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Nutritional Care Of Peptic Ulcer

by Dr Mohan Krishnarao Kale(more info)

listed in nutrition, originally published in issue 165 - December 2009

Abstract

Peptic Ulcer is one of the most common diseases today. It refers to an eroded lesion in the gastric intestinal mucosa. An ulcer may form in any part of the digestive tract, which is exposed to acid gastric juice, but is usually found in the stomach (gastric ulcer) and the duodenum (duodenal ulcer). Nutritional Care/Diet is of utmost importance in the treatment of ulcer. The diet should be arranged as to provide adequate nutrition to afford rest to the disturbed organs, to maintain continuous neutralization of the gastric acid, to inhibit the production of acid and to reduce mechanical and chemical irritation. Before as well as after treatment, nutritional care is vital to prevent, heal and cure Peptic Ulcer.

Peptic ulcer

Introduction

Peptic Ulcer is one of the most common diseases today. It refers to an eroded lesion in the gastric intestinal mucosa. An ulcer may form in any part of the digestive tract, which is exposed to acid gastric juice, but is usually found in the stomach (gastric ulcer) and the duodenum (duodenal ulcer). Duodenal ulcers are about ten times more frequent than gastric ulcers. They are more common in sedentary workers. The incidence of peptic ulcers is four times higher in men than women. Men are more affected by duodenal ulcers whereas women usually get ulcers in the stomach. Both kinds affect young to middle-aged persons, and are most common in the 35-40 age groups.

Symptoms 

The most common symptoms of peptic ulcer:
  • Sharp and severe pain and discomfort in the upper central abdomen;
  • The pain is commonly described as burning or gnawing in character;
  • Gastric ulcer pain usually occurs an hour after meals and rarely at night;
  • Duodenal ulcer pain usually occurs between meals when the stomach is empty and is relieved by food, especially milk. It is often described as hunger pain;
  • There is distension of the stomach due to excessive flatulence, besides mental tension, insomnia and gradual weakening of the body. It may also cause constipation with occasional blood in the stools. If an ulcer bleeds slowly, there is anaemia, while massive bleeding lead to shock, or even death if untreated.
Intestine

Causes

  • Peptic ulcers result from hyperacidity in the stomach. This strong acid secreted by the cells lining the stomach can be potentially dangerous and it may eat the lining of the stomach or duodenum producing, first, irritation of the stomach wall and eventually an ulcer;
  • Dietetic indiscretion, like overeating, taking of heavy meals or highly spiced foods, coffee, alcohol and smoking are the main factors contributing to this condition. Alcohol is a very powerful acid producer and has a burning effect on the stomach lining. Coffee also increases the production of acid especially when it is taken black;
  • The ingestion of certain drugs particularly aspirin, food poisoning, infections like influenza, septicaemia and gout may also cause ulcers;
  • Emotional stress, excessive worry, anger, tensions, jealousy, and hurry also plays a major role in the formation of ulcers. Presumably stress and strain, hurried and irregular meals, and inadequate mastication are important contributory factor in ulcers.

Pathogenesis – Imbalance between mucosal defensive factors and aggressive factors 


Defensive Factors
Prevent the stomach and duodenum from being harmed (self-digestion); Mucus – continually secreted, protective effect; Bicarb – secreted from endothelial cells, neutralized hydrogen ions; Blood flow – good blood flow helps to maintain mucosal integrity; Prostaglandins – stimulate secretion of bicarb and mucus and help promote blood flow, suppress secretion of gastric acid. Aggressive factors
em>Helicobacter pylori – gram negative bacteria, can live in stomach and duodenum; May break down mucus layer, inflammatory response to presence of the bacteria may break down defences, also produces urease – forms CO2 and ammonia which are toxic to mucosa; NSAIDS – inhibit the production of prostaglandins; Decrease blood flow, decrease mucus production and bicarbonate synthesis, promote gastric acid secretion; Gastric Acid – also needs to be present for ulcer to form – activates pepsin and injures mucosa; Pepsin; Smoking.

Treatment

Classes of drugs: Antibiotics, Antisecretory agents, Mucosal protectants, Antisecretory agents that enhance mucosal defenses, Antacids etc; Nondrug therapy: Diet – change in eating pattern, 5-6 small meals a day, Smoking cessation, NSAID(analgesics) should be avoided whenever possible and avoid alcohol; Raise the head of the bed, or lie on left side; Decrease fat intake; Nutritional / Dietic Control.

Nutritional Care

Diet is utmost importance in the treatment of ulcer. The diet should be so arranged as to provide adequate nutrition to afford rest to the disturbed organs, to maintain continuous neutralization of the gastric acid, to inhibit the production of acid and to reduce mechanical and chemical irritation. To achieve the above objectives, the following nutrient modifications are recommended

Energy
Most patients suffering from active peptic ulcers are undernourished and therefore need an increased energy intake. However, since they are confined to bed the energy needs for activity are not utilized and make up the extra needs.

Proteins
A high protein intake is recommended to provide essential amino acids for tissue protein synthesis and thus promote healing. Proteins are also included because of their good buffering action. They may be increased by about 50 %. However meat proteins are to be avoided because meat extractives have a stimulating effect. Though milk protein has a good buffering action, the high calcium content of milk stimulates excess acid production hence, should be used in moderation. Eggs and other protein foods need to be included to provide essential amino acids.

Fats
Since fat delays the emptying of stomach, an increased intake is beneficial. However, fat is only moderately increased since patients suffering from peptic ulcers are generally middle aged executives who are also prone to atherosclerosis. Emulsified fats like butter, cream etc are better tolerated.

Carbohydrates
Carbohydrates are included to meet the energy needs. Foods containing harsh, irritating fibre should be avoided.

Vitamins
Requirements of nearly all vitamins remain normal. Adequate amount of vitamin C should be provided for the healing of ulcers and better iron absorption.

Minerals
Care should be taken to include sources of iron and calcium in the diet. Generally, bland diets are found to be low in iron and vitamin C due to the restriction in fruits and vegetables, and medicinal supplements may have to be given.

fruit
Eating habits are essential. One should never eat when tired or emotionally upset, nor when he is dry. One should chew every morsel thoroughly. One should eat only natural foods and take food in as dry from as possible. Meals must be small and frequent. All foods and drinks, which are either too hot or too cold, should be avoided. The patient should drink eight to ten glasses of water every day. However, he should not drink water during or with meals, but only half an hour before or one hour after meal. Daily massage and deep breathing exercises also help. Above all, the patient must try to rid himself of his worries and stay cheerful. One should also cultivate regularity in his habits-be it work, exercise or rest with Peptic Ulcer; Milk, cream, butter, fruits and fresh raw and boiled vegetables, natural foods and natural vitamin supplements are the best diet for an ulcer patient. Milk should be taken in moderate quantities; The fruits such as bananas, mangoes, melon reduce the acidity in the stomach. Some raw fruits and vegetables should be avoided, as many of these are especially irritating. Potatoes, squashes, yams and raw bananas are, however, well tolerated; A low-salt diet can greatly help in curing hyperacidity and ulcer; Ayurvedic doctors in India have traditionally used dried banana powder (Musa paradisiaca) to treat ulcers. Banana powder protects the lining of the stomach from acid. Bananas are highly beneficial. They are said to contain an unidentified compound called, perhaps jokingly, vitamin U (against ulcers). Well-cooked millet and cooked white rice with milk can be added later; Almond milk made from balanced almonds in a blender is very beneficial as it binds the excess of acids in the stomach and supplies high quality protein; Goat's raw milk is also highly-beneficial as it helps to heal the peptic ulcer; Those in an advanced state of the disease should avoid whole grains, nuts and whole grain bread; All sour fruits should be avoided, especially citrus fruits. Greasy foods, flesh foods, tea, coffee, tobacco, alcohol, condiments, preserves and sugar should be completely eliminated in ulcers; Several studies have shown that vitamin E and A, especially taken together, have not only a protective effect against development of ulcers caused by stress, but also a curative effect on existing ulcers. Vitamin A is needed to heal the linings (called mucous membranes) of the stomach and intestines; Cabbage juice accelerated healing of peptic ulcers. Drinking a quart of cabbage juice per day may provide relief. Carrot juice may be added to improve the flavour; Fibre slows the movement of food and acidic fluid from the stomach to the intestines, which should help those with duodenal, though not stomach ulcers. Avoiding food allergens may be helpful for people with peptic ulcers. Aspirin and related drugs (non-steroidal anti-inflammatory drugs), can aggravate or interfere with the healing of peptic ulcers; Zinc is also needed for the repair of damaged tissue and has protective effect against stomach ulceration. Zinc supplements with 25 to 50 mg of zinc per day and 1 to 3 mg of copper per day must be taken. Experimental animal studies have shown that a zinc salt of the amino acid carnosine exerts significant protection against ulcer formation and promotes the healing of existing ulcers. This compound can help eradicate H. pylori, an organism that has been linked to peptic ulcer. Glutamine, an amino acid, is the principal source of energy for cells that line the small intestine and stomach. Some suggest 500 to 1,000 mg of glutamine taken two to three times per day may help people to overcome peptic ulcers; Oral supplementation with dimethyl sulfoxide (DMSO) reduce relapse rates for peptic ulcer. DMSO in combination with cimetidine is more effective than cimetidine alone; 
Rice and other foods
Licorice may protect the stomach and duodenum by increasing production of mucin, a substance that protects the lining of these organs against stomach acid and other harmful substances. According to laboratory research, deglycryrrhizinated form of licorice may also inhibit growth of H. phlori and also provide soothing effect. The gummy extract of Pistachia lentiscus, also known as mastic or gum mastic, may heal peptic ulcers by its ability to kill H. pylori.; Chamomile tea has a soothing effect on inflamed and irritated mucous membranes. It is also high in the flavonoid apigenin that inhibit growth of H. pylori; Calendula is another plant with anti-inflammatory and healing activities that can be used as part of a traditional medicine approach to peptic ulcers; Marshmallow is high-mucilage containing herbs and may be used for irritated or inflamed mucous membranes in the digestive system; Garlic has been reported to have anti-Helicobacter activity and may be useful; Extracts of the herb corydalis are not only helpful as pain-relief agents but also may be useful in the treatment of stomach ulcers; Comfrey has a long traditional use as a topical agent for improving healing of wounds, skin ulcers and stomach ulcers. People should only use comfrey preparations made from the leaves and avoid those made from the roots; Because of the anti-inflammatory and healing effects of plantain, it may be beneficial in some people with peptic ulcer. Stress reduction techniques or psychological counselling helps to prevent ulcers or ulcer recurrence. People with peptic ulcer due to infection from Helicobacter pylori (H. pylori) should follow conventional treatment.

References

1. Malhotra S.L. New approaches to the pathogenesis of peptic ulcer based on the protective action of saliva with special reference to roughage, vegetable fibre and fermented milk products. Medical Hypotheses, 4 (1): 1-14. 1978.
2. FrankI. T., Jayaraj A. P., Clark C. G. Diet and Ulcer. The Lancet, 330( 8555) : 398. 1987.
3. Kuipers EJ, Thijs JC, Festen HP. The prevalence of Helicobacter pylori in peptic ulcer disease. Aliment Pharmacol Ther; 9(2): 59-69. 1995.
4. Vaira D, Menegatti M, Miglioli M. What is the role of Helicobacter pylori in complicated ulcer disease? Gastroenterology.113(S): 78-84. 1997.
5. Russell MK, Mueller C., Nutrition screening and assessment. In The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach: American Society for Parenteral and Enteral Nutrition,163 –186, 2007.
6. Walid H A. et al, Prospective Study of Diet and the Risk of Duodenal Ulcer in Men, American J Epidemiology 145(1):42-50. 1997.
7. Grace H E et al. Comparison of Coffee Intake and Coffee-Induced Symptoms in Patients with Duodenal Ulcer, Nonulcer Dyspepsia, and Normal Controls. American J Gastroenterology 85(10):1339-1342 .1990.

Comments:

  1. Priya said..

    is there any specified amount of energy to be consumed?

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About Dr Mohan Krishnarao Kale

Dr Mohan Krishnarao Kale PhD is Professor (Pharmacology) at Sharad Pawar College of Pharmacy, Wanadongri, Nagpur, (INDIA) 441 110.   His highest Qualifications include  M. Pharm (Pharmacology) PhD. He has 27 years of administrative and Teaching experience  and is a recognized PhD Supervisor RTM  at Nagpur University, MJRP University  Jaipur and Sant Gadgebaba Amaravati University. He is the recipient of the prestigious "MPA Award" from Maharashtra Pharmacist Association, Mumbai for contribution to Pharmacy Profession. (8th  Feb.2009). He has published and received three best poster presentation awards  at  National Conventions. Dr Kale’s areas of research include: Oxidative Stress and the Thyroid,  Kidney failure and future drug development, Diabetic Complications etc. He has published many research articles in national and international journals and a book titled Pharmacology and Toxicology published by VBD Printers, Nagpur.
His associations with professional organizations include: Vice-President, APTI. Maharashtra branch. (2008-2011);  Secretary, Pharmaceutical Society of India (2003-2011);  Secretary NYSS - NCP alumni association , Secretary RTMNU - UDPS alumni association.
Dr Kale may be contacted via kalemkpharm@gmail.com

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