Acid peptic disease and Homoeopathy

Dr Sreelekshmi S

ABSTRACT:
Peptic ulcers are the areas of degeneration & necrosis of the gastrointestinal mucosa exposed to acid-peptic secretions (break in the inner lining of the mucosa in general). Though they can occur at any level of the alimentary tract that is exposed to HCL & pepsin, they occur most commonly (98 – 99%) in either the duodenum or the stomach in the ratio of 4:1.

KEYWORDS: Peptic ulcer disease (PUD), Gastric and Duodenal ulcers, Homoeopathic medicines.

INTRODUCTION:
Acid peptic diseases results from distinctive but overlapping pathogenic mechanisms which involve reduced mucosal defence due to acid effects. Glands in the stomach produces acid and an enzyme called as pepsin that helps the body to digest food in the process of digestion. Normally, the stomach and the duodenum also produce mucus that protects the inner lining of the wall of these organs from the effect of acid secreted during the process. But sometimes excessive gastric acid secretion occurs and so, due to repeated attack of this acid, there is decreased mucosal activity of the wall lining of these organs, due to which various symptoms of Acid Peptic Disorder develops.

Peptic ulcers are mainly of 2 types:

Acute peptic ulcers
Stress ulcers              

Chronic peptic ulcers
Gastric Ulcer
Duodenal Ulcer

ACUTE PEPTIC ULCER

Also stress ulcers are usually multiple erosions due to disruption of the mucosal barrier with multiple, small mucosal erosions seen most commonly in the stomach.

CAUSES:

occurs following severe stress

• may be psychological or physiological stress involving:
•  Shock
•  Severe trauma
•  Septicemia
•  Extensive burns (curling’s ulcer)
•  Intracranial lesions(Cushing’s ulcer)
•  Drug intake(eg: Aspirin , steroids etc.)
•  Local irritants(eg: Alcohol, smoking, coffee etc.)

Clinical Features:

• Sudden onset of a/c pain & tenderness in epigastric region.
• Vomiting with or without hematemesis.
• often a/c peptic ulcers can lead to perforations(curling’s & cushing’s ulcers).
• Diagnosis by gastroscopy.

Morphological features:

• multiple, more than 3 in 75% cases.
• Oval or circular in shape, usually <1cm in diametre.

Microscopically:

• Are shallow & do not invade the muscular layer.
• Margins & base may show some inflammatory reaction.
• Depending upon the duration of the ulcers these ulcers heal by complete reepithelialisation without leaving any scars.

CHRONIC PEPTIC ULCERS

• Gastric Ulcer
• Duodenal Ulcer

AETIOLOGY:

Causative factors	Gastric ulcer	Duodenal ulcer
Helicobector pylori(H.pylori)	Important	Very important(90%)
NSAIDs	Important	Important
Acids	Normal or low acid output	High or normal acid output
Bile reflux	Important	Unimportant
Smoking	Important	Important
Stress	Due to head injuries and burns.
Family history	Uncommon	Common

GASTRIC ULCER

Gastric ulcer is large in size, usually lies in lesser curvature, its floor being formed by the muscular layer.

• Posteriorly, it may penetrate into the pancreas & may cause torrential bleeding by eroding left gastric vessels(common) or splenic vessels or vessels in the gastric ulcer wall.
• Anteriorly, it may penetrate into the liver & may lead into hour glass contracture or tea-pot deformity.
• Microscopically, it shows ulcer crater with chronic inflammatory cells & granulation tissue, endarteritis obliterans & epithelial proliferation.
• Gastric ulcer >3cm is called Giant gastric ulcer. It has got 6-23% chance to turn into malignancy. Incidence of perforation & bleeding is also high. Endoscopy & biopsy is a must to rule out malignancy. Partial gastrectomy is done if complete remission has not occurred.
• Grossly, margin of the benign gastric ulcer is clear; deep; near lesser curvature; edge is not everted converging towards the base of the ulcer.
• 95% of benign gastric ulcer occurs in the lesser curvature, as it takes more burden of passage of food & hence, more of wear & tear. This ulcer is rare in greater curvature, fundus, & cardia.
• Acute ulcer is confined to mucosa & submucosa
• Chronic ulcer penetrates the muscularis layer of stomach

Types of Gastric Ulcers:

• Type I – In the antrum, near the lesser curvature(55%)
• Type II – Combined gastric ulcer (in the body) with duodenal ulcer(25%)
• Type III – Prepyloric ulcer(15%)
• Type IV – Gastric ulcer in the proximal stomach or cardia(5%).

Pathology:
The development of a gastric ulcer, a type of peptic ulcer occurring in the stomach lining, involves a complex interplay between aggressive factors (such as gastric acid, pepsin, H. pylori infection, NSAID use) that can damage the gastric mucosa and defensive mechanisms (like mucus-bicarbonate barrier, epithelial cell renewal, and mucosal blood flow) that protects it. The disruption of this balance leads to the breakdown of the gastric mucosal barrier, resulting in mucosal damage, inflammation, and ulcer formation. This imbalance in acid level leads to low acid output, eventually weakens the protective mucosal barrier leads to damage and hence, formation of Ulcer.

Clinical Features:

M = F, >40yrs, becoming > females

• Pain in epigastric region after taking food, lasting up to two hours. Pain is uncommon during night. It is relieved by vomiting or by inducing vomiting.
• Periodicity: Symptom free interval may be 2-6 months. Often with seasonal variation.
• Vomiting relieves pain & often induced by the patient himself for relief of pain.
• Haematemesis and melaena(hematemesis more common)
• Appetite is good but hesitant to eat, because eating induces pain and that results in loss of weight. Aversion to spicy, fried foods.

DUODENAL ULCER:

Ulcer occurs in the first part of duodenum, usually with in the first inch, involving the muscular layer.

Eventually it shows cicatrisation causing pyloric stenosis. Serosa overlying the site of duodenal ulcer shows petechial hemorrhages with speckeled red dots, appears like sprinkled cayenne pepper.

SITES:

• In the bulb (bulbar)—95%.
• Post-bulbar (5%).

Pathology:
Enzymatic activity is to be explored in the development of duodenal ulcers. Gastrin is an enzyme produced by G-cells in antrum of the stomach, it plays a crucial role in the digestive process by stimulating the secretion of gastric acid (HCL) from parietal cells of stomach also aiding gastric motility & Somatostatin is produced by the D-cells in corpus of stomach, plays a vital inhibitory role by inhibiting gastric acid, pepsinogen & other digestive hormones and enzymes hence protects gastric mucosa from excessive acidity. When antral H.pylori infection develops, it leads to exaggerated gastrin release thus, a trophic effect on Parietal cells promoting increased acid secretion. Hence, duodenal damage-Gastric metaplasia occurs leading into Duodenal Ulcers.

CLINICAL FEATURES:

• Type A personality (stressed professionals). In india, duodenal : gastric is 30 : 1 ( very high incidence)
• Pain is more before food, in early morning and decreases after taking food. It is classically called as hunger pain. Relieved by taking food. Night pains are common.
• Common in males.
• Periodicity is more common than in chronic gastric ulcer with seasonal variation.
• Water-brash, heart burn, vomiting may be present.
• Melaena is more common, haematemesis also can occur.
• Appetite is good and there is gain in weight, decreases once stenosis develops.
• Eats more frequently without any restrictions.

INVESTIGATIONS:

• Barium meal X-ray
• Deformed or absence of duodenal cap (because of spasm).
• Appearance of ‘trifoliate’ duodenum is due to secondary duodenal diverticula which occurs as a result of scarring of ulcer.
• Gastroscopy  & biopsy (to look for H.pylori presence. Biopsies taken from duodenum, pylorus, antrum, fundus, body).
• Estimation of serum gastrin level, serum calcium level.

PUD-Related Complications:

• Gastrointestinal Bleeding(common)
• Perforation/Penetration(common)
• Gastric outlet obstructions
• Recurrent ulcerations
• Maldigestion & malabsorption
• Loop syndromes
• Gastric adenocarcinoma

In certain cases, where the pathological changes are gross and irreversible, the cure is very difficult, in such cases surgery indicates, the indications are development of complication like peptic perforation, uncontrolled haemorrhage, pyloric stenosis, hourglass stomach, tea-pot stomach, the symptoms persists for prolong period, in spite of conservative     treatment.

It is believed that Peptic ulcers is a lifestyle disease whose main causes are—food with too much spices and oil, having meal at irregular timings, lack of exercise and sedentary habits. Some patients may complain of bloating and belching. Many may say that the food is lodged in the chest and the digestion process has painfully slowed down. Some patients may complain of chest burn and feeling of uneasiness.

DIETARY MANAGEMENT:
Dietary management for peptic ulcer disease (PUD) aims to reduce symptoms, promote healing of the ulcer, and prevent complications. While diet alone cannot cure peptic ulcers, it can play a significant role in managing symptoms and improving quality of life.

Foods to Include:

• High-Fiber Foods:

Examples: Fruits, vegetables, whole grains, legumes.

Benefits: Fiber may reduce the risk of developing ulcers and help with healing by promoting a healthy digestive system.

• Lean Proteins:

Examples: Poultry, fish, lean cuts of meat, tofu, legumes.

Benefits: Protein is essential for tissue repair, including the lining of the stomach and intestines.

• Probiotic-Rich Foods:

Examples: Yogurt with live cultures, kefir, sauerkraut, kimchi.

Benefits: Probiotics help maintain a healthy balance of gut bacteria, which may aid in the healing process and prevent infection by H. pylori, a common cause of ulcers.

• Non-Citrus Fruits:

Examples: Bananas, apples, pears, melons.

Benefits: These fruits are less acidic and less likely to irritate the stomach lining.

• Vegetables:

Examples: Broccoli, carrots, sweet potatoes, spinach.

Benefits: Rich in vitamins, minerals, and antioxidants, which support overall health and healing.

• Healthy Fats:

Examples: Olive oil, avocados, nuts, and seeds.

Benefits: These fats are less likely to cause stomach irritation compared to saturated and trans fats.

Foods to Avoid:

• Spicy Foods:

Examples: Hot peppers, spicy sauces, and foods with strong spices.

Effects: Can irritate the stomach lining and exacerbate symptoms.

• Acidic Foods:

Examples: Citrus fruits (oranges, lemons), tomatoes, tomato-based products.

Effects: Can increase stomach acid and cause discomfort.

• Caffeinated Beverages:

Examples: Coffee, tea, soda, energy drinks.

Effects: Can increase stomach acid production and lead to irritation.

• Alcohol:

Examples: Beer, wine, spirits.

Effects: Irritates the stomach lining and can increase acid production, slowing the healing process.

• Carbonated Beverages:

Examples: Soda, sparkling water.

Effects: Can cause bloating and increase stomach acid, leading to discomfort.

• Fried and Fatty Foods:

Examples: Fast food, greasy snacks, high-fat desserts.

Effects: Slow down digestion and can cause increased acid production and irritation.

Additional points

• Eat Small, Frequent Meals:

Smaller, more frequent meals can help reduce stomach acid production and prevent discomfort.

• Stay Hydrated:

Drink plenty of water throughout the day. Avoid drinking large amounts of liquid with meals as it can increase stomach distension and discomfort.

• Avoid Eating Before Bedtime:

Allow at least 2-3 hours between your last meal and bedtime to reduce the risk of nighttime symptoms.

• Monitor and Identify Trigger Foods:

Keep a food diary to track what you eat and identify any foods that worsen your symptoms.

• Practice Stress Management:

Stress can exacerbate symptoms, so incorporating stress-reducing activities like yoga, meditation, or gentle exercise can be beneficial.

• Avoid Smoking:

Smoking can increase stomach acid production and hinder the healing process.

HOMOEOPATHIC MEDICINES:

Abies Canadensis:

• Burning and distension of stomach with palpitation.
• Tendency to eat far beyond the capacity for digestion.
• Great appetite, craving for meat, pickles, radish, turnips, coarse food. Flatulence disturbs the heart’s action.
• Wants to lie down all the time.
• Gnawing, hungry faint feeling at the epigastrium.

Abies Nigra:

• Pain in stomach always comes on after eating.
• Sensation as if a hard boiled egg had lodged in the cardiac end of stomach.
• Great craving for food at noon and night.
• Dyspepsia of the aged, after tea or tobacco.
• Sour eructations.

Acetic acid :

• Indicated in pale, lean, persons with lax, flabby muscles.
• Intense burning thirst, cold drinks distress.
• Violent burning pain in stomach and chest, followed by coldness of skin and cold sweat on forehead.
• Epigastric tenderness.
• Burning pain as of an ulcer.
• Sour belching and vomiting.
• Burning water brash and profuse salivation.
• Vomits after every kind of food.

Aloe socotrina:

• Bad effects of sedentary life and habits.
• Irritability; moroseness; sadness. Indolent and averse to mental and physical labour.
• Suitable to lymphatic and hypochondriacal patients.
• Taste bitter.
• Pain: aching; burning; stitching; griping; cramping.
• Pain in pit when making false step.
• < Early morning, afternoon, summer, heat, after eating or drinking.
• > Cold, open air, motion.

Anacardium orientale:

• Duodenal ulcer; All gone sensation when stomach is empty, > by eating, during the process of digestion.
• Apt to choke while eating and drinking.
• Swallows food and drink hastily. Ineffectual desire for stool, rectum seems to be plugged up. Sensation of a band or hoop around a part.
• Sudden loss of memory.
• Hypochondriac.

Argentum Nitricum:

• Withered up and dried constitutions present a favourable field for its action, especially when associated with unusual or long continued mental exertion.
• Great desire for sweets.
• Belching accompanies most gastric ailments.
• Painful swelling of pit.
• Painful spot over stomach that radiates to all parts of the abdomen.
• Gnawing, ulcerating pain, burning and constriction.
• < Warmth in any form, at night, cold food, sweets or sugar, morning, mental exertion, emotional excitement, after eating.
• > Cold, fresh air, pressure, eructation, forenoon.

Arsenicum Album:

• Burning pains in abdomen, burns like fire, as if hot coals were applied to the parts. > by heat, hot drinks.
• Vomiting of bile, blood, brown black mucus mixed with blood.
• Gastralgia < at mid day and mid night.
• Cannot bear the smell or sight of food. Excessive thirst for warm drinks at short intervals.
• Diarrhoea, stool scanty, dark, offensive < after eating and drinking.
• Bad effects of decayed food or animal matter.
• Gastric derangements after fruits, ice creams, beer, strong cheese, alcohol. Fear, anxiety, restlessness. Prostration.

Bismuth:

• Gastralgia, pain from stomach through to spine.
• Vomiting of water as soon as it reaches the stomach, food retained longer, of enormous quantities at intervals of several days when food has filled the stomach.
• Purging, offensive stools.
• Pressure in stomach as from a load in one spot, alternating with burning, pain crampy, spasmodic.
• Anguish, always desire company.

Calcarea Carbonica:

• Acidity of the digestive tract, sour eructations, sour vomiting, sour stool, sour odour of the whole body.
• Ravenous hunger. Pit of stomach swollen like an inverted saucer, painful to pressure.
• Aversion to milk and meat, craving for eggs.
• Habitual constipation, stool has to be removed mechanically.
• Leucophlegmatic, fair, obese persons.

Calcarea  Phosphorica

• Heart burn. Much flatulence.
• At every attempt to eat colicky pain in stomach.
• Craving for bacon, ham, salted or smoked meat.
• Flatulence temporarily > by sour eructations.
• Easy vomiting. Green, hot, spluttering diarrhea.
• Sunken, flabby abdomen. Feeble digestion. anaemic, thin, spare subjects.
• Ailments from grief, disappointed love.
• Feels complaints more when thinking about them.

Cadmium Sulphuricum

• Burning and cutting pains in stomach.
• Carcinoma stomach
• Persistent vomiting, violent nausea, retching, vomiting of black, coffee ground matter, of blood.
• Severe prostration.
• Black offensive clots of blood from bowels.
• Chilliness and coldness.

Carbo vegetabilis

• Weak digestion, simplest food disagrees, excessive accumulation of gas in stomach and intestines ( upper abdomen), sensation as if abdomen would burst.
• Eructations give temporary relief.
• Haematemesis and malena.
• Bad effects of fatty food, pork, butter, late supper, debauch, salted meat, spoiled fish or meat.
• Frequent involuntary cadaverous smelling stools.
• Carcinoma of stomach, late stages of disease.
• Complaints from loss of vital fluids, broken down constitution.

Cinchona officinalis

• Hyperacidity, vomiting of undigested food.
• Hungry with out appetite.
• Excessive flatulence of stomach and bowels ( lower abdomen ), fermentation, belching gives no relief.
• Colic at a certain hour, each day, periodical. < night, eating fruits, touch. > hard pressure, bending double.
• Diarrhoea painless at night, undigested food particles.
• Haematemesis and malena.
• Haemorrhage long continued.
• Ulcers with persistent suppuration.
• Longing for sour things.
• Broken down constitution, loss of vital fluids.

Condurango

• Gastric ulcer, carcinoma of stomach.
• Constant burning pains.
• Vomiting of food, burning behind sternum, where food seems to stick.
• Stricture of oesophagus.
• Chronic gastric catarrh.
• Painful cracks at corners of mouth.

Crotalus Horridus

• Gastric ulcer, cancer of stomach.
• Vomiting of bloody slimy mucus.
• Black or coffee ground vomiting. Violent vomiting of food.
• Haematemesis and malena.
• Chronic alcoholism.
• Intolerance of clothing around stomach.
• Diarrhoea, stool black, offensive, like coffee grounds.
• Black, dark, fluid, non coagulable blood.
• Tongue fiery red, smooth and polished.
• Prostration, broken down constitution.

Graphites

• Patient with tendency to skin affections & constipation, fat, chilly, and costive, with delayed menstrual history.
• Aversion to meat; sweets nauseate. Hot drinks disagree.
• Pressure in stomach; burning in stomach, causing hunger.
• Eructation difficult; constrictive pain in stomach.
• Stomach pain is temporarily > by eating, hot drinks especially milk and lying down.
• It is a great anti-psoric remedy; patients take cold easily. This medicine good for duodenal ulcer; cancer of pylorus

 Hydrastis canadensis

• Gastroduodenal catarrh.
• Carcinoma of stomach.
• Cachetic or malignant dyscrasia.
• Ulcerations, profuse discharge of thick yellow stringy mucus.
• Atonic dyspepsia, cannot eat bread or vegetables.
• Chronic constipation.
• Enlarged liver, jaundice. Cancer pains.
• Broken down by excessive use of alcohol.
• Old debilitated persons.

Kali bichromicum:

• Pain immediately after eating.
• Pain in small spots, can be covered with the point of finger; appears and disappears suddenly, rapidly shifting.
• Neuralgia every day at the same hour.
• Gastric ulcer ; punched out or round ulcer of stomach.
• Weight in pit of stomach, flatulence, vomiting of stringy, ropy mucus and blood.
• Loss of appetite.

Kali carbonicum

• Fleshy aged people. Dyspepsia of old people.
• Feeling of lump in pit of stomach.
• Burning, acidity, bloating.
• Sour vomiting, throbbing and cutting in stomach.
• < About 3 a.m., soup & coffee.
• > While moving about.

Kreosotum:

• Vomiting of sweetish water in the morning.
• Vomiting of food some hours after it was eating. This Vomiting is due to weakness of stomach, which cannot digest.
• Soreness in stomach > by eating.
• Haematemesis.
• < Open air, cold, rest ,when lying.
• > Warmth, motion, warm diet.

Lachesis:

• Very important during the climacteric and patients of a melancholic disposition. Patient is Loquacious& suspiciousness.
• Sense of constriction all over; intolerance of tight bands about neck or waist.
• Gnawing pressure made better by eating, but returning in a few hours.
• Haemorrhagic diathesis, small wounds bleed much- blood dark and non- coagulable.
• < After sleep, hot drinks, warm bath.
• > Warm applications.

Lycopodium:

• Patients are thin, withered, intellectually keen.
• Pains come and go suddenly.
• Excessive flatulence; hunger with sudden satiety.
• Dyspepsia, sour eructation, sour vomiting, heartburn.
• After eating, pressure in stomach with bitter taste in mouth.
• < 4 to 8 p.m., cold drinks.
• > Warm drinks, motion, after midnight.

Mercurius Corrosivus

• Burning in stomach extending to mouth; bloated abdomen painful to touch. Epigastrium very sensitive.
• Tongue coated with white thick mucus, or dry and red excessively swollen & inflamed; red with black coated; cover with grayish white crust; moist edges, red, pale, dirty yellow posteriorly and in the edges.
• < Evening, night, acids.
• > At rest.

Nitric Acid:

• Patients are dark complexioned. Irritable, peevish; anxiety about his disease, fear of death, depressed.
• Pains are as from splinters.
• Loves fat and salt, indigestible things.
• All discharges are offensive.
• < Evening, night, cold and hot weather.
• > While riding in carriage.

Nux Vomica:

• It is pre-eminently the remedy for many of the conditions incident to modern life.
• Patient has habit of taking tobacco, stimulants, quack remedies etc.
• Region of stomach very sensitive to pressure.
• Sour, bitter eructation.
• Nausea, vomiting with much retching.
• Ineffectual desire to pass stool.
• < Morning, after eating, spices, cold, dry weather.
• From a nap, evening, damp, wet weather, strong pressure.

Ornithogalum:

• Gastric ulcer, carcinoma of stomach and caecum.
• Haematemesis and malena.
• Vomiting of coffee ground matter.
• Pains increased when food passes pyloric outlet.
• Frequent belching of offensive flatus.
• Flatus rolls in balls from one side to another.
• Loss of appetite, phlegmy retchings, loss of flesh.

Phosphorus:

• Tall, slender persons weakened by loss of animal fluids
• Marked thirst for ice cold drinks which are vomited as soon as they become warm in the stomach.
• Empty, gone feeling in the epigastrium.
• Ravenous hunger with faintness or fainting if hunger is not appeased; hunger at night or after meals.
• Burning pain and sensation of heat.
• Pain in stomach > by cold food, ices.
• Region of stomach painful to touch or on walking.
• Inflammation of stomach with burning extending to throat and bowels.
• < Touch, warm food or drink, evening, lying on left or painful side.
• > Cold food, open air, sleep, dark.

Pulsatilla Nigricans:

• Mild, gentle patients. Tendency to weep.
• Symptoms fickle; erratic; changeable.
• Pain appearing gradually, disappearing suddenly.
• Pain as from subcutaneous ulceration.
• Heartburn, dyspepsia with great tightness after a meal.
• Thirstlessness, peevish, chilliness.
• < Heat, rich fat food, after eating.
• > Motion, cold applications, cold food, drinks.

Robinia:

• Hyperchlorhydria.
• Nausea, sour eructations.
• Profuse vomiting of an intensely sour fluid.
• Great distension of stomach and bowels.
• Flatulent colic. Sour stools.
• Nightly burning pains in stomach.
• Acidity accompanied by frontal headache.

Sepia:

• Best adapted to women, chilly patients. Sadness ,weeping and aversion to company; loss of affection for those near & dear.
• Sensation of ball in stomach. Bearing down sensation.
• Burning in pit of stomach.
• Disposition to vomit after eating.
• Feeling of gone ness, not > by eating.
• Acid dyspepsia with bloated abdomen, sour eructation.
• < Dampness, left side, forenoons, evenings.
• > Exercise, pressure, drawing limbs up.
• Great sensitiveness to cold air.

Sulphur:

• Ailments from suppression of skin eruption; of discharge.
• Usually dirty, filthy, stoop-shouldered person.
• Orifices of body red, lips red as vermilion; ears very red; anus red; urethra red.
• Drinks much, eat little. Great desire for sweets; milk disagrees.
• Great acidity, sour eructation. Food tastes too salty.
• Burning, painful, weight-like pressure.
• Very weak and faint about 11a.m.; must have something to eat
• Internal feeling of rawness and soreness.
• < Warmth in bed, alcoholic stimulants etc.
• > Dry, warm weather, lying on right side.

REFERENCE:

• SRB manual of Surgery
• Harrisons textbook of medicine
• Davidsons textbook of medicine
• Boericks materia medica

Dr. Sreelekshmi S
MD Scholar Department of Practice Of Medicine
Guide : Dr. M K KAMATH
Father Muller Homoeopathic Medical College, Mangalore
Email: sreelekshmisunilnair@icloud.com.