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Nutritional care in peptic ulcer

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ABCD Arq Bras Cir Dig Review Article

2014;27(4):298-302
DOI: http://dx.doi.org/10.1590/S0102-67202014000400017

Nutritional care in peptic ulcer

Cuidados nutricionais na úlcera péptica

Nathália Dalcin VOMERO, Elisângela COLPO

From the Curso de Nutrição do Centro ABSTRACT - Introduction: Peptic ulcer is a lesion of the mucosal lining of the upper gastrointestinal
Universitário Franciscano – UNIFRA tract characterized by an imbalance between aggressive and protective factors of the mucosa,
(Nutrition Course of Franciscan University having H. pylori as the main etiologic factor. Dietotherapy is important in the prevention and
Center), Santa Maria, RS, Brazil. treatment of this disease. Aim: To update nutritional therapy in adults’ peptic ulcer. Methods:
Exploratory review without restrictions with primary sources indexed in Scielo, PubMed, Medline,
ISI, and Scopus databases. Results: Dietotherapy, as well as caloric distribution, should be
adjusted to the patient’s needs aiming to normalize the nutritional status and promote healing.
Recommended nutrients can be different in the acute phase and in the recovery phase, and
there is a greater need of protein and some micronutrients, such as vitamin A, zinc, selenium,
and vitamin C in the recovery phase. In addition, some studies have shown that vitamin C has
a beneficial effect in eradication of H. pylori. Fibers and probiotics also play a important role in
the treatment of peptic ulcer, because they reduce the side effects of antibiotics and help reduce
treatment time. Conclusion: A balanced diet is vital in the treatment of peptic ulcer, once food
HEADINGS - Nutrition. Dietotherapy. can prevent, treat or even alleviate the symptoms involving this pathology. However, there are
Helicobacter pylori. Nutritional therapy, few papers that innovate dietotherapy; so additional studies addressing more specifically the
treatment. dietotherapy for treatment of peptic ulcer are necessary.

Correspondence: RESUMO - Introdução: A úlcera péptica é uma lesão que ocorre na mucosa do trato
Elisângela Colpo gastrointestinal, sendo caracterizada por um desequilíbrio entre fatores agressores e protetores
E-mail: [email protected] da mucosa gástrica, tendo como principal fator etiológico o H. pylori. A dietoterapia é
fundamental na prevenção e tratamento dessa patologia. Objetivo: Rever a terapia nutricional
Financial source: none na úlcera péptica em adultos. Métodos: A metodologia utilizada foi um estudo exploratório
Conflicts of interest: none de revisão do conhecimento disponível na literatura científica. Resultados: A dietoterapia bem
como a distribuição calórica deve ser ajustada as necessidades do paciente com objetivo de
Received for publication: 13/02/2014 normalizar o estado nutricional e promover a cicatrização. As recomendações de nutrientes
Accepted for publication: 23/05/2014 podem ser diferenciadas nas fases aguda e de recuperação, havendo uma maior necessidade
proteica e de alguns micronutrientes como vitamina A, zinco, selênio e vitamina C na fase de
recuperação. Além disso, alguns estudos evidenciam que a vitamina C tem efeito benéfico na
erradicação do H. pylori. As fibras e probióticos também possuem um importante papel no
tratamento da úlcera péptica, reduzindo os efeitos colaterais dos antibióticos e auxiliando na
redução do tempo de tratamento. Conclusão: Percebe-se que poucos são os trabalhos que
evidenciam a terapia nutricional da úlcera e não há consenso sobre o tema. Com isso, mais
estudos são necessários para abordar com maior especificidade o tratamento dietoterápico da
úlcera péptica. Dieta equilibrada é fundamental no tratamento da úlcera péptica, uma vez que
DESCRITORES - Nutrição. Dietoterapia. o alimento pode prevenir, tratar ou mesmo aliviar os sintomas que envolvem esta doença. No
Helicobacter pylori. Terapia nutricional, entanto, existem poucos trabalhos que inovam dietoterapia; assim, são necessários estudos
alimentação. Tratamento. adicionais abordando mais especificamente a dietoterapia para o tratamento de úlcera péptica.

INTRODUCTION

P
eptic ulcer is a disease of chronic development, characterized by an
imbalance between the factors that damages the mucosa and those for
its protection, resulting in a lesion of the lining of the upper digestive
tract22. It has been one of the most prevalent diseases in the world, and some of its
complications have been the major causes of morbidity and mortality34. The prevalence
differs in the world population between the duodenal and gastric ulcers, and the mean
age of people with the disease is between 30 and 60 years, but it can happen in any
age. Racial difference has also been observed, and in Africa duodenal ulcers are found
to be rare in black people, but in the United States the incidence is the same for blacks
and whites; regarding gender, there is predominance of ulcers in males16.
Peptic ulcer has a multifactor etiology. Environmental elements such as alcohol
and nicotine can inhibit or reduce secretion of mucus and bicarbonate, increasing acid
secretion. Genetic factors can influence, and children of parents with duodenal ulcer
are three times more likely to have ulcer than the population14. In the past decades, the
identification of Helicobacter pylori and ulcers associated with the chronic use of anti-
inflammatory drugs contributed to a better understanding of the events associated to
the genesis of peptic ulcers36.
Nutrition and its recommendations define aspects of a healthy diet, and the

298 ABCD Arq Bras Cir Dig 2014;27(4):298-302

 Nutritional care in peptic ulcer

need to establish nutritional benchmarks is long recognized used to measure the body mass, liquid volume, and body
as a way to promote health and prevent and treat diseases. fat, being recognized by the Brazilian Ministry of Health
Accordingly, dietotherapy has played a key role in the and the Food and a Food and Drug Administration as a
prevention and treatment of Peptic ulcer, with the main valuable technique for this purpose14. Indirect calorimetry is
purpose of recovering and protecting the gastrointestinal a non-invasive method to determine the nutritional needs
lining, improving digestion, relieving pain, and contributing and the utilization rate of energy substrates from oxygen
to a satisfactory nutritional status29. consumption and carbon dioxide production obtained by
Peptic ulcer is a disease known since antiquity, but there analysis of the inhaled and exhaled air by the lungs8.
are few studies innovating dietotherapy as treatment for this The upper arm muscle circumference is a measure
disease. For this reason, the objective of this study was to to assess somatic protein compartment, and the corrected
review nutritional therapy of peptic ulcers in adults. muscle arm area is a more accurate method because it
reflects the actual magnitude of muscle tissue alterations
appropriately. The triceps skinfold is the most used skinfold
METHOD because it is the triceps region that best represents the
adipose subcutaneous layer28.
Review of the knowledge available in the scientific Biochemical tests are able to diagnose possible
literature about nutritional therapy of peptic ulcer, without deficiencies still in the subclinical phase and includes
restrictions of date, based on Scielo, PubMed, Medline, ISI, serum albumin, which plays a key role in the nutritional
and Scopus databases. Was also included data from national assessment - serum pre-albumin a sensitive indicator of
and international health committees. For the search in protein deficiency -, having several advantages to help
databases, were used the following descriptors: dietotherapy, determine the nutritional status and intervention needs18.
nutrition, peptic ulcer, Helicobacter pylori, pepper, iron, Complete blood test is often used in this case, because it
protein, antioxidants, bioavailability of nutrients, food fibers, involves counts of white and red blood cells, reticulocytes
zinc, probiotics, vitamin C and E. and platelet, hematological indices, thus allows to monitor
blood alterations and a progress analysis of the disease18.
RESULTS Nitrogen balance is a noninvasive and accessible technique
consisting of the difference between taken-in oxygen and
excreted oxygen used to assess metabolic stress, and is
Physiopathology and etiology a good parameter to assess protein intake and protein
Peptic ulcer is characterized by a solution of continuity degradation17.
the upper digestive tract mucosa exposed to chloride
peptic secretion. It often occurs in the duodenum (5-10% Characteristics of nutritional therapy
of the population), stomach or esophagus36. It is a chronic The objective of peptic ulcer dietotherapy is to prevent
disease, with activation and remission periods and its hyper secretion of peptic chloride in order to reduce the sore
pathogenesis is characterized by the imbalance between and pain in the gastric and duodenal mucosa. In addition,
the factors that damages the mucosa (chloride acid, pepsin, nutritional therapy aims to promote healing, based on a
and ulcerogenic drugs) and those that protect it (mucosal complex sequence of events going from the initial trauma to
barrier, prostaglandins, and mucosal secretion) 18. Clinical the repair of the damaged tissue. Investigation of nutritional
manifestations are characterized by epigastric discomfort, deficiencies is essential in the preparation of an appropriate
burning or severe and continuous pain, which tends to be recovery diet. In the early 20th century, Sippy proposed a diet
worse at night. Pain usually happens one to three hours based on milk and milk cream, combined with antacids, for
after eating, and may be followed by nauseas, vomiting, treatment of gastrointestinal ulcer, based on the principle
discomfort in the gastrointestinal tract, flatulence, and that milk would provide gastric alkalinization and relieve
significant loss of body weight22. pain. Today milk is not recommended due to the buffering
Important factors in the etiopathogenesis are tobacco, effect and the significant gastric acid secretion effect of
alcohol, and Helicobacter pylori, which is able to move in milk29.
high viscosity medium, adhering to the mucosa epithelium, According to Marrota and Floch18, calories distribution
where it remains protected18. Diagnosis of this infection may for patients with peptic ulcer should be normal, with values
be achieved through various tests, each with a sensitivity and ranging from 50-60% of carbohydrates, 10-15% of proteins,
specificity above 80%. The golden standard test is the upper and 25-30% of lipids, with total energy value sufficient to
endoscopy, which allows the physician to collect material to maintain or recover the nutritional status.
check for the presence of H. pylori besides other therapeutic Reis29 suggested that calories distribution should be
procedures36. adjusted according to the patient’s needs to normalize the
nutritional status, having as recommended macronutrients
Nutritional assessment on peptic ulcer a protein intake of up to 1.2 g/kg/weight/day in the acute
It aims to identify possible nutritional alterations and stage (5th to 8th week) and up to 1.5 g/kg/weight/day in the
determine proper intervention to ensure the individuals’ recovery stage. Carbohydrates should be adjusted to the
health. Malnutrition in this case may occur especially when patient’s needs, without disaccharides concentration, so as
there is stenosis, which prevents normal ingestion of foods18. to avoid fermentation, and lipids without concentration of
For nutritional assessment, some important indicators saturated fats.
are used in this process, such as the anthropometric, To accelerate the healing process, in addition to
biochemical, and clinical evaluations. The anthropometric protein, there are specific micronutrients such as zinc, which
assessment consists of weight and height measurements is essential to maintain the immune system function, as a
that may be used in conjunction in the assessment of the response to oxidative stress, and to heal wounds25. Selenium
nutritional status by means of BMI (Body Mass Index), but may reduce infection complications and improve healing10.
this method does not distinguishes losses of fat or lean mass. In addition, vitamin A may be used as a supplement, but the
In addition, weight may be concealed by hyper-hydration or research that supports this practice is of limited effectiveness,
de-hydration, thus not resulting in an accurate determination because very high dosages do not promote cure, and
of the nutritional status in these specific cases18. excessive intake may be toxic2. Nutritional recommendations
Total body bioelectrical impedance is a method for patients with peptic ulcer are described in Table 1.

ABCD Arq Bras Cir Dig 2014;27(4):298-302 299

Review Article

Despite the small number of references covering the special interest in probiotics for treating infection by H.
required amounts of nutrients in the treatment of peptic ulcer, pylori, because it plays a crucial role in the pathogenesis of
it can seen that the authors agree with the recommendations chronic gastritis and peptic ulcer in adults9. Probiotics have
to improve healing, differing only when the patient is in the therapeutic agents against H. pylori, which can be shown
active or remission phase. Therefore, to help plan a more by clinical data that prove the efficacy of some probiotics
specific and safe action, it is important to investigate the in diverse gastrointestinal diseases and also due to the
individual’s nutritional status and if the patient has any increasing resistance of pathogenic bacteria to antibiotics35.
associated pathology. One of the measures that may contribute to reduce
the infection rate by H. pylori is dietary modulation with the
TABLE 1 - Recommended daily diet for peptic ulcer addition of probiotics. However, probiotic organisms do not
appear to eradicate H. pylori, but have the ability to reduce
Characteristics Recommendations the bacterial load and infection in animals and humans 32.
Sufficient to maintain or recover the Studies on humans indicate that probiotics improve slightly
nutritional status
the elimination rate in treatment against H. pylori, being
Daily energy needs 20-25 Kcal/Kg: weight loss
(DEN) 25-30 Kcal/Kg: maintenance
useful to decrease the bacterial load and likely improve
30-35 Kcal/Kg: weight gain31 dyspeptic symptoms37. Thus, an intake of 10⁹ to 10¹¹ CFU/
Acute phase Recovery phase day of lactic acid bacteria is recommended.
Carbohydrate (%)29 50-60 50-60 Among the clinical applications of probiotics,
Protein (g/Kg/weight)29 1.2 1.5 reduction of the side effects associated with antibiotics is
Lipid (%)18,29 25-30 25-30 the best indication documented. According to Cats et al.4,
Zinc (mg)¹³ 11 40 who conducted an intervention study, 14 patients infected
Selenium (µg)20 55 400 with H. pylori receiving L. acidophilus (108 CFU) for three
Vitamin A (µg)113 900 3000 weeks, it was capable of inhibiting the growth H. pylori in
Vitamin C (mg)13 75 500 64% of the volunteers. Similarly, in a study by Wang et al.38
Vitamin B¹² (µg)13 2.4 2.4 with 59 volunteers, they received Bifidobacterium animalis
Folic acid (µg)13 400 400 and L. acidophilus (10¹0 CFU) twice a day during six weeks,
Iron (mg)13 45 45 and concluded that regular intake of yogurt containing
Fibers (g)13 20 to 30 20 to 30 Bifidobacterium animalis and L. acidophilus can effectively
10⁹ to 10¹¹ lactic acid 10⁹to 10¹¹ lactic suppress the infection caused by H. pylori in humans.
Probiotics (UFC/day)18
bacteria acid bacteria
Sources: 18Marrota; Flock (1993); 29Reis (2003); 13DRI’S (UL); 13DRI’S (RDA
Use of antioxidants to eradicate Helicobacter pylori
Some authors show that the best treatment is the
Use of food fibers in peptic ulcer treatment eradication of the bacteria 18. Accordingly, some studies
The physicochemical properties of fiber fractions in humans 40 used antioxidants to eradicate H. Pylori and
produce different physiological effects in the organism. observed that vitamin C has important effects in the bacteria
Soluble fibers, found in apple, oatmeal, and pear are eradication in patients with peptic ulcer. But these studies
responsible, for instance, for an increased viscosity in the showed that smaller doses of vitamin C for a longer period
intestinal content. Insoluble fibers (whole grains, granola, of time had a better response when compared with higher
flaxseed) increase stool bulk, reduce transit time in the large doses. Thus, it is observed that patients with peptic ulcer by
intestine, and make fecal elimination easier and quicker. H. pylori can take up to 500 mg/day of vitamin C for a period
Fibers regulate the bowel function, which make them vital for of three months, which does not exceed the recommended
the well being of healthy people and in the dietary treatment UL of 2000 mg, according to DRIs13.
of many pathologies19. Another antioxidant used to eradicate H. pylori is the
Räihä et al.26 reported a large number of patients with capsaicin present in pepper and chilies. Studies on animals
peptic ulcer having diets poor in fibers and antioxidants. A diet showed that capsaicin has effect in healing gastrointestinal
rich in fibers for individuals with peptic ulcer is advisable (20 lesions. Likewise, some researchers 39 studied the effect
to 30 g/day, according to WHO – World Health Organization), of capsaicinoids in individuals with peptic ulcer by H.
because fibers act as buffers, reducing concentrations of bile pylori or aspirin and showed that these substances are
acids in the stomach and the intestinal transit time, resulting gastroprotective only in individuals with aspirin-induced
in less abdominal bloating, thus decreasing discomfort and lesions. It is worth noting that peppers may be associated
pain in the gastrointestinal tract18. with irritations in the gastric mucosa, and may not have a
gastroprotective effect in some individuals with peptic ulcer.
Use of probiotics in peptic ulcer
Probiotics are defined as a food supplement based on Substances that can potentiate peptic ulcer symptoms
live microorganisms, which affect beneficially the human According to César et al.5, damages caused by ulcer can
organism by providing a microbial balance 33. There is a be reverted, often after treatment of an infection caused H.
TABLE 2 - Allowed foods, foods that should be consumed with caution, and foods that must be avoided

Food groups Allowed Use with caution Prohibited

Fatty cheeses (mascarpone, cream cheese,
Dairy Milk, low-fat cheeses, yogurt, fermented milk -
gorgonzola)
Oilseeds Flaxseed, Brazilian nut, walnuts - -
Oils and olive oils Vegetable oils, olive oil - Fried foods
Fruits Apple, papaya, melon, banana Orange, pineapple, acerola, passion fruit Lemon
Leafy dark green vegetables, carrot, beet, green bean, Broccoli, cauliflower, cabbage, cucumber,
Vegetables Spicy peppers (black pepper, chilies)
spinach, kale, radish, zucchini, leek onion, red pepper
Legumes Bean soup, lentils, chickpeas, soybean Beans -
Meats Lean meat (beef, pork, chicken, fish) Fatty meats, organ meats and sausages -
Sweets - Concentrated sweets Chocolate
Beverages Natural juices Citrus/acidic fruit juices Coffee, black tea, fizzy/cola drinks
Industrialized seasonings, spices and
Other foods - Mustard grain
condiments (Ketchup, mayonnaise, mustard)

300 ABCD Arq Bras Cir Dig 2014;27(4):298-302

 Nutritional care in peptic ulcer

Pylori, by changing diet and lifestyle. Ferri-De-Barros et al.11 their efficacy and safety in humans27.
observed that alcohol consumption causes damages to the In peptic ulcer this is also obser ved. In a study
digestive tract with appearance of symptoms of ulcer and conducted by Mentz and Schenkel20, in which they assessed
other alcohol-related diseases, such as esophagitis, chronic plants with popularly known effects to scientifically prove
pancreatitis, gastritis, among others. them, they observed that plants like Symphytum Officinale
According to Reis29, smoking diminishes secretion of L. (Comfrey), besides having no proven efficacy it may be
mucus and bicarbonate, raising the duodenal and gastric harmful because of their pyrrolizidine alkaloids, of proven
flow and increasing the risk of ulcers formation. Prospective hepatotoxic action. Another studied plant was Zantoxylon
and retrospective studies show higher mortality from peptic rhoifoliun Lan (“mamica-de-cadela”), popularly indicated for
ulcer in smokers when compared to nonsmokers. Researches ulcers and healing, but its benefits have not been proved
show that, among other tobacco constituents, nicotine either. In addition, Maytenus ilicifolia Mart, commonly known
accounts for most of the peptic ulcer development, because in Brazil as “espinheira-santa”, used for healing peptic ulcer,
it has a harmful effect on the protective mucus of the gastric has not proven this effect in trials either.
epithelium, altering bicarbonate30. Studied the effects of Peumus boldus (“boldo”) and
Coffee, even decaffeinated coffee, raises gastric acid Baccharis genistelloides (“carqueja”), both commonly used to
production, resulting in mucosal irritations. The same goes treat digestive problems and ulcers. The studies that proved
for soft drinks, which, besides increasing acid production, various activities popularly attributed to these plants are
are gaseous and cause gastric distension and is dyspepsia- associated with the isolate chemical compounds, such as,
related 18. However, it is important to take into account for example, flavonoids, antioxidants found both in boldo
individual tolerances, with attention to the existence of and carqueja leaves. However, the benefits of these teas in
misconceptions about foods and their actions in the body. the cure of peptic ulcer have not been scientifically proven27.
Table 2 indicates foods that are prohibited and should be The use of natural products in treatment of ulcer has
avoided by people with peptic ulcer. been widely studied. However, most of the studies7 that have
proven an anti-ulcer effect were conducted with animals, and
Antacids versus nutrients bioavailability therefore do not provide reliability for alternative treatments
Deficiency of vitamin B12 is common in patients with in the prevention of relapses or for treatment of peptic ulcer
peptic ulcer due to the prolonged use of antacids, making in humans.
difficult the bioavailability of this vitamin. Vitamin B 12 can
be synthetized by the intestinal microbiota in the colon, but
is not absorbed. Deficiency of this vitamin causes impaired
CONCLUSION
cell division and megaloblastic anemia. It is estimated that
80-90% of patients lacking vitamin B12 develop neurological A balanced diet is vital in the treatment of peptic ulcer,
alterations, if not treated24. As a result, recommendation is once food can prevent, treat or even alleviate the symptoms
for 2.4 µg/day of this vitamin, which can be obtained from involving this pathology. However, there are few papers that
animal foods, such as milk, meat and eggs. innovate dietotherapy; so additional studies addressing more
Absorption of folic acid can be impaired in subjects that specifically the dietotherapy for treatment of peptic ulcer,
make chronic use of aluminum-based antacids (Pepsamar®, a disease that affects a large part of the population, are
Gastran®, Alca-Luftal®), because antacids make the pH of necessary.
the jejunum more alkaline23. In these cases, intake of 400
µg/day of this vitamin is necessary, which can be supplied
with ingestion of leguminous foods, such as lentils, and
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