Gastritis refers to irritation and inflammation of the lining of the wall of the stomach. An ulcer (also known as a peptic ulcer) is a deep crater in the wall of the stomach. Gastritis and ulcers affect up to 50 percent of adult populations in Westernized countries.

These disorders result from an imbalance between gastric acid, which irritates the stomach lining, and the mucus barrier, which protects the stomach lining.

In the past, gastritis and ulcers were thought to be due to emotional stress. However, in recent years, researchers have found that, while stress may play a minor role, infection by bacteria called Helicobacter pylori, or H. pylori, are the cause of most cases worldwide. These bacteria damage the protective mucus barrier, making the stomach more vulnerable to acid damage and inflammation.

An additional common cause of gastritis and ulcers is nonsteroidal anti–inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, and others. Other causes include aspirin, steroids, alcohol, tobacco, severe trauma or burns, and major surgery.

Symptoms

• Upper abdominal pain, which may also be felt in the back
• Nausea and vomiting
• Weight loss and loss of appetite
• Indigestion
• In advanced cases when an ulcer results in bleeding from the stomach, symptoms may include vomiting of blood, rectal bleeding, dark black stools, and anemia
• The sudden onset of severe pain may signify a perforation (a hole in the stomach), which is a surgical emergency.

Risk Factors

• Increasing age: Ulcers typically occur in individuals over 40 years old.
• Helicobacter pylori infection: One in six individuals exposed to these bacteria will develop an ulcer.
• Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen)
• Tobacco use: Nicotine increases acid production and reduces the protective mucus layer of the stomach
• Alcohol use: Alcohol can cause gastritis by increasing acid secretion and damaging the mucus barrier
• Major surgery or severe illness
• Family history: More than 25 percent of ulcer patients have a family history of ulcers, compared with 5 percent of non-ulcer patients.

Gastritis and Peptic Ulcer Disease: Diagnosis and Treatment

Diagnosis

• The evaluation begins with a medical history and a physical examination.
• Blood testing may be helpful, especially if anemia is suspected.
• The best test to diagnose gastritis and ulcers is endoscopy of the stomach. In this test, a thin tube with a camera on its end is slowly advanced through the mouth and throat and into the stomach. It allows for direct visualization of the stomach lining and for biopsy to evaluate for H. pylori infection and rule out cancer.
• X-rays may also be used, but these are less accurate than endoscopy.

Treatment

• Factors that increase risk should be avoided. These include tobacco use, alcohol, nonsteroidal anti-inflammatory medications (e.g., ibuprofen), aspirin, and steroids.
• Antacid therapy to reduce acid production is the most common treatment. There are several types of antacids, including over-the-counter antacid medications (e.g., Maalox, Mylanta, Rolaids, and Tums), histamine-2 (H2) receptor blockers (e.g., cimetidine and ranitidine), and proton pump inhibitors (e.g., omeprazole).
• It is important to treat H. pylori infection, if present. Removal of H. pylori decreases the risk of recurrence from 50 to 80 percent to less than 10 percent, and also reduces the likelihood of complications, such as bleeding. Several antibiotic medications are available (e.g., clarithromycin, amoxicillin, metronidazole, and tetracycline). Most cases are treated with a combination of two or three antibiotics to ensure that H. pylori are eliminated.
• Surgery may be necessary for severe cases.
• Psychological distress should be addressed to ensure successful treatment. Compared with healthy people, patients with ulcers are particularly likely to respond to stress by producing more stomach acid, as much as 10 to 20 times the normal levels. Depression, anxiety, and ongoing stressful life circumstances have been shown to decrease ulcer healing, whereas psychologically stable individuals who develop an ulcer during a stressful period tend to remain free of symptoms after treatment.
• Exercise may decrease the risk for gastritis and ulcer disease. Exercise reduces acid secretion, and some evidence suggests it significantly decreases the risk for ulcer and for severe bleeding in persons with ulcers.

Gastritis and Peptic Ulcer Disease: Nutritional Considerations

For decades, doctors have recommended dietary changes to prevent or treat gastritis and ulcers. Common suggestions have included avoiding spicy foods, coffee, and alcohol, or increasing consumption of bland foods and milk. While these suggestions have seemed reasonable, some have not stood up well in controlled trials. For example, milk ingestion tends to increase acid production. And although certain spices (black pepper, chili powder, and red pepper) may cause indigestion, they have not been shown to contribute to either gastritis or ulcers. 

The following factors have been associated with reduced risk of gastritis or ulcers in epidemiologic studies:

• High-fiber diets: A large study at the Harvard School of Public Health found that high-fiber diets were associated with reduced risk of developing ulcers. Over a six-year period, the risk was 45 percent lower for those with the highest fiber intake, compared with those with the lowest. Food sources of soluble fiber (oats, legumes, barley, certain fruits and vegetables) were especially protective, resulting in a 60 percent lower risk in this group.
  
  However, supplementation with dietary fiber in the form of wheat bran had no effect on ulcer recurrence. Similarly, high-fiber diets appeared to have no benefit on ulcer healing rates compared with diets low in fiber.
• Diets high in vitamin A: In the same Harvard study, total vitamin A intake (from food and supplements) was associated with lower risk. The risk was 54 percent lower among persons consuming the most vitamin A, compared with those consuming the least.
• Green tea: Several studies show that regular green tea consumption is associated with a 40 to 50 percent lower risk for gastritis. Cellular tests suggest that the catechins in green tea may act as antioxidants and antibacterials to suppress the H. pylori bacteria.
• Avoiding alcohol: The relationship between alcohol and gastritis and ulcers is complex and may be related to the amounts consumed. Chronic alcohol abuse favors H. pylori infection and also slows the rate of healing in existing ulcers.
  
  However, alcohol may also have antibiotic effects on H. pylori. Studies have found moderate consumption was associated with the lowest risk for infection. However, in combination with smoking, alcohol in any amount increases the risk for ulcers.

In addition, the following are under study for their role in disease management:

• Avoiding coffee: Coffee, in either its caffeinated or decaffeinated forms, stimulates acid production, and some studies have suggested a close association between coffee intake and symptoms. However, it is unclear whether coffee consumption increases or decreases the risk of H. pylori infection.
• Probiotics: Probiotics (e.g., Lactobacillus caseii) may interfere with H. pylori growth. Further, some studies have shown that probiotics also increase the effectiveness of antibiotic treatment for H. pylori and may reduce the side effects of treatment. However, further study is necessary before probiotics can be recommended for prevention or treatment of gastritis or ulcers.