PEPTIC ULCER DISEASE: AN OVERVIEW

ABSTRACT:

Peptic ulcer disease (PUD) is a common gastrointestinal ailment characterised by the formation of ulcers in the stomach or duodenum. It is frequently caused by Helicobacter pylori infection, overuse of nonsteroidal anti-inflammatory medicines (NSAIDs), and stress. Despite the availability of conventional treatments such as proton pump inhibitors (PPIs) and antibiotics, PUD is a recurring illness, necessitating the investigation of new therapeutic options. This review focusses on the role of homoeopathy in the treatment of peptic ulcer disease. Individualised to each patient’s symptoms and constitutional characteristics, homoeopathic therapies seek to treat the underlying causes of PUD, encourage recovery, and stop recurrence. The review also addresses how homoeopathic treatments can supplement conventional therapy, promote healing, and improve overall patient outcomes.

KEYWORD:

Peptic Ulcer Disease, recent updates, homoeopathy.

INTRODUCTION:

ICD-11 -DA61

The term “peptic ulcer disease” refers to a stomach or duodenal mucosal lesion that penetrates the muscularis mucosa and reaches the deeper layers. This ulceration results from an imbalance between the gastrointestinal tract’s defensive systems, such as prostaglandins and the mucosal barrier, and its aggressive forces, including stomach acid and pepsin. Due to active inflammation, ulceration may spread to excavation. Gastric ulcers are typically seen in the lower curvature of the antrum or the body-antrum junction. The first part of the duodenum is generally affected by a duodenal ulcer, most notably the anterior wall. It typically manifests as epigastric pain or dyspepsia with periodicity that is influenced by food intake, but it can also be asymptomatic for years. [1,2] PUD can affect people of the O blood group.[3] The intricate processes in PUD are brought on by a combination of host and bacterial factors, as well as vulnerability to infection-induced changes in immunological tolerance. Duodenal ulcers typically measure less than 1 cm; however, they can grow up to 3–6 cm. Some genetic variables that are significant for PUD were identified by genome-wide association study (GWAS) research. This explains the immunological tolerance response to inflammatory damage, the vulnerability to H. Pylori infection, and the imbalance between acid and pepsin. There are eight identified genes: MUC1, MUC6, FUT2, PSCA, ABO, CDX2, GAST, and CCKBR.[4] 

The revised guidelines emphasize the use of bismuth-based quadruple therapy as the first line of treatment for H. pylori eradication in regions with high levels of antibiotic resistance. This treatment plan, which consists of metronidazole, tetracycline, bismuth subsalicylate, and a proton pump inhibitor (PPI), has proven to be more effective than triple therapy, particularly in areas with high levels of clarithromycin resistance. Current recommendations advise patients who need long-term NSAID medication to take PPIs or misoprostol and emphasise the significance of stopping NSAIDs whenever feasible. Furthermore, for people who are susceptible to ulcer development, selective COX-2 inhibitors are regarded as an alternate option for pain management. [1,5,6] All patients with a history of PUD who are treated with NSAIDs or anti-platelet agents are taken under H. Pylori eradication programme.[7] The identification of antibiotic resistance in H. pylori infection has resulted in a more individualised treatment approach.

EPIDEMIOLOGY:

PUD is a global health issue with a lifelong prevalence. In high-income nations, the prevalence is 50% among adults over 50 years, but in low- and middle-income nations, it is 90% of people. Gastric ulcers are more common in women, while duodenal ulcers are more common in men.[8] The incidence rate in the United Kingdom is 500,000 per year. The lifetime frequency is 11.22% in India. The incidence is 6–12% worldwide. Incidences are higher in the fifth and sixth decades. The World Health Organization (WHO) reports that in 2019, the prevalence worldwide was 99.4 per 100,000.[9]

ETIOLOGY WITH ITS MECHANISM:

Etiological Factor [10,11,12,13]	Mechanism
Helicobacter pylori	Chronic infection leads to gastric inflammation, increased acid secretion, and impaired mucosal defense.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)	Inhibit COX-1 enzyme, reducing prostaglandin production, leading to reduced mucosal protection and increased gastric acid secretion.
Excessive Gastric Acid Secretion	Overproduction of gastric acid causes damage to the mucosa, leading to ulceration, especially in the presence of impaired mucosal defenses.
Genetic Factors	Genetic predisposition, including polymorphisms in cytokine genes and gastrin receptors, may influence susceptibility to ulcers.
Smoking and Alcohol Use	Smoking impairs mucosal defense and promotes gastric acid secretion, while alcohol can irritate the gastric lining, worsening ulcer formation.
Stress	Acute or chronic stress can increase acid secretion and impair mucosal defenses, contributing to ulcer formation in susceptible individuals.

FIG 1: Showing etiological factors

CLINICAL FEATURE:

Epigastric pain (dyspepsia) is a hallmark symptom but not diagnostic. Patients with silent ulcers may remain asymptomatic. Pain is gnawing, aching > by food and recur after 2-4 hrs. Pain may aggravate after meals or may not be affected by the meal. It is periodic and rhythmic. Attacks often last for days to weeks with intervals of months to years. Constitutional symptoms as nausea, vomiting, anorexia, and weight loss may be seen. Physical examination is usually normal except in cases of complication of gastric outlet obstruction or perforation where tenderness or succussion splash may be present.

DIAGNOSIS:

• Upper endoscopy is the diagnostic investigation for PUD. The biopsy is done in all cases.
• Computed Tomography is required to exclude the complications of PUD such as perforation, penetration or obstruction.
• H. Pylori infection can be diagnosed by invasive and non-invasive procedures. Noninvasive:
  • PCR assay: stool polymerase chain reaction is done in patients with PUD or following successful H. Pylori eradication. It has specificity 95%
  • urea breath test by 13C isotope mass spectrometer. It has high sensitivity and specificity.
  • Faecal antigen test: specificity 95% 

Invasive:

• Histology
• Rapid urease test: specific 95%
• Microbiological culture is the gold standard for H. Pylori.

 

MANAGEMENT:

Maintaining regular and balanced diet at 3-4 hrs. interval. Restricted or reduced use of aspirin and NSAIDs to prevent further damage of mucosal wall. Cessation of smoking, as smoking is responsible for the non-healing of the ulcerated mucosa and recurrence of PUD. Mental, physical and social well-being can be improved by minimising stressors.

Conventional treatment:

Antibiotics for H. Pylori combined regiment with 2-3 antibiotics and PPI and bismuth to achieve the eradication. H. Pylori eradication programme includes screening of PUD individuals for testing and taking them under antibiotic treatment in combination with bismuth and PPI regimens for 14 days, which achieved an 85% eradication rate. Proton-pump inhibitor (PPI) and H2 receptor antagonists as acid anti-secretory agents.[12] It binds with acid-secreting enzyme H+-K+-ATPase and inactivates them. It may cause false negative results; for this reason, it should be kept on hold for 14 days before testing. Surgery is only required in cases of complications of PUD or when persistent or recurrent ulceration despite medical therapy.

DIFFERENTIAL DIAGNOSIS [1,2,14]:

Differential Diagnosis	Key Features
Gastroesophageal Reflux Disease (GERD)	Characterized by heartburn, regurgitation, and a burning sensation in the chest or upper abdomen, especially after meals. GERD does not involve ulcers.
Functional Dyspepsia	Symptoms include chronic upper abdominal discomfort, bloating, and early satiety without any identifiable structural abnormality like ulcers.
Eosinophilic Gastritis	Presents with nonspecific symptoms such as nausea, vomiting, and abdominal pain. Often associated with peripheral eosinophilia and a history of allergies.
Pancreatitis	Epigastric pain radiating to the back, associated with nausea, vomiting, and elevated pancreatic enzymes (amylase and lipase).
Gastric Cancer	Symptoms overlap with PUD, including upper abdominal pain, weight loss, early satiety, and gastrointestinal bleeding. Gastric cancer is more insidious and progressive.
Zollinger-Ellison Syndrome (ZES)	Severe, recurrent ulcers, often in unusual locations like the duodenum and jejunum, caused by gastrin-secreting tumors (gastrinomas).
Biliary Colic or Gallbladder Disease	Pain localized to the right upper quadrant or epigastric region, often triggered by fatty meals, and may be associated with nausea and vomiting

FIG 2: Differential Diagnosis of PUD

 

MIASMATIC BACKGROUND OF PEPTIC ULCER DISEASE:

An important factor in homoeopathic treatment for Peptic Ulcer Disease is its miasmatic basis. Understanding an individual’s constitutional miasm helps the homeopath choose the most effective treatments. A history of stress, anxiety, poor digestion, or inadequate coping strategies may be present in psoric individuals. Psora often predisposes people to situations where stress exacerbates physical symptoms, as is typical for PUD. Sycosis contributes to the formation of ulcers in PUD by causing inflammation and excessive stomach acid production. Individuals with a sycotic constitution may produce too much acid in the stomach, be prone to indigestion and bloating, or be more susceptible to persistent infections such as H. pylori, which can lead to ulcers. Peptic ulcers in a syphilitic background may be more severe, exhibiting deep and extensive tissue destruction, particularly when the ulcer is associated with a long-standing infection or tissue degeneration.

HOMOEOPATHIC THERAPEUTICS [15,16,17,18]:

Arsenic alb: Vomiting of blackish and brownish substances (due to decomposed blood) Intense burning pains in stomach. Always worse after eating or drinking.

Atropinum: Hard swelling in pyloric region, just above naval towards right; very sensitive to touch.

Anacardium: The great characteristic of the remedy is the great relief after eating; the symptoms return, however, and increase in intensity until the patient is forced to eat again for relief. The gastralgia of the Anacardium is relieved by eating, and that of the Argentum nitricum is worse from eating.

Bismuth: Pressure as from a load in one spot, with pressure in spine, > by bending backward, nausea and vomiturition after eating; vomiting of all fluids as soon as taken.

Carbo Vegetabilis: There is a burning in the stomach extending to the back and along the spine to the interscapular region. There is great distension of the stomach and bowels, which is temporarily relieved by belching. The flatulence of Carbo vegetabilis is more in the stomach, and that of Lycopodium more in the intestines. The eructations are rancid, sour or putrid. There is heaviness, fullness and sleepiness after eating.

Ignatia: Pain is located in a small circumscribed spot. Relief from eating. Pains may appear gradually and subside suddenly or appear as suddenly as they disappear.

Kali bichrome: Ulcers, excavating in depth without spreading in circumference; pressure and heaviness in stomach after eating; dizziness, followed by violent vomiting of a white mucus; acid fluid, with pressure and burning in stomach; vomiting of sour, undigested food; of bile, with pinkish, glairy fluid; of blood, with cold sweat on hands; hot face.

Phosphorus: It corresponds to rumination and regurgitation. Craving cold food and cold drinks is characteristic of Phosphorus, and they relieve momentarily but are vomited as soon as they become warm in the stomach. It has a special relation to destructive and disintegrating processes, and hence is one of the remedies for cancers, indurations, erosions, etc.

Lycopodium: A grand characteristic of Lycopodium is this: the patient goes to meals with a vigorous appetite, but after eating a small quantity of food, he feels so full. Here, it is seen that the distress is immediately upon eating, not a half hour after, as in Pulsatilla and Anacardium.

Pulsatilla: A sensation as if food had lodged under the sternum are characteristics of this remedy. A bad taste is a special indication for Pulsatilla. There is a craving for lemonade and an aversion to fats.

Nux Vomica: Atonic dyspepsia with a putrid taste in the mouth in the morning compelling the patient to rinse out the mouth, with a desire for beer and bitters, and an aversion to coffee will strongly indicate Nux.

Uranium nitr: Vomiting of sour, watery fluid or blood; tasteless or eructation, burning, gnawing pains paroxysms; great thirst, no appetite.

Morgan Gaertner: flatulent indigestion: eructation excessive. Eructation of bad odour. Sour mouthfuls (Pyrosis). Fulness epigastrium, unrelated to food. Pain in epigastrium after food. Vomiting after food afternoon or night. History of duodenal ulcer.

Sycotic co.: Nausea. Anorexia. Burning pain in stomach. Eructation (acid); bilious attacks. Pain and dis tension in epigastrium. Flatulence. Nocturnal vomiting, must empty stomach. Acidosis attacks.

Dys. Co.: Pain > eating. Indigestion for years- distension and discomfort. Eructation; heartburn. Ptosis stomach; dilation; splashing. No heartburn, no vomiting, no nausea, no pain.

Proteus: Acidity; heartburn; sourness. Flatulence. Hunger pain is not better with eating. Vomiting after meals. Dilated stomach. Bilious at menstrual period.

Gaertner: Pains stomach. Vomited everything. Vomiting < after sweets. Headache and vomiting, acidosis attacks. Dilated stomach.

Morgan (PURE): Waterbrash; heartburn, Sour, acid, bitter, mouthfuls. Eructation; pyrosis. Burning in throat and stomach. Pain and acid with food. Nausea; vomiting haematemesis. Duodenal and peptic ulcer.

CONCLUSION:

Homeopathy offers a complementary treatment modality for Peptic Ulcer Disease. It focuses on the whole person and considers both the physical and psychological aspects of the illness. While scientific evidence continues to grow, homeopathy’s personalized, constitutional approach remains a promising avenue for patients seeking more natural, side-effect-free alternatives. By treating the individual holistically, homeopathic remedies may provide lasting relief and contribute to the long-term management of peptic ulcers.

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About the Author:

Prof (Dr) Rajat Chattopadhaya1, Dr. Ritika Bose2, Dr. Meghamala Chakraborty3

1. Principal & Administrator, The Calcutta Homoeopathic Medical College & Hospital (Govt of WB) 
2. PGT (Final Year), Dept. of Medicine, The Calcutta Homoeopathic Medical College & Hospital (Govt of WB)
3. PGT (2nd Year), Dept. of Medicine, The Calcutta Homoeopathic Medical College & Hospital (Govt of WB)