Western Medicine

Peptic ulcer disease (PUD) is a mixed group of disorders that involve the gastrointestinal (GI) tract. The stomach and duodenum (upper part of the intestine) are the most common locations where ulceration occurs. The rate of occurrence of PUD is variable and depends on ulcer type, age, gender and geographic location. For example, in Japan, stomach ulcers occur at five to ten times the rate of duodenal ulcers, while in the United States and most European countries duodenal ulcers are about two times as common as stomach ulcers.

Individuals with chronic peptic ulcer disease will experience periods of remission and recurrence of the disease, while acute peptic ulcers are limited to a specific patient population and clinical scenario. When left untreated, PUD may result in serious complications such as gastrointestinal bleeding and cancer. Stomach ulcers are much more likely to result in death or disability due to a greater likelihood of causing hemorrhage, perforation, or obstruction. In addition, while duodenal ulcers are almost never cancerous, approximately 55% of stomach ulcers are cancerous.

The western digestive tract

Chinese Medicine

Peptic ulcer is a terminology that belongs to modern medicine; there is no mention of it in the history of Traditional Chinese Medicine (TCM). Instead, because of the nature of its symptoms, it is categorized as "stomach ache" or "epigastric pain." It is associated with the spleen, liver and gall-bladder because these organs play an important role in the development of the disease.
According to the five elements theory, the spleen and stomach belong to earth, and the spleen has an interior-exterior relationship with the stomach. Both of these organs are responsible for the digestion, absorption and transportation of food, and control blood production and its circulation.

The liver and gall-bladder belong to wood and they jointly regulate qi (vital energy) and the emotions, enhancing digestion and blood flow. In normal circumstances, wood (liver and gall-bladder) restricts the earth (spleen and stomach) which means that the spleen and stomach are under the control of the liver and gall-bladder. If the liver is hyperactive, it unduly restricts functioning of the spleen, causing an imbalance in the body. According to the five elements theory, the resulting situation is described as "wood overacting on earth."

The spleen and stomach belong to the earth element, while the liver and gall bladder belong to the wood element.

Western Medicine

The cause of peptic ulcer disease (PUD) may be best described as an imbalance between the body's aggressive and protective factors. Aggressive factors that can cause damage to the gastrointestinal (GI) tract include a bacteria called helicobacter pylori (h. pylori), non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, stomach acid, and pepsin (a digestive enzyme).

The factors that protect the lining of the GI tract from the effects of the aggressive factors include an intact mucus layer, bicarbonate from the pancreas as a buffering agent, prostaglandins, and a substance called epidermal growth factor that reduces acid secretion. H. pylori and NSAIDs are the most significant factors that have been linked to the development of PUD. H. pylori initiates a compromise in the lining of the stomach that allows acid and pepsin to enter the tissue and cause damage. NSAIDs inhibit prostaglandins, thus leading to a reduction in protective factors. Other risk factors associated with PUD include smoking, stress, diet and alcohol use.

The mucus layer protects the stomach or duodenal lining from acid erosion and is secreted by the cell-rich loose connective tissue (the mucosa) located underneath. With a peptic ulcer, the mucus layer is disrupted.

Chinese Medicine

According to TCM, peptic ulcer can be caused by any of the following:

1. Dietary injury
Diet is an important cause of stomach disorders. The stomach receives and ripens food; the spleen transforms and transports refined nutrient essence up towards the lungs, whilst the stomach sends waste down towards the intestines. The descending function of the stomach corresponds with the ascending function of the spleen, and this is crucial in ripening, transporting and transforming nutrient essence and wastes in the middle burner. Improper eating habits affect the stomach easily which leads the stomach-qi to flow in the wrong direction, and results in nausea, vomiting, hiccups or belching.

2. Emotional distress
Emotional problems have a profound influence on stomach disorders. When emotions such as anxiety, pensiveness, grief and anger predominate, liver yang ascends and liver qi stagnates which, in turn, affects the functioning of the spleen and stomach. In the absence of the liver's regulatory function, the spleen cannot successfully transport and transform food into qi and blood, and the stomach cannot send waste down to the intestines. This causes epigastric pain, belching or nausea.

3. Weakness of spleen and stomach
This may be due to genetic constitutional weakness, or mental over-exertion over a long period. A person tends to get digestive problems like a poor appetite, vomiting or diarrhea, and possibly also muscle weakness and low energy. When attacks from pathogenic factors become more serious, stomach disorders occur easily.

Western Medicine

The location of gastrointestinal (GI) ulcer can be implied by the symptoms. People with stomach ulcers usually complain of pain being caused or worsened by food. They also describe the pain as being widespread over the lower abdomen. When someone has a duodenal ulcer the pain is typically described as sharp and burning in nature with a specific point of tenderness. In contrast to stomach ulcers, people with duodenal ulcers usually experience relief of pain with food.
Other symptoms of a duodenal ulcer include a feeling of abdominal pressure, fullness or hunger. People with duodenal ulcers may also be awakened at night due to the normal nighttime peak in acid secretion. It is important to be aware of "alarm symptoms" which can be present in people who have serious complications from peptic ulcer disease (PUD) such as bleeding or people with stomach cancer. These "alarm symptoms" include weight loss, vomiting, back pain, vomit that has the appearance of "coffee grounds" and dark tarry stools.

Chinese Medicine

Gastric pain, a major manifestation of peptic ulcer, usually occurs in the epigastric region or upper abdomen. Episodes of pain may be periodic, rhythmic or chronic. If seasonal, the pain usually occurs in late autumn, and the nature of pain is manifested as a dull, stabbing, distending, burning or hunger pain. Among the different types of pain, intermittent mild dull pain is most frequent. This usually lasts one or two hours but, in rare cases, it can last several days. The pain can be relieved by alkaline drugs or food. Along with pain, associated symptoms are belching, sour regurgitation, excessive saliva, nausea or vomiting.

Upper abdominal pain is the major complain of peptic ulcer.

Western Medicine

The most accurate method available to determine the presence of peptic ulcer disease (PUD) is through endoscopic examination of the upper gastrointestinal (GI) tract. This procedure uses a fiber optic instrument called an endoscope that is composed of a flexible tube and a lighted mirror lens system. The device allows your doctor to directly visualize and examine your esophagus, stomach and duodenum. A local anesthetic spray is applied to the throat to prevent gagging and the endoscope is placed in the mouth, passed through the throat, along the esophagus, and into the stomach and duodenum. In people with suspected PUD, this procedure may be used to determine the cause of bleeding, look for the presence of ulcers or inflammation, to perform a tissue biopsy to look for cancer cells or h. pylori, or to evaluate ulcer healing after a course of medication has been given.

Endoscopic examination of the upper gastrointestinal tract

If you are going to have an endoscopy performed you must not eat anything for 6 hours before the procedure. You also need to avoid using antacids after 10:00pm on the day before the procedure. In addition to the local anesthetic mentioned above, your doctor may give you several medications beginning 30 minutes before the examination. These medications include atropine to decrease secretions, narcotics and benzodiazepines (i.e. fentanyl and midazolam) to decrease anxiety, decrease discomfort and provide mild sedation.

There are several methods for diagnosing the presence of h. pylori infection. These include tissue biopsy for culture or CLO test, blood test for the presence of antibodies, the carbon-isotope breath test or a fecal test. Medications such as antibiotics, proton pump inhibitors, bismuth subsalicylate and sucralfate may cause false negative results for the breath test. You should avoid these medications for two weeks before taking the breath test for h. pylori.

It is well known that duodenal ulcer is caused by h. pylori infection in 95% of cases in people who are not taking NSAIDs. If this applies to you, your doctor may prescribe antibiotics for h. pylori eradication without doing a test for it first as this has become a safe and acceptable medical practice.

Chinese Medicine

Diagnosis in TCM places importance on determining the circumstances and manifestations of a disease through inquiry and observation of symptoms. A diagnosis is based on the traditional four examination techniques:

1. Questioning The TCM practitioner will establish the medical history of both the patient and his family.
2. Observation Examination of the physical features of the body, such as the face, tongue, hair, nails, sputum (mucus that is coughed up), and location of pain, all offer clues to the problem. The tongue is a particularly useful indicator of the functioning of the internal organs.
3. Listening and smelling The smelling of sputum and breath and listening to the sounds produced by the chest offer additional clues to the patient's health.
4. Touching Feeling the pulse is a cornerstone of TCM diagnosis and gives the practitioner much information about any bodily imbalance.

For details, please see article on "What to Expect from a TCM Doctor's Examination".

TCM practitioners will usually begin with a thorough investigation of the patient's complaints and categorize the symptoms under special syndrome groups known as "disharmony patterns." The disharmony patterns are present at different stages of a disorder. The practitioners will look at both the major manifestations, and "disharmony patterns" which are described below:

1. Qi stagnation
The patient feels distending pain in the epigastric region, and fullness and oppression in the hypochondrium (the upper lateral sides of the abdomen). These symptoms would worsen with emotional disturbance, and can be relieved by discharge of intestinal gas or belching. The patient tends to sigh, has a poor appetite and experiences oppression in the chest and sour regurgitation. On examination, the tongue is covered by a thin white fur, and the pulse is taut.
2. Heat retention
The patient feels a burning pain in the epigastric area. Eating offers no obvious relief; instead, it may even make the symptoms worse. The mouth is dry with a bitter taste. Other symptoms include thirst and a desire for cold drinks, sour regurgitation, irritability, clamoring stomach and constipation. On examination, the tongue is red with yellow fur, and the pulse is taut or rapid.
3. Yin deficiency
The patient feels a dull, burning epigastric pain which becomes worse on an empty stomach. Other associated symptoms include thirst and a disinclination to drink, dryness of the mouth, poor appetite, retching, constipation, and a feverish sensation in the palms, soles and chest. On examination, the tongue is red and dry, with cracks in the central portion. It is covered with little or scattered, cracked fur. The pulse is thready or rapid.

A pale tongue with indented margin, the cracks in the central portion indicate spleen and stomach dysfunction.

4. Deficient cold
The patient feels a dull epigastric pain which tends to ease with warmth and massage. An attack can be easily induced or worsened by over-exertion. The pain worsens on an empty stomach. Although the pain can be relieved by eating, abdominal distention will follow. Other associated symptoms are fatigue, sleepy, reluctance to speak, and loose stools. On examination, the tongue is pale and bulky with indented margin, and it is covered by a thin white fur. The pulse is deep, thready or slow.
5. Blood stasis
The patient experiences a fixed, stabbing pain in the epigastric area. But when the pain becomes extreme, it sometimes radiates towards the chest and the back. This may be accompanied by coldness of the limbs, sweating, vomitting blood or blood in the stools. On examination, the tongue is dark purple, and may have bruises or patches on the surface. The pulse is hesitant.
In general, during the pathological course of peptic ulcer, the above syndromes develop at different stages. In the early or active stages of peptic ulcer, qi stagnation and heat retention syndromes are quite common. TCM terms these as a sthenia or excess (shi) syndromes in which the body offers a relatively strong resistance.
In the late or recovery stages of peptic ulcer, yin deficiency and deficient cold syndromes are more common. TCM terms these as a sthenia or deficiency (xu) syndromes in which the body's resistance is very weak.
Blood stasis syndromes can develop at any stage, but occurs mostly in the middle and late stages. The syndrome has a deficiency nature but presents excitatory signs, or having both excess and deficiency syndromes inter-mixed.

Western Medicine

The short-term goals of peptic ulcer disease (PUD) treatment are to promote ulcer healing, prevent potential complications, and when h. pylori is present, provide an optimal environment for an effective antibiotic therapy. The long-term goals of treatment include resolving the ulcer, preventing recurrence and avoiding potential complications. The treatment plan for PUD differs by the cause (NSAID vs. non-NSAID users) and location (stomach vs. duodenum) of the ulcer. The medications used in PUD management include acid suppressants (antacids, histamine-2 receptor blockers, and proton pump inhibitors) and gastric mucosal protectants, for relief of symptoms and to promote ulcer healing, and antibiotics to eradicate h. pylori when it is present.

NSAID induced ulcers are generally treated by stopping NSAID use and providing acid suppressive therapy. Increased mucosal protection may also be included in the treatment plan in people who cannot stop taking NSAIDs. Non-NSAID induced ulcers are usually caused by h. pylori and are treated with a combination of antibiotics and acid suppressive therapy. In both NSAID and non-NSAID induced ulcers, acid suppressive therapy is given in higher doses and for a longer duration for stomach ulcers than for duodenal ulcers because stomach ulcers take longer to heal. Please refer to the text below and table (1) for details on the medications used in the treatment of PUD.

I. Acid suppressants

1. Antacids

Antacids neutralize acid in the stomach and prevent activation of pepsin. They provide short-term (45 minutes to 3 hours) relief of ulcer symptoms. Drawbacks to antacid use include side effects, such as constipation and diarrhea, and the potential to interact with other drugs.

2. Histamine-2 (H2)-receptor blockers

H2-blockers work by blocking the histamine stimulated secretion of acid by the parietal cell. Although infrequent, potential side effects include: diarrhea, headache and mental status changes in elderly persons. Patients taking cimetidine need to be especially cautious of using other prescribed and over-the-counter medications as there are a lot of drug interactions associated with this drug. The major drawback to the use of H2-blockers is the potential for development of tolerance to the acid suppression effects of the drugs.
3. Proton pump inhibitors (PPIs)
Proton pump inhibitors (PPIs) are the most potent acid-suppressing medications in use today. They block acid secretion at its source by binding directly to the proton pump which is the final step in the metabolic pathway of acid secretion. These medications may also facilitate the transport of anti- h. pylori antibiotics to the site of infection. Most people who take PPIs experience little to no side effects, but the most common potential side effects include nausea, diarrhea, abdominal pain, dizziness or headache. Patients taking omeprazole need to be especially cautious of using other medications as there are a lot of drug interactions associated with this PPI. Drug interactions may also occur with lansoprazole, but are far less frequent.

II. Gastric mucosal protectant

Sucralfate forms a physical barrier over ulcerated tissue to protect it from aggressive factors. The drug is not absorbed into the body to any significant extent and is not an acid suppressant. Side effects with sucralfate are uncommon, but may include constipation, nausea, flatulence and gastric discomfort. Sucralfate may reduce the absorption of other medications, so it is a good idea to separate this medication from others by at least 2 hours.

III. Antibiotics

Antibiotics are used to eradicate h. pylori when it is present. The antibiotics that are commonly used for this purpose include bismuth subsalicylate, metronidazole, amoxicillin, tetracycline and clarithromycin. Important patient information about these antibiotics is listed below.

Bismuth subsalicylate

• Shake the liquid well before using;
• Chew tablets or allow to dissolve in the mouth. Do not shallow whole;
• May cause dark discoloration of tongue or stool.

Metronidazole

• May cause harmless discoloration of urine;
• Avoid alcoholic beverages for the entire time you are taking this medication;
• You may notice a metallic taste in your mouth;
• Take with food to decrease stomach upset.

Amoxicillin

• You can take this medication with or without food;
• Females using oral contraceptives should use an additional method of contraception during treatment.

Tetracycline

• Take this medication 1 hour before or 2 hours after meals;
• Do not take any antacids, iron, or dairy products for 2 hours before or after this medication;
• Avoid prolonged exposure to sunlight and use sunscreen when if you are going to be out in the sun;
• Females using oral contraceptives should use an additional method of contraception during treatment.

Clarithromycin

• You can take this medication with or without food;
• You may notice an abnormal taste in your mouth.

If you are found to have h. pylori infection, your treatment regimen should include at least two of these antibiotics. Treatment with just one antibiotic has been found to be highly ineffective in eliminating the organism. It is very important that you adhere to the prescribed treatment and finish the entire course of antibiotics in order to aid in successful eradication of h. pylori. Please refer to table (2) for a summary of commonly used anti-h. pylori treatment regimens.

Chinese Medicine

In TCM, treatment for peptic ulcer is based on "disharmony patterns," or therapies according to the western symptoms of peptic ulcer syndromes. An alternative is to integrate western and Chinese approaches to create a synergetic effect on the disease, thus enhancing clinical efficacy. The following are brief introductions to TCM approaches:

A. Treatment based on TCM syndromes

Qi stagnation

Therapeutic aim: Soothing the liver to regulate qi. Commonly used prescriptions are modified chaihu shugan tang, sini san and xiaoyau san.

Sample of Prescription: chaihu shugan tang

chai hu	Chinese tororwax root
chen pi	dried tangerine peel
shao yao	peony
zhi ke	bitter orange
zhi gan cao	liquorice root (processed with honey)
chuan xiong	Szechuan lovage
xiang fu	nut grass

Heat retention

Therapeutic aim: Soothing the liver and eliminating heat. Commonly used prescriptions are modified huagan jian, zuojin wan and banxia xiexin tang.

Sample of prescription: banxia xiexin tang

ban xia	pinella tuber
huang qin	baical skullcap
gan jiang	fried ginger
ren shen	ginseng
zhi gan cao	liquorice root (processed with honey)
huang lian	golden thread
da zao	common jujube fruit

Yin deficiency

Therapeutic aim: Nourishing yin to strengthen the stomach. Commonly used prescriptions are modified
yiguan jian, yangwei tang and liuwei dihuang tang.

Sample of Prescription: yiguan jian

sha seng	adenophora
mai dong	dwarf Lily-turf
dang gui	Chinese angelica root
sheng di	dried rehmannia root
qi zi	Chinese wolfberry fruit
chuan lian zi	toosendan fruit

Deficient cold

Therapeutic aim: Warming the middle burner to strengthen the spleen. Commonly used prescriptions are modified huangqi jianzhong tang, sijun zi tang, lizhong tang and liangfu wan.

Sample of Prescription: huangqi jianzhong tang

huang qi	Mongolian milkvetch root
gui zhi	cassia twig
zhi gan cao	liquorice root (processed with honey)
da zao	common jujube fruit
shao yao	peony
sheng jiang	fresh ginger
yi tang	maltose

Blood stasis

Therapeutic aim: Activating blood to resolve stagnation. Commonly used prescriptions are xuefu zhuyu tang and gexia zhuyu tang.

Sample of Prescription: xuefu zhuyu tang

dang gui	Chinese angelica root
sheng di	dried rehmannia root
tao ren	peach seed
hong hua	safflower flower
zhi ke	bitter orange
chi zhao	common peony root
niu xi	twotooth achyranthes root
jie geng	balloonflower root
chuan xiong	Szechuan lovage
chai hu	Chinese tororwax root
gan cao	liquorice root

During the treatment, herbs like liquorice root (gan cao), tendrilleaf fritillary bulb (chuan bei), common bletilla tuber(bai ji), notoginseng (san qi) rhubarb (da huang) are added in the prescription for additional relief of dyspeptic symptoms. Some prescriptions to astringe (lessen) acid secretion are effective for related complaints, e.g. mixed powder of thunberg fritillary bulb(zhe bei mu) and cuttle-fish bone (wu zei gu) can be used.

B. Single Proven Prescription

In practice, a lot of recipes have been proved effective against the disease but were not listed in medical journals. These recipes do not follow any particular diagnostic rules in TCM but are used only when the disease is confirmed as peptic ulcer. For example pearl powder is effective in providing relief from symptoms and speeding up the healing of an ulcer.

C. Acupuncture and moxibustion

This method is used to provide pain relief, and commonly applied according to the differentiation of the affected meridian. For example, in the case of liver and stomach disharmony, acu-points in the Leg Yang Ming Stomach Meridian and Leg Jue Yin Liver Meridian are chosen.

Leg Jue Yin Liver Meridian

D. Others

Besides the above therapeutic methods, dietary therapy, qi-gong, massage and physical exercise benefit the patient. These methods complement the drug therapy to improve total efficacy.

Western Medicine

Initial occurrence

In general, eliminating or minimizing lifestyle habits that have been associated with an increased risk of peptic ulcer disease (PUD) such as smoking, stress, diet, and alcohol use can help reduce the risk of developing PUD.

No Smoking, No Alcohol, Reduce stress

More specifically, NSAID induced ulcers can be prevented by using an alternative medication for pain such as acetaminophen. If you must take NSAIDs, make sure you always take them with food. Prevention of the initial occurrence of non-NSAID induced ulcers is difficult as they are primarily caused by h. pylori.

Recurrence

The risk of ulcer recurrence in people with a history of NSAID induced ulcers who must continue to use NSAIDs can be reduced by using H2-blockers, Proton pump inhibitors (PPIs), or a medication called misoprostol. Misoprostol is a prostaglandin derivative that increases bicarboante and mucus production and decreases acid secretion. If you are a woman of child-bearing age, you must use a reliable form of contraception if you are going to use this medication. Non-NSAID induced ulcer recurrence can be prevented by making sure you are compliant with the prescribed antibiotic regimen. Make sure you go back to your doctor to have a test to confirm elimination of h. pylori after you finish the antibiotic treatment and take a second course of antibiotics if the first one is not effective. If continued acid suppression is needed your doctor may prescribe H2-blockers or PPIs in lower doses.

Chinese Medicine

In order to avoid a relapse or speed up recovery, appropriate emotion and dietary management are major concerns.

• Avoid stress and negative emotions at all times.
• Chinese medicine stresses the importance of eating according to a set routine. Regular meals should be taken at the same time, with similar amounts eaten for corresponding meals every day. It is best to eat cooked and light food and avoid foods that are too cold or hot-spicy.

Western Medicine

Chinese Medicine