcers. If one is detected, a small tissue sample (a biopsy) may be removed for examination in a lab. A biopsy can also identify the presence of Helicobacter pylori in your stomach lining. Your doctor is more likely to recommend this test if you are older, have signs of bleeding, or have experienced recent weight loss or difficulty eating and swallowing.

Your doctor may also suggest an X-ray. Sometimes referred to as an “upper gastrointestinal (GI) series” or a “barium swallow,” this series of X-rays creates images of your esophagus, stomach and small intestine. During the X-ray, you swallow a white liquid containing barium that coats your digestive tract and makes an ulcer more visible.

Treatment

If you’ve been diagnosed with an ulcer, your treatment will depend on the cause. Treatments can include:

• Antibiotic medications to kill Helicobacter pylori. If Helicobacter pylori is found in your digestive tract, your doctor may recommend a combination of antibiotics and other drugs to kill this bacterium. You’ll likely need to take these medications for several weeks, in addition to medications to reduce the production of stomach acid.

• Medications that block acid production and promote healing. Proton pump inhibitors are a group of drugs used primarily to reduce the production of gastric acid. These drugs include over-the-counter medications such as omeprazole (Prilosec) and prescription drugs such as lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium) and pantoprazole (Protonix).

• Medications to reduce acid production. Acid blockers, also called histamine (H-2) blockers, reduce the amount of stomach acid released into your digestive tract, which can relieve ulcer pain and encourages healing. Available by prescription or over the counter, acid blockers include the medications ranitidine (Zantac), famotidine (Pepcid), cimetidine (Tagamet) and nizatidine (Axid).

• Antacids that neutralize stomach acid. Your doctor may recommend an antacid as part of your treatment regimen. Antacids neutralize stomach acid and can provide rapid pain relief. Some of the side effects can include diarrhea, rash, dizziness, headaches and fatigue. While antacids can ease your symptoms, they can’t heal your ulcer.

What can you do?

To ease the pain of a stomach ulcer, try these tips:

Choose a healthy diet containing lots of fruits, vegetables and whole grains. For more information on how you can make your diet healthier, visit www.choosemyplate.gov.

Reduce stress in your life. Stress may worsen the signs and symptoms of a peptic ulcer. Determine the sources of your stress and do what you can to address it. While some stress is unavoidable, you can find methods to cope. In some cases, seeking the assistance of a counselor or therapist may be helpful.

Stop smoking. In addition to the other hazards it creates, smoking increases stomach acid and can interfere with the protective lining of the stomach, making it more susceptible to developing ulcers.

Avoid or limit alcohol. Excessive use of alcohol can irritate and erode the lining in your stomach and intestines, causing inflammation and bleeding. If you drink alcohol at all, don’t exceed one drink per day for women or two drinks per day for men. Some people should drink less or no alcohol at all. Consult your doctor to see what’s best for you.

See your doctor if you have any signs or symptoms suggestive of an ulcer.

Ask your doctor for suggestions on the best ways to relieve any pain you may be having.

Here are some ways to prepare for the visit with your doctor:

• Write down personal information such as other medical problems, previous surgeries, major stresses or recent life changes.

• Make a list of all of your prescription and over-the-counter medications, vitamins and supplements that you may be taking. It's especially important to note any pain relievers you take, and at what dosage and frequency.

• When you make your appointment, ask if there’s anything you need to do in advance, such as restrict your diet. Some medications can affect ulcer tests, so your doctor may want you to stop taking them, and can suggest alternatives to these drugs. Food may also alter the results of laboratory tests that might be done.

• Write down any symptoms that you’ve been experiencing, even those that might seem unrelated. It’s also a good idea to keep a food diary that you can share with your doctor.

• Make a list of questions for your doctor and don’t hesitate to ask if you are having problems understanding his explanations or instructions.

Nicholas Tibaldi, M.D., is the gastroenterology department chief for Southwest Medical Associates.

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