Counseling Sheet

Agatha M. Thrash, M.D.
Preventive Medicine

An ulcer is a cavity in the lining and wall of the esophagus, stomach, pylorus, or duodenum. Gastric ulcers are peptic ulcers occurring in the stomach; duodenal ulcers are peptic ulcers occurring in the first 11 inches of the intestine. A duodenal ulcer is found in males about four times as often as in females, and is most frequent in 25-40 year olds. Gastric ulcers occur in males two-and-one-half times as often as in females and is most frequently found in the 40-55 age group. Duodenal ulcers occur ten times more frequently than gastric ulcers. In the United States population 5-15% have ulcers, but probably only about half of them are diagnosed. Many ulcers never produce symptoms severe enough to lead to diagnosis. Peptic ulcers apparently have somewhat of a tendency to run in families as they are 2 to 2.5 times more likely to occur if siblings have ulcers. Ulcers tend to flare up during the spring and fall of the year. Pain located just beneath the breastbone is a typical symptom of an ulcer. Pain may radiate to the back in some cases. The pain is often considered to be heartburn, or an empty stomach. The pain more often appears when the stomach is empty, and is relieved by the intake of food. Some ulcers are not diagnosed until the person vomits blood. Severe ulcers cause pain at night and may awaken the patient at 2 or 3 a.m.

Treatment

• Ulcer treatment has changed drastically in the past few years. The "Sippy diet" with its frequent feedings during waking hours, milk and cream intake, antacids, and a bland diet is rapidly being discarded. It is now known that the calcium in milk only stimulates acid production rather than decreasing it as was taught for many years. Milk does indeed initially neutralize stomach acid, but then the calcium promotes the secretion of gastrin, a hormone which triggers the release of more acid, giving a rebound effect. Acid stimulation is not the only unfavorable result of a Sippy diet. The incidence of myocardial infarcts (heart attacks) was more than twice as high in a group of ulcer patients treated with the Sippy diet than in two other control groups. It is felt that the butterfat content of the Sippy diet caused the myocardial infarctions.
• The bland low fiber diet is also being discarded, and the patient is encouraged to eat whatever foods agree with him. Bland diets do not relieve ulcer pain, nor do they speed healing of ulcers. Not only are they ineffective; as a rule they are poor nutritionally.
• The presence of any food in the upper gastrointestinal tract is one of the chief stimulants to acid secretion, and reducing the frequency of food intake is far more important than the composition of the food. The program of frequent meals can actually be harmful to the patient with an ulcer. The bedtime feeding is particularly dangerous. Gastric acid production is known to follow a circadian rhythm. It normally increases during the day, is encouraged by meals, but decreases in the evening, and nearly stops during the night. Gastric acid concentration remains at relatively low levels during the first hour and a half after a meal, even though acid secretion during this time may be as high as eight times normal. About two hours after the meal, the majority of the stomach content has been emptied, and the concentration of gastric acid rises rapidly even though the secretion of acid decreases to about four times normal. This balance is maintained until about four hours after a meal. If an ulcer patient eats a bedtime meal, at 10 or 11 o'clock p.m. the normal circadian rhythm of acid production is disrupted so that high levels of acid are secreted until 2 or 3 a.m. Unfortunately, this is when the patient has the fewest available defenses to cope with the acid load. We recommend a two meal plan, with breakfast around 7 a.m. and dinner at about 1 p.m. with no between-meal snacks. Regularly scheduled meals allow one to take advantage of the rhythmic production of acid.
• Even antacids are being discarded as they may actually increase acid production. The calcium carbonate nearly doubles the amount of gastric acid in people who suffer from duodenal ulcers. Side effects of magnesium antacids include diarrhea, potassium deficiency, abnormally high magnesium levels, and iron deficiency. Aluminum based antacids may cause constipation, weakness, anemia, delayed gastric emptying, and perforation of the colon. Calcium-containing antacids may cause milk-alkali syndrome, rebound acidity, and calcium phosphate deposits in the kidney tubules to initiate kidney stones. Sodium in antacids may induce salt and water retention worsening edema and ascites, hypertension, and cardiac failure. Bicarbonate antacids may induce alkalosis. Other adverse effects of antacids include osteomalacia induced by lack of phosphorus. Aluminum-containing antacids block the absorption of phosphorus, and phosphorus is required for strong bones. While consuming antacids, patients absorb up to 20 times less fluoride. Aluminum is currently under scrutiny as a cause of premature senility. Aluminum is retained in the brain and other organs, and some scientists believe that excess levels of aluminum are responsible for the increasing incidence of Alzheimer's disease (premature senility) we are currently seeing. Any effective antacid is expected to cause either diarrhea or constipation. Antacids containing sodium bicarbonate could be harmful to the kidneys.
• Avoid the use of any drugs if possible. Aspirin has long been known to induce gastrointestinal bleeding. A single dose of aspirin tablets is sufficient to induce prolongation of bleeding time, and the effect may persist for up to two days. Alka seltzer is irritating to the gastric mucosa. Steroids have potent adverse effects, and may increase the incidence of serious complications. It is felt that many drugs (including aspirin) inhibit the synthesis of prostaglandins, and some feel that prostaglandins exert a protective influence on the mucosa.
• Do not smoke. Smokers have more gastric and duodenal ulcers, a higher death rate from ulcers, and slower healing of their ulcers. Smoking inhibits pancreatic bicarbonate secretion and promotes duodenogastric reflux.
• Caffeine and caffeine-containing beverages cause a prolonged increase in the stomach acid output. Even decaffeinated coffee stimulates gastric secretion and should not be used.
• Gastric ulcers may be caused by food stagnation in the stomach. Food stimulates secretion of the hormone gastrin as long as it is in the stomach. Gastrin stimulates excessive production of gastric acid, which in turn leads to ulcers. Eating between meals slows gastric emptying.
• Chew food properly. Proper mastication mixes urogastrone from the salivary glands with food. Urogastrone protects the intestinal mucosa from erosion in animal tests. Inadequately chewed food is one of the known causes of ulceration.
• Cabbage and several green leafy vegetables contain a factor known as "anti-gizzard erosion factor," later called vitamin U. It was observed that large amounts of fresh cabbage and lettuce protected stressed guinea pigs from ulcers. The factor was found in the juice of cabbage, thus eliminating the need to eat huge quantities of cabbage. Sixty-two ulcer patients were given at least a liter of cabbage juice daily. The average healing time for seven patients with duodenal ulcer was 10.4 days, compared to 37 days for patients with standard therapy. Six patients with gastric ulcer healed in only 7.3 days, while six patients receiving conventional therapy required 42 days. The cabbage must be freshly squeezed and not boiled, as boiling destroys the factor. A mixture of 75% cabbage juice and 25% tomato or celery juice was used with patients who objected to the flavor of the cabbage juice. Raw celery has been found to be high in the healing factor. Some patients develop gas, abdominal distress, bloating, and constipation during the first few days of therapy, but after the fifth day of treatment digestive disturbances are rare. If symptoms become severe, the juice may be eliminated for a day. Ordinarily it takes four to five pounds of cabbage to produce one quart of juice. Only fresh, green cabbage should be used. Wilted cabbage contains considerably less factor, and cabbage and cabbage juice held at room temperature for two or three days loses some anti-ulcer potency. Spring, summer, and late summer cabbages are suitable for use, but winter cabbages have very little juice. The juice may be taken in four or five 6-8 ounce servings. Cabbage juice maintains its anti-ulcer activity for at least three weeks if frozen and preserved at approximately 0 degrees C.
• Aloe vera gel or liquid has been used in the treatment of peptic ulcers with good success. One ounce of gel appears to be an effective dose. After the ulcer heals, patients should continue taking a single tablespoonful of Aloe vera gel at bedtime for several weeks. Patients have no ulcer recurrences after up to 18 months of follow-up, apparently the Aloe vera inhibits the secretion of hydrochloric acid.
• A diet high in sugar stimulates acid production. A high sugar diet for only two weeks drove stomach acid levels up by 20% in a group of healthy volunteers.
• White bread seems to act the same way tobacco does in the production of ulcers. The researchers who did the study felt that whole-grain bread might be of benefit to ulcer patients.
• Dr. Maxwell Berry of Emory University reported to the 1956 meeting of the American College of Gastroenterology that 75% of peptic ulcer patients also have the hypoglycemic syndrome. He stated that there was tremendous acid production in the stomachs of patients with low blood sugar. He feels that a very large percentage of people with the hypoglycemic syndrome will develop ulcers. Any problem with one's blood sugar should be treated.
• Potatoes are often very helpful to peptic ulcer patients. Vitamin C has an important healing influence on wounds, and potatoes are high in vitamin C. Furthermore, potatoes have an alkaline reaction, assisting in acid neutralization. Two or more potato feedings daily may be helpful. Potatoes may be baked, boiled, mashed, etc., but should not be fried, and dairy milk should not be added.
• Dried sweet almonds, well-chewed, raise the pH of the gastric juice, decrease hydrochloric acid production, and significantly inhibit peptic activity.
• Ripe olives are known to be soothing to the stomach. Four to eight olives may be taken with meals. Use only black or green ripe olives; avoid those canned in vinegar or oil.
• Millet is soothing to the gastrointestinal tract, and is usually well tolerated by peptic ulcer patients.
• A concentrate of apricot juice has been used as a Japanese folk remedy for gastritis and enteritis since ancient times. The major ingredients in the Japanese concentrate are the apricot puree, citric acid, malic acid (essentially apricot concentrate and fruit acids). H. pylori is usually killed by the fruit concentrate, a sour medium such as lemon juice. Do not use vinegar or other concentrated fruit acids regularly as they are stomach irritants.
• Chamomile, charcoal, licorice, papaya, slippery elm, and catnip are all good for stomach ulcers.
• Take goldenseal capsules two to four times a day just after eating and at bedtime.
• Take Nutribiotic (grapefruit seed extract which is antibacterial), four drops in a glass of water three times a day. It is quite bitter and some get a stomachache from it, but if tolerated, increase after about a week to six drops in water three times a day.
• Avoid all between meal feedings, putting at least five hours between the end of one meal and the beginning of the next meal.
• Eat a low-protein diet, as acid is formed most freely in response to the presence of protein in the stomach.
• Fast for 24 hours. Drink plenty of water at room temperature, and do not fear that you will have pain. Most patients are surprised at the reduction of pain by fasting. Control any pain by hot applications over the painful area. Take 8 to 10 charcoal tablets at the beginning of the fast, and once daily for one week.
• Have a set mealtime not to be varied by so much as 20 minutes during the first month.
• Drink water at room temperature freely between meals. Use no liquid foods (soups, juices, milks, or beverages) for the first month. Take food in small bites as dry as possible, and chew well.
• Test yourself for allergies by omitting the ten groups of foods known to cause most food sensitivities: (1) milk, (2) coffee, tea, colas, and chocolate, (3) citrus fruits and juices, (4) corn, wheat, rice, and yeast, (5) eggs, pork, beef, and fish, (6) tomatoes, potatoes, strawberries, and apples, (7) peanuts, soy products, and all beans, (8) cane sugar, cinnamon, and all spices, (9) lettuce, onion, and garlic (10) nuts and seeds. After two weeks, begin adding back groups in the following order: #4, 7, 10, 3, 6, etc., putting at least three days between the reintroduction of food groups.
• Attention should be paid to dress. The extremities should be well clothed to balance the circulation and avoid congestion in the abdomen.
• Remember that exercise neutralizes stress. Have a regular program of out-of-door exercise daily.
• For peptic ulcer pain apply an ice bag to the abdomen just above the navel or to the portion of the spine between the shoulder blades.

Treatment of Peptic Ulcers

For the acute phase of the ulcer: Chew and swallow two tablets of deglycerized licorice tablets (trade name Rhizinate) on arising, between meals, and at bedtime. Two more can be used at any time for pain, especially at night. This substance markedly increases upper bowel mucus production to give a protective coating.