A Functional Medicine Protocol for Peptic Ulcers

Living with peptic ulcer disease (PUD) can be incredibly challenging, with symptoms like abdominal pain and discomfort making everyday life difficult. It's estimated that over four million people in the United States are affected by PUD each year, highlighting the widespread impact of this condition. However, there is hope. 

A comprehensive approach to managing PUD can provide relief and improve quality of life. This approach involves various steps, including addressing potential contributing factors, such as Helicobacter pylori infection, and making lifestyle changes to support healing. By following these steps, individuals may better manage their symptoms and reduce the risk of complications associated with PUD.

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What Is Peptic Ulcer Disease?

Peptic ulcer disease (PUD) refers to painful sores (ulcers) that form most commonly in the lining of the stomach or small intestine. These ulcers develop when the protective lining of these organs is eroded, exposing the underlying tissue to stomach acid and digestive enzymes.

Ulcers in the stomach lining are called gastric ulcers; those that occur in the lining of the upper portion of the small intestine (called the duodenum) are duodenal ulcers. Duodenal ulcers are four times more common than gastric ulcers. 

Signs & Symptoms of Peptic Ulcers

Having a peptic ulcer can feel like indigestion and cause symptoms like: 

• Burning stomach pain: Gastric ulcers typically cause pain within 15-30 minutes of starting a meal. Pain associated with duodenal ulcers subsides at the beginning of meals and then increases 2-3 hours after mealtime. 
• Bloating
• Burping
• Heartburn
• Nausea and vomiting
• Indigestion
• Increased fullness/reduced appetite 
• Unintentional changes in weight (loss or gain)
• Black, tarry stool

Root Causes of Peptic Ulcer Disease

The most common causes of PUD are Helicobacter pylori infection and the use of nonsteroidal anti-inflammatory drugs.

Helicobacter pylori

H. pylori is a bacteria that infects up to 75% of the world's population and is associated with 90% of duodenal ulcers and 70-90% of gastric ulcers. H. pylori is highly capable of evading the immune system, adhering to intestinal mucosa, inducing inflammation, and contributing to ulceration in the gastrointestinal (GI) mucosa. (5, 16)

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs, including aspirin and ibuprofen, inhibit the COX-1 enzyme responsible for producing prostaglandins, which are molecules that protect the gastric mucosa. Taking high-dose or long-term NSAIDs decreases intestinal mucus secretion and mucosal blood flow, which may contribute to ulcer formation. (16)

Other Causes

Less common causes of PUD include:

• Viral, fungal, and bacterial other than H. pylori
• Loss of blood supply to the GI tract
• Chemotherapy or radiation therapy
• Zollinger-Ellison Syndrome: A condition characterized by tumors (called gastrinomas) that cause the stomach to make too much acid
• Crohn's disease: an autoimmune disease that causes chronic inflammation in the GI tract
• Stomach cancer

Lifestyle

Other risk factors for PUD include:

• Smoking
• Drinking alcohol
• Eating spicy foods
• Stress

How to Diagnose Peptic Ulcer Disease

When a doctor is suspicious of a peptic ulcer causing clinical symptoms, they will follow these outlined steps to make a definitive diagnosis, find its cause, and rule out complications.

Step 1: Endoscopy

An upper endoscopy is a procedure that allows doctors to visualize the upper digestive tract, including the esophagus, stomach, and duodenum. It is the most accurate test for finding active ulcers. During the procedure, doctors can take tissue biopsies and address bleeding ulcers that they find. 

Step 2: H. pylori Testing

H. pylori infection can be diagnosed with a:

• Serum ELISA antibody test
• Urea breath test
• Stool antigen test
• Endoscopic biopsy

Examples of H. pylori tests that can be ordered through Rupa Health include:

• H. Pylori (IgG) by Alletess Medical Laboratory
• H. Pylori Antigen by Doctor's Data

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Step 3: Screen for Iron Deficiency Anemia

Upper GI bleeding occurs in 15-20% of patients with PUD. Chronic GI bleeding is a common cause of iron deficiency and iron deficiency anemia (IDA). To rule out IDA as a secondary complication of PUD, your doctor will assess red blood cell numbers and iron concentrations with complete blood count (CBC) and ferritin blood tests.

Approaches to Managing Peptic Ulcer Disease

A specific approach to managing PUD will depend on the underlying factors contributing to the ulcer, but the basic principles of supporting ulcer healing include addressing H. pylori infection, avoiding NSAID use, and supporting mucosal health.

1. Address Inflammatory Triggers

Here's Why This Is Important: 

Supporting ulcer healing may be difficult if underlying inflammatory triggers are not addressed. Managing these triggers supports efficient mucosal health and can provide the patient with symptom relief. 

How Do You Do This?

Doctors should take a comprehensive patient history to determine possible triggers contributing to PUD. Addressing these triggers should be tailored to each patient's risk factors, but may include:

• Discontinuing NSAID use
• Avoidance of alcohol
• Elimination diet to avoid triggering foods, such as spicy foods
• Smoking cessation
• Stress management

2. Support Mucosal Health

Here's Why This Is Important:

This helps to restore the integrity of the mucous membrane lining the stomach or small intestine, which the ulcer has affected. Supporting mucosal health may reduce the risk of ulcer recurrence, help prevent ulcer-related complications, and alleviate symptoms such as pain and discomfort.

How Do You Do This?

The administration of a histamine 2 (H2) blocker or proton pump inhibitor (PPI) for four weeks may support healing in most ulcers. PPIs are often recommended as a first-line option for many patients because they are effective at managing pain and supporting ulcer healing. (20) 

There are many natural supplemental options with properties that may support anti-inflammatory and healing processes. Evidence suggests that the following dietary and herbal supplements can be used to support the management of PUD symptoms and promote GI health:

• Zinc carnosine: 150 mg daily
• Boswellia: 250 mg daily
• Deglycyrrhizinated licorice (DGL): 760-1,520 mg between or 20 minutes before meals
• Probiotics: 20 billion CFU daily

3. Address H. pylori Infection

Here's Why This Is Important:

Since H. pylori bacteria are a leading factor in ulcer development, addressing the infection is essential for effectively managing PUD and supporting long-term outcomes for affected individuals.

How Do You Do This?

The American College of Gastroenterology (ACG) recommends antibiotic therapy as a first-line option for all patients who test positive for H. pylori infection. Standard antibiotic protocols include: 

• Clarithromycin triple therapy: PPI + clarithromycin + amoxicillin or metronidazole for 14 days
• Bismuth quadruple therapy: PPI + bismuth + tetracycline + metronidazole or tinidazole for 10-14 days
• Concomitant therapy: PPI + clarithromycin + amoxicillin + metronidazole or tinidazole for 10-14 days

4. Address Iron Deficiency Anemia

Here's Why This Is Important:

Complications associated with untreated IDA include chronic fatigue, restless legs syndrome, heart problems, pregnancy complications, hypothyroidism, and hair loss (4, 8). 

How Do You Do This?

Patients with IDA secondary to a bleeding ulcer may be treated with iron to support iron and red blood cell levels to an optimal range. The recommended oral dose of iron for addressing IDA in adults is 120 mg of elemental iron daily, divided into multiple doses. However, newer evidence suggests that every-other-day dosing can improve the absorption rate of oral iron and support serum iron levels more effectively. (8) 

The Risks of Untreated Peptic Ulcer Disease

Left untreated, PUD can result in:

• Chronic GI bleeding, leading to severe blood loss, iron deficiency, and anemia
• Perforation (hole) of the stomach or small intestinal wall
• Obstruction of the upper GI tract
• Increased risk of gastric cancer in those with H. pylori (17)

Alarm symptoms that warrant the need for prompt medical evaluation include: 

• Anemia
• Vomiting of blood
• Blood in stool 
• Loss of appetite
• Unintentional weight loss
• Persistent, severe upper abdominal pain radiating to the back

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Key Takeaways:

• Peptic ulcer disease is most commonly associated with H. pylori infection and chronic NSAID use. 
• Supporting the healing of peptic ulcers involves addressing underlying factors and supporting the health of the intestinal mucosa. 
• Comprehensive testing allows doctors to identify the specific factors contributing to PUD so that an individualized and effective management plan can be implemented to support healing, relieve PUD symptoms, and help prevent ulcer recurrence.