Introduction

Peptic ulcer Diseases (PUDs) are painful sores that can be found on the inner lining of the stomach (gastric ulcer), the esophagus (esophageal ulcer) or on the upper part of the small intestine (Duodenal ulcer) (Nall, 2018). Normally, the lining of the stomach is usually protected from digestive juices by a thick layer of mucus. However, this protective layer can be reduced by many things, including inflammation caused by the bacteria Helicobacter pylori (H. pylori), which allows stomach acid to damage the tissue (National Institute of Diabetes and Digestive and Kidney Diseases, 2014). It is possible to have the 2 types of ulcers at the same time, it is called gastroduodenal ulcer (Nall, 2018).

Types of PUDs

Figure 1: Types of PUD (Source; iStock, 2021)

According to Caufield (2012), the following are the various types of PUDs:

Gastric Ulcer: These develop inside the stomach.

Esophageal Ulcer: These develop inside the esophagus.

Duodenal Ulcers: These develop in the upper section of the small intestine known as the duodenum. 

Statistics on PUD in Africa

Cameroon, Chad and the Central African Republic recorded high cases of PUD, but it wasn’t indicated which gender was affected more by PUDs in these countries (Figure 2). However, in Nigeria, both males and females were recorded to have been affected by PUD alongside Gabon and Ghana. 

Figure 2: World map showing PUD Death Rate Per 100,000 (Source: WHO, 2018)

From the table below (Figure 3), Cambodia was observed to have the highest PUD death rate, with ~24 deaths per 100,000 people in 2018, while Nigeria recorded ~6 deaths per 100,000 person-years.

Figure 3: List of PUD Death Rate Per 100,000 by Country (Source: WHO, 2018)

The incidence and prevalence of PUDs vary based upon the presence of H. pylori, with higher rates found in countries where H. pylori infections are higher (Li, 2010).

The incidence of PUD in H. pylori-infected individuals is approximately 1 case per year, a rate that is 6 to 10 fold higher than for uninfected individuals (Kuipers, 1995).

From a systematic review of 31 published studies, in the general population, the pooled global incidence of uncomplicated PUD (1 case per 1000 person-years) is slightly higher than the incidence of complicated PUD (0.7 cases per 1000 person-years) (Lin, 2011).       

PUD affects about 5 million of the world’s population annually, with 1 in 10 people developing an ulcer (OMICS International, 2019). According to the latest WHO data published in 2018, PUD Deaths in Nigeria reached 5,123 or 0.26% of total deaths. The age-adjusted Death Rate (6.26 deaths per 100,000 population) ranks Nigeria 54th in the world (WHO, 2018).

Causes

The following can cause PUDs:

Helicobacter pylori bacteria (H. pylori): This is the most common cause of PUDs. It is a bacterium that affects the mucus protecting the inner lining of the small intestine and stomach. It does this by causing inflammation (irritation) (Nall, 2018), leading to the breakdown of the protective mucus layer. Without the mucus layer to protect it, the acid then eats into the tissue, damaging it (Fashner, 2015). However, for most people, the presence of H. pylori doesn’t have a negative impact. Only 10% to 15% of people with H. pylori end up developing ulcers.

Medications (pain relievers and others): People that use or rely on non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, and naproxen are more likely to develop PUDs. NSAIDs irritate and damage the stomach and intestinal lining (Nall, 2018). They do this by reducing the enzyme that produces a chemical that protects the lining of the digestive tract and controls bleeding (National Institute of Diabetes and Digestive and Kidney Diseases, 2014).

Other medications like steroids, low-dose aspirin, anticoagulants, selective serotonin reuptake inhibitors, when taken along with NSAIDs, can increase the chances of developing ulcers. 

a. Excess stomach acidity (hyperacidity): This can occur due to several reasons, from smoking to genetics (MacGill, 2018).

b. Zollinger-Ellison syndrome: This is a rare cancerous and noncancerous tumor/disease that causes the production of excessive stomach acid (Nall, 2018). It does this by releasing a large amount of gastrin, a hormone that causes the stomach to produce an excessive amount of acid (MacGill, 2018).

Risk factors

Some of the following factors can increase the risk of developing PUDs:

The risk factors of PUDs caused by NSAIDs

According to Nall 2018, the following factors can increase the risk of getting PUDs caused by NSAIDs:

1. Consuming excessive alcohol 

2. Having two or more medical conditions or diseases 

3. Being over 70 years of age

4. Experiencing severe injury or physical trauma

5. Having a history of PUD.

6. Taking anticoagulants

7. Taking certain chemotherapy medications

8. Having some genetic factors

9. Frequently using nonsteroidal anti-inflammatory drugs (Ibuprofen, aspirin and naproxen sodium)

10. Partaking in osteoporosis treatments

11. Taking some selective serotonin reuptake inhibitors (SSRIs)

12. Overproducing calcium (hypercalcemia)

The risk factors of PUDs caused by H. pylori

According to the National Institute of Diabetes, Digestive and Kidney Diseases 2014, the following factors can increase the risk of getting PUDs caused by H. pylori: 

1. Consuming contaminated and unclean water

2. Consuming contaminated and unclean food

3. Eating with unclean utensils

4. Being in contact with an infected person’s saliva and other bodily fluids 

General misconceptions of ulcer

The general misconception is that stress, coffee (Shimamoto 2013), a steady diet of fast foods and spicy foods can cause ulcers. Although stress and spicy foods are known to make ulcers worse, they don’t cause PUDs. 

It is even common to still hear that people with ulcers should eat a bland diet, this isn’t completely accurate, they are just meant to avoid eating excessively spicy food.

Symptoms

According to Felman (2017), National Institute of Diabetes, Digestive and Kidney Diseases (2014) and MacGill (2018), the following are the signs and symptoms that indicate the presence of an ulcer:

1. A dull or burning pain in the stomach.

2. Nausea and vomiting

3. Burping

4. Poor appetite

5. Weight loss

6. Bloating

7. Difficulty swallowing food 

As the ulcer progresses in severity, the following symptoms are experienced:

8. Difficulty breathing

9. Vomiting blood

10. Blood in stool or black or tarry stool

11. Feeling faint or losing consciousness

12. Fatigue

Complications

An untreated gastric or duodenal ulcer can develop into a serious problem, especially if one already has pre-existing medical conditions. The following complications can arise:

Bleeding: As an ulcer wears away the small intestine and stomach, blood vessels are broken as well, leading to bleeding.

Peritonitis: This is the inflammation and infection of the abdominal cavity due to perforation.

Perforation: As the ulcer breaks through the lining of the stomach and the stomach wall, this can lead to the leakage of acid, bacteria, and food (Nall, 2018).

Blockage due to scar tissue: Sometimes food can be prevented from leaving the stomach or duodenum because of the scar tissue resulting from ulcers (Nall, 2018).

Gastric ulcers can also increase the risk of developing cancerous tumor growth (Nall, 2018).

Hemodynamic instability: This results from internal bleeding which can affect multiple organs (Felman, 2017).

Prevention

According to Lanza (2009) and Nall (2018), PUDs can be prevented by doing the following:

1. Lowering the intake of NSAIDs, or switching to an alternative medication.

2. Taking the NSAIDs with meals or medications that will protect the stomach lining 

3. Taking all prescribed antibiotics regularly when diagnosed with H.pylori bacteria.

4. Refraining from smoking and excessive consumption of alcohol.

5. Increasing physical activities as this helps to lower inflammation throughout cells

6. Washing of hands regularly to avoid infections.

Diagnosis

According to Panhak (2021) and Nall (2018), the following are ways in which ulcers can be diagnosed:

The doctor will first ask questions about medical history and symptoms.

Physical exam: The doctor will then feel the belly and ask about tenderness, pain, or bloating. A stethoscope might also be used to listen to any sounds the stomach is making.

A blood test: This will test for the presence of a certain infection-fighting cell that might indicate the presence of the H. pylori infection.

A stool antigen test: This also tests for the presence of some proteins related to the H. pylori infection.

A urea breath test: This involves the measurement of carbon dioxide levels by swallowing a pill (a special formation of urea) and breathing into a collection bag. If H. pylori is present, the urea in the pill is broken down into a certain type of carbon dioxide that can be detected.

Esophagogastroduodenoscopy (EGD) or Upper endoscopy: This involves passing a lighted flexible instrument with a camera on its end, known as a scope, through your mouth and down into the esophagus, stomach, and small intestine. This will enable the doctor to look for ulcers and also take a sample tissue for further testing.

Upper gastrointestinal series: The doctor may also order a test called a barium swallow or an upper GI series. This test involves drinking a solution with a small amount of liquid material that easily shows up on an X-ray. This allows them to look for conditions that affect the esophagus, stomach, and small intestine.

Treatment

Treatment of PUDs depends on the causes and the severity of the symptoms.

Histamine receptor blockers (H2 blockers) or Proton pump inhibitors (PPIs): This is prescribed by the doctor to reduce the amount of acid the stomach produces and also protect the digestive system lining (Numico, 2017). This might have to be taken for up to 8 weeks.

Antibiotics: Doctors will prescribe a combination of antibiotics if tests show the H. pylori infection as the cause of the ulcer. This medication has to be taken for up to 2 weeks (Higuera, 2020).

If the ulcer is caused by over-the-counter painkillers (NSAIDs), the doctors will advise the patient to stop taking them completely or suggest an alternative medication

Protectant: This might be prescribed by the doctor. This drug coats the ulcer and protects them from stomach acid (Pathak, 2021)

Protective medications: These medications are like a liquid bandage that covers the ulcer forming a protective barrier to prevent further damages from digestive acids and enzymes (Fahner, 2015).

Antacids: Doctors may include an antacid with the drug regimen for the treatment of ulcers. This medication neutralizes existing stomach acids, providing immediate ulcer pain relief.

Living with ulcer

People with ulcers should avoid the things that make the ulcer pain worse. This means avoiding spicy foods, alcohol and smoking. If aspirin or ibuprofen are taken for chronic pain, talk to a doctor. He or she may suggest an alternative. Mostly balanced meals should be eaten and try eating small, frequent meals when in pain.

What should ulcer patients eat?

1. Dietary changes can be important for treating and preventing PUDs. According to Charlesbois n.d. and Fahey (2015), the following dietary changes aid in the prevention and treatment of PUDs. 

2. Foods and flavorings that induce the stomach to produce acids should be avoided. This includes garlic, chili powder, black pepper, and caffeine.

3. A diet that contains plenty of foods that provide vitamin A and fibers. Sources of soluble fibers include apples, carrots, oats, legumes, nuts, and barley. Sources of vitamin A include liver, broccoli, spinach, sweet potatoes, kale, etc.

4. Foods that are also high in antioxidants should also be included in the diet.

5. Foods that may be helpful against ulcer-causing bacteria are also highly recommended. Some of them include cabbage, apples, blueberries, radishes, cauliflower, cherries, bell peppers, carrots, etc.

Recommendation and conclusion

Stomach ulcers are relatively easy to cure, as they normally rely on removing the cause. They can cause significant problems if left untreated. Having a support system that’s been there and understands is important. As well as taking prescribed medications early or completely quitting tobacco, alcohol, and nonsteroidal pain relievers during treatment. Doctors normally schedule a follow-up appointment after the initial treatment to evaluate recovery.

References

Caufield SP, et al. (2012). Peptic ulcer disease. http://patients.gi.org/topics/peptic-ulcer-disease/  

Charlesbois, A. (n.d.). Diet for ulcer disease https://www.badgut.org/information-centre/health-nutrition/diet-for-ulcer-disease/  

Fahey JW, et al. (2015). Dietary amelioration of Helicobacter infection [Abstract]. DOI: 10.1016/j.nutres.2015.03.001 

Fleman, A., Choi, N. (2017). What’s to know about peptic ulcer?. https://www.medicalnewstoday.com/articles/9273  

Higuera, V., Rogers, Graham. (2020). Peptic Ulcer. https://www.healthline.com/health/peptic-ulcer 

Julia Fashner, MD, and Alfred C. Gitu, MD. Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection. (https://www.aafp.org/afp/2015/0215/p236.html) American Family Physician. 2015;91(4):236-242. Accessed 6/24/2020. 

Kuipers EJ, Thijs JC, Festen HP. The prevalence of Helicobacter pylori in peptic ulcer disease. Aliment Pharmacol Ther 1995; 9 Suppl 2:59.

Lanza FL, et al. (2009). Prevention of NSAID-related ulcer complications. https://gi.org/guideline/prevention-of-nsaid-related-ulcer-complications/  

Li Z, Zou D, Ma X, et al. Epidemiology of peptic ulcer disease: endoscopic results of the systematic investigation of gastrointestinal disease in China. Am J Gastroenterol 2010; 105:2570.

MacGill, M., Butler, N. (2018). Everything you need to know about stomach ulcers. https://www.medicalnewstoday.com/articles/312045#symptoms  

Nall, R., Marcin, J. (2018). What’s the Difference Between Gastric and Duodenal Ulcers?. https://www.healthline.com/health/gastric-and-duodenal-ulcers  

National Institute of Diabetes and Digestive and Kidney Diseases. Definition & Facts for peptic ulcer (Stomach Ulcers). (2014). https://www.niddk.nih.gov/health-information/digestive-diseases/peptic-ulcers-stomach-ulcers/definition-facts. Accessed 6/24/2020.

Numico G, et al. (2017). Proton pump inhibitors in cancer patients: How useful they are? a review of the most common indications for their use. DOI: doi.org/10.1016/j.critrevonc.2017.01.014 

Pathak, N. (2021). Understanding ulcers. https://www.webmd.com/digestive-disorders/understanding-ulcers-basic-information  

Peptic ulcer. OMICS International. Available at https://www.omicsonline.org/united-states/peptic-ulcer-peer-reviewed-pdf-ppt-articles/. Accessed: August 1, 2019.

Shimamoto T, Yamamichi N, Kodashima S, et al. No Association of Coffee Consumption With Gastric Ulcer, Duodenal Ulcer, Reflux Esophagitis, and Non-Erosive Reflux Disease: A Cross-Sectional Study of 8,013 Healthy Subjects in Japan. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3680393/)  2013; 8(6): e65996. Accessed 6/24/2020. 

World Health Organization. (2018). Peptic Ulcer death per 100,000. https://www.worldlifeexpectancy.com/cause-of-death/peptic-ulcer-disease/by-country/   

WorldHealthRanking. (2021). Peptic Ulcer Disease: Death Rate Per 100,000 Age Standardized. https://www.worldlifeexpectancy.com/cause-of-death/peptic-ulcer-disease/by-country/