STOMACH AND DUODENUM
The most common clinical problem affecting the upper gastrointestinal tract is peptic ulcer-the general term given to an eroded mucosal lesion in the stomach, or duodenum. Occasionally the lesion may be located in the lower esophagus. Gastric ulcers are less common. The majority occur in the duodenal bulb, where the gastric contents emptying into the duodenum through the pyloric valve are most concentrated in acid.
Causes. The fundamental cause of peptic ulcer is not clear. However, two main factors seem to be involved:
(1) The amount of gastric acid and pepsin secreted and
(2) The degree of tissue resistance to the digestive action of these secretions. In the development of gastric ulcers, although the presence of acid is essential, the degree of tissue sensitivity seems to be the paramount factor. In the development of duodenal ulcers excessive production of acid and pepsin is the primary factor. In either case hydrochloric acid in the gastric juice is generally acknowledged to be the essential factor in the development, perpetuation, and recurrence of peptic ulcer.
The psychologic factor in peptic ulcer is variable. The so-called ulcer personality has been described in many tests. Although overdrawn perhaps in some sources, the ulcerprone individual does tend to be anxious or tense, aggressive, and competitive. Peptic ulcer usually occurs in men between the ages of 20 and 50 years. This is a time of life when career and personal strivings are likely to be at a peak.
Clinical symptoms. Increased gastric contractions that are especially painful when the stomach is empty are cardinal symptoms of peptic ulcer. The amount and concentration of hydrochloric acid is increased in duodenal ulcer but may be normal in gastric ulcer. Nutritional deficiencies may be seen in low plasma protein levels, anemia, and loss of weight. Hemorrhage may be the first sign of the ulcer in some patients. Confirmation of the diagnosis comes from clinical finding" x-ray tests or visualization by gastrocopy.
General medical management. Three factors form the basis of treatment:
(1) Drug therapy and antacids to counteract the hypermotility and hypersecretons,
(2) Rest, both physical and mental, aided as necessary by sedatives, and
(3) Diet therapy to provide maximum healing and prevent further tissue damage.
Diet therapy. The general term bland has been used to describe the various ulcer diets found in common practice. The word comes from the Latin word blandus meaning a smooth tongue or soothing and has taken on the meaning of something insipid, dull uninteresting and unattractive. Such meanings are all too often conveyed by the usual ulcer diets in many hospitals. These diets are often nutritional inadequate, esthetically unappealing scientifically unsound, and emotionally disturbing. That such a state is not necessary is increasingly made evident by research that indicates that the usual rigid and restrictive approach is based more on tradition and assumption than on scientific fact. Perhaps a better perspective may be gained by seeing the background development of diet therapy for peptic ulcer, which forms the rationale given for the two basic approaches to treatment:
(1) The traditional conservative management and
(2) The liberal individual approach.
TRADITIONAL, CONSERVATIVE DIETARY MANAGEMENT. In the latter part of the nineteenth century the prevailing belief concerning treatment for peptic ulcer was that food was harmful to the ulcer and that only complete rest, meaning an empty stomach, would permit healing. Therefore semi-starvation regimens became the accepted practice among European physicians and were soon introduced to countries like the United States.
In 1915 an American physician. Bertram Sippy began the principles of continuous control of gastric acidity through diet and alkaline medication. His rather rigidly outlined program of milk and cream feedings with slow additions of single soft food items over a prolonged period of time allowed little variation for individual need or nutritional adequacy. Some increase in the diet was made in 1935 by a Danish physician, Meulengracht, who introduced a somewhat more liberal approach in feeding peptic ulcer patients, especially as a treatment for hemorrhage. In the main, however, Sippy’s regimen, although clearly establishing the important acid-neutralizing principle of frequent feedings, continued to place rigid restrictions on the traditional dietary programs followed in common practice.
Although many changes in the details of management have occurred since Sippy’s day, his general restrictive pattern has been the mold for much of the traditional conservative management still used by some clinicians today. This traditional diet therapy is based on several principles. The food must be both acid neutralizing and nonirritating.
Acid-neutralizing food. Assumptions underlying this rigid form of therapy are unfounded and have not been supported by recent research. The therapy usually begins with milk and cream feedings every hour or so, allegedly to neutralize free acid with the milk protein, suppresses gastric secretion with the cream, and generally “soothes” the ulcer by “coating” the stomach. However, after the food has been mixed with stomach acids, its physical nature changes. No coating of the stomach results.
Afterward, soft, bland foods are added gradually and some food is kept in the stomach at all times to mix with the acid to prevent its corrosive action on the ulcer. These bland foods are usually limited to choices of white toast or crackers, refined cereals, egg, milk cheeses, a few cooked pureed fruits and vegetables, and later ground meat.
Nonirritating food. This therapy is concerned with eliminating chemical, mechanical, and thermal irritation:
- Chemical irritation. Any food believed to stimulate gastric secretions is prohibited. These would include any highly seasoned, fried, or spiced foods.
- Mechanical irritation. Any foods believed to be abrasive in their effect on the ulcer are prohibited, including all raw food, plant fibers, whole grains, and gas formers.
- Thermal irritation. Any hot or cold foods believed to irritate the lesion by their effect on surface blood vessels are prohibited, including hot beverages and soups, frozen desserts, or iced beverages.
After the initial hourly milk and cream, the diet is gradually increased as the ulcer heals. Such a traditional conservative routine usually follows a progressive four-stage pattern prescribed.
Liberal individual approach. Accumulating experience and research, however, has begun to challenge the validity of some of these beliefs. In contrast to the traditional, conservative management stands the increasingly accepted liberal individual approach. Numerous studies have found that healing is related not so much to restrictive diet and medications as to the personal care and concern of the health team. In all instances results have indicated that the current concept of rigid dietary treatment is not verified as superior or even sound therapy. Bland foods do not increase the rate of healing, and no particular benefit accrues from avoidance of all foods thought to be commonly irritating.
Traditional practices questioned. Current studies have refuted several traditional practices:
- Gastric irritation. A number of spices and herbs and other such substances have been tested to determine their effect on gastric acidity. No significant change in gastric pH was noted with any of these items with four basic exceptions. These exceptions are black pepper, meat extracts, caffeine, and alcohol. No food (such as orange juice) was found sufficiently acid of itself to cause a significant pH change or direct irritation of an ulcer.
2. Buffering foods. Protein foods are effective buffering agents because of their amphoteric nature , Milk has some buffering effect, but other protein foods seem to be as effective or more so. All proteins influence acid secretion, however, more than do carbohydrates and fat. Any form of fat tends to suppress gastric secretion and motility. A volume of any food sufficient to exert pressure on the stomach wall stimulates gastric secretion,
3. Fiver or residue, The routine omission of any fiber in the diet also seems to have no basis in fact, Individual modes of eating, improper chewing, and rapid consumption of meals are more involved as sources of irritation, So-called coarse or rough foods, such as lettuce, raw fruits, celery, cabbage, and nuts, do not necessarily hurt a peptic ulcer when they are properly chewed and mixed with saliva. Grinding or straining of food is needed only when teeth are poor or absent.
4. Gas formers. Foods labeled "gas formers" also are questionable routine omissions for all persons with peptic ulcer. Tests have shown little consistency in the responses of hospitalized patients to a variety of foods such as onions, fried foods, cabbage, baked beans, orange juice, milk, nuts, and spiced foods. Because of the wide valiance in symptoms and responses among patients tested, individual tolerances seem to be the basic factor. It is entirely a matter of individual response.
Basic principles of liberal dietary management. In the light of such findings and the cumulative experiences of many physicians and nutritionists in daily practice, what reasonable principles of diet therapy for peptic ulcers may be deduced? That sound dietary management does play an important part in total therapy is clear, but it seems equally clear that the individual must be the focus of treatment. It is not an ulcer; it is his ulcer. It is conditioned by his unique makeup and life situation, and the presence of the ulcer in turn affects the patient's life. Therefore two basic principles guide the more liberal approach:
1. The individual must be treated as such. A careful initial history will give information about daily living situations, attitudes, and food reactions and tolerances. On the basis of such a history a reasonable and adequate dietary program that the patient can follow may be worked out.
2. The activity of the patient's ulcer will influence dietary management, During acute periods of active ulceration more vigorous treatment is necessary to control acidity and initiate healing, however, when pain disappears, feedings should be liberalized according to individual tolerance and desire using a variety of foods. Optimum nutrition and emotional outlook are essential for recovery. Both these are more likely to be supported by such a liberal program, During quiet periods and for long-term prophylaxis when the patient does not have symptoms, he fares better from judicious choice of a wide range of foods and regular, unhurried eating habits.
SUMMARY PRICIPLES OF GENERAL DIET THERAPY.
The following is a summary of the diet therapy principles for patients with peptic ulcer:
- Optimum total nutrition based on individual needs and food tolerances is necessary to support recovery and maintenance of health,
- Protein must be adequate for tissue healing needs and for buffering,
3. Fat should be used in moderate amounts for suppression of gastric secretion and motility when cardiovascular disease is a concern, reduction of saturated fat may be desirable and substitution made of polyunsaturated fats.
4. Meal intervals and size should be adequate to maintain individual control of gastric secretions. Frequent small feedings may be required during more active stress periods. Regular meals, moderate in size and sufficient in number for individual need, should be an established habit.
5. Positive individual needs on a flexible program rather than negative blanket restrictions on a rigid regimen should be the guide.
In any event treatment based on the elimination prejudiced ideas and the use of wise individual counseling instead forms the keystone of therapy.