Peptic ulcers are so named because their formation and progression are related to the digestive action of gastric acid and pepsin; since the vast majority of cases (more than 95%) occur in the stomach and duodenum, they are also referred to as gastric and duodenal ulcers. This condition is a common and prevalent disease found worldwide, though incidence rates vary significantly among countries. Factors such as geographical environment, climate, ethnicity, genetics, customs, and dietary habits all influence its occurrence. It can affect people of any age, but is most common among young and middle-aged adults, with men being more affected than women. Episodes can occur throughout the year, but are most frequent in the spring and fall.
In Traditional Chinese Medicine, this condition falls under the categories of “stomach pain,” “epigastric pain,” “heart-stomach qi pain,” and “vomiting and regurgitation.”
I. Etiology and Pathogenesis of Peptic Ulcers
The etiology and pathogenesis of this condition are relatively complex but are associated with emotional distress, irregular diet or excessive alcohol consumption, smoking, genetic factors, and the use of certain medications.
Emotional distress—such as worry, anxiety, or anger—that remains unresolved injures the liver. Stagnation of liver qi then invades the stomach, disrupting the harmonious descent of stomach qi and leading to epigastric pain; when liver qi remains stagnant for an extended period, it transforms into fire, depleting stomach yin and resulting in dull epigastric pain; When liver qi invades the spleen, the spleen fails to transport and transform properly, leading to the internal generation of dampness and turbidity; as a result, stomach qi rises in a counterflow, causing symptoms such as belching, acid reflux, nausea, and a sensation of fullness; if the constitution is inherently deficient, or if stomach pain persists for a long time and damages spleen yang, resulting in a deficiency of central yang, symptoms of spleen-stomach deficiency-cold may appear, such as fatigue and weakness, aversion to cold and preference for warmth, dull pain in the upper abdomen, and pain aggravated by cold; Prolonged liver qi stagnation leads to qi stagnation and blood stasis, manifesting as stabbing pain in the upper abdomen at a specific location; in severe cases, it may damage the blood vessels, resulting in symptoms such as vomiting blood or black stools. Irregular eating habits—such as alternating between hunger and overindulgence—or binge eating can damage the spleen and stomach, impairing the spleen’s ability to transport and transform nutrients and preventing the descent of stomach qi, thereby causing qi stagnation. Similarly, excessive consumption of spicy foods or alcohol, or unrestrained intake of raw and cold foods, can also damage the spleen and stomach, leading to the accumulation of dampness and turbidity within the body. Additionally, the use of certain medications may contribute to the onset of this condition.
Modern medicine holds that the true cause of this disease remains unclear, and its etiology and pathogenesis are relatively complex. It is believed that the formation of ulcers results from an imbalance between protective and damaging factors affecting the gastric and duodenal mucosa.
Chemical and mechanical factors in food, as well as the digestive action of hydrochloric acid and pepsin in gastric juice, are potential damaging factors for the gastric and duodenal mucosa. Under normal circumstances, however, these factors do not damage the gastric and duodenal mucosa to the point of causing disease. This is due to a series of protective mechanisms within the body, including gastric mucus, the gastric mucosal barrier, the rapid turnover of mucosal cells, the rich blood supply to the gastrointestinal wall, the neutralizing effect of alkaline duodenal fluid and pancreatic juice on gastric acid, intestinal gastrin, other gastrointestinal hormones, and normal rhythmic gastric and duodenal motility. Some foods themselves also neutralize and dilute stomach acid. Under neuroendocrine regulation, these protective factors form a series of defensive mechanisms. This ensures that, under normal physiological conditions, the body can not only complete the digestive process but also protect the gastric and duodenal mucosa from damage—or limit damage to a minimal degree—and facilitate rapid healing.
In addition to neurological and endocrine dysfunction, which can promote ulcer formation, dietary imbalances are also significant factors. Foods and beverages can cause physical (e.g., coarse foods, bone fragments) or chemical (e.g., excessively acidic or spicy foods, alcohol) damage to the gastric and duodenal mucosa; coffee can stimulate increased gastric acid secretion, while irregular mealtimes can disrupt the rhythm of gastric secretion. All of the above are contributing factors to ulcer formation. Certain medications, such as aspirin, indomethacin, reserpine, and glucocorticoids, can indirectly cause damage to the gastric and duodenal mucosa and lead to ulcers when taken in certain doses. Smoking causes vasoconstriction and inhibits the secretion of pancreatic juice and bile, thereby reducing their ability to neutralize stomach acid in the duodenum. Smoking can also cause bile to reflux into the stomach, damaging the gastric mucosal barrier and leading to reflux gastritis or ulcers. Long-term, heavy smoking hinders ulcer healing and can also cause ulcers to recur. In addition, individuals with blood type O have a higher incidence of duodenal ulcers than those with other blood types. The incidence of this disease is higher among relatives of patients with gastric or duodenal ulcers than in the general population.
II. Symptoms of Peptic Ulcers
1. Pain: Upper abdominal pain or discomfort is the primary symptom.
(1) The nature of the pain varies and may manifest as hunger-like discomfort, dull pain, distending pain, burning pain, or severe pain.
(2) Location of pain: Pain from gastric ulcers is often located in the midline or slightly to the left of the xiphoid process; pain from duodenal ulcers is often located in the midline or slightly to the right of the upper abdomen. The area of pain is generally about the size of a palm, and there may be localized tender points. When the ulcer is deep or perforated, the pain may radiate to the back.
(3) Timing of pain: The pain is rhythmic. In patients with gastric ulcers, upper abdominal pain usually occurs half an hour to two hours after a meal and subsides before the next meal. This pattern repeats daily; if left untreated, it can persist for several days, weeks, or longer; In patients with duodenal ulcers, upper abdominal pain typically occurs before meals—hence the term “fasting pain”—and may lessen or resolve completely after eating. The pain may also occur in the evening before bedtime or in the middle of the night.
(4) The pain may be exacerbated by factors such as improper diet, emotional fluctuations, or sudden drops in temperature.
2. Other Symptoms: Other gastrointestinal symptoms include belching, acid reflux, nausea, and vomiting, which may occur alone or alongside pain.
3. Diagnostic Tests
(1) Barium meal X-ray examination: A niche shadow may be observed during a barium-air double-contrast examination.
(2) Fiberoptic endoscopy: This allows visualization of the ulcer’s location, size, shape, and the condition of its edges and base. Tissue samples can also be obtained for examination to distinguish between benign and malignant lesions.
(3) Gastric juice analysis: Gastric acid secretion in patients with gastric ulcers is normal or slightly below normal; in patients with duodenal ulcers, gastric acid secretion is often elevated.
(4) Fecal occult blood test: A positive result (after a 3-day vegetarian diet) indicates an active ulcer. The result typically resolves after 1–2 weeks of treatment.
III. Treatment of Peptic Ulcers
1. Traditional Chinese Medicine (TCM) Treatment Based on Pattern Differentiation
(1) Deficiency-Cold Pattern: Patients present with dull pain in the upper abdomen, aversion to cold and preference for warmth, worsening pain when exposed to cold, a sallow complexion, fatigue and weakness, clear saliva, loose stools, a pale tongue, and a deep, fine pulse. The treatment principle is to strengthen the spleen, harmonize the stomach, warm the middle burner, and dispel cold. Huangqi Jianzhong Decoction, augmented with ingredients such as Alpinia officinarum and Cyperus rotundus, may be used.
(2) Qi Stagnation Type: Due to liver depression and qi stagnation, resulting in disharmony between the liver and stomach, patients present with pain in the right hypochondrium, epigastric distension and fullness, belching and acid regurgitation, decreased appetite, a thin white tongue coating, and a string-like or deep-string-like pulse. The treatment principle is to soothe the liver and regulate qi, harmonize the stomach, and relieve pain. Chaihu Shugan San with appropriate modifications may be used for treatment.
(3) Damp-Heat Pattern: Patients present with epigastric pain that worsens after eating, a burning sensation in the stomach, a dry and bitter mouth, a red tongue with a yellow coating, and a string-like or rapid pulse. The treatment principle is to clear heat and harmonize the stomach; Er Chen Tang with additions such as Gardenia, Scutellaria, Coptis, and Citrus reticulata may be used.
(4) Yin Deficiency Pattern: Patients present with dull epigastric pain, internal restlessness and heat, dry mouth with little saliva, heat in the palms and soles, dry and hard stools, a red tongue with little or no coating, and a string-like, fine or deep, fine pulse. The treatment principle is to nourish stomach yin; the Sha Shen Mai Dong Decoction with appropriate modifications may be used.
(5) Blood Stasis Pattern: Due to prolonged liver qi stagnation leading to qi stagnation and blood stasis, patients present with severe upper abdominal pain, often described as stabbing or knife-like, with a fixed location that does not shift; in severe cases, there may be recurrent black stools or hematemesis, a dark purple tongue with ecchymotic spots, and a string-like or涩 pulse. The treatment principle is to promote blood circulation and resolve stasis, while regulating qi and harmonizing the stomach. The Shi Xiao San combined with Jin Ling Zi San, plus Sanqi and Bai Ji, may be used for treatment; for cases accompanied by bleeding, it is advisable to cool the blood and stop bleeding using Xie Xin Tang with additions such as Di Yu Tan, Ce Bai Tan, and Ou Jie Tan, or by taking Yunnan Baiyao.
2. Modern Medical Treatment for This Condition
(1) Use of Antacids: Antacids reduce acidity in the stomach and duodenum, relieve pain, and promote ulcer healing. Commonly used medications include sodium bicarbonate, aluminum hydroxide gel, Gaisuping, and Gaidel.
(2) Anticholinergic Drugs: These drugs inhibit gastric acid secretion, relieve smooth muscle and vascular spasms, improve local nutrition, and delay gastric emptying. Due to contraindications and potential complications, they are rarely used for peptic ulcers. They are commonly used for temporary pain relief, such as atropine, metoclopramide, and propantheline.
(3) Histamine H₂ receptor antagonists: These drugs block histamine-induced gastric acid secretion and are therefore used to treat peptic ulcers. There are many synthetic varieties; currently, cimetidine is commonly used and has shown good efficacy. The recommended dosage is 200 mg three times daily, taken after meals, with a treatment course lasting 4 to 6 weeks.
IV. Complications of Peptic Ulcers
Common complications include: bleeding, perforation, pyloric obstruction (temporary and persistent), and malignancy. Once complications arise, active treatment is required. If conservative medical treatment proves ineffective, surgical intervention is necessary; otherwise, the condition may become life-threatening.
V. Prevention of Peptic Ulcers
Prevention of this condition should focus on the following points:
1. Avoid worry and anger; maintain an optimistic outlook and alleviate excessive mental stress;
2. Maintain a regular eating schedule: eat at set times, in moderate portions, and avoid overeating or binge eating;
3. Avoid spicy or overly acidic foods, and limit consumption of coffee and similar beverages;
4. Limit or quit smoking and drinking;
5. Avoid medications that damage the gastric mucosa; for example, anti-rheumatic drugs should not be taken for prolonged periods;
6. If an ulcer has already developed, seek prompt treatment to ensure healing and prevent recurrence.