GASTRIC ULCERATION

Gastric ulcer may develop without an apparent cause. As a rule, however, it manifests itself in individuals between the years of fifteen and forty, particularly after prolonged digestional disturbances, especially those accompanied by a hypersecretion of acid. As the disease progresses, anemia is more or loss severe, adding difficulty to the feeding problem. Many of the symptoms are like those of chronic gastritis, such as pain. However, the character of this pain may be different, beginning soon after eating and radiating toward the back. This point may be affected by position. As a rule there is a tenderness over the seat of the ulcer. This is detected by palpation. Vomiting is one of the most general symptoms in gastric ulceration. This may begin from one to two hours after eating when the pain is at its height, or it may start as soon as food enters the stomach. As a rule the latter condition is found more often in very nervous women whose mental attitude affects the stomach to such an extent as to make it difficult to give them sufficient food to nourish them.

Hemorrhage.—Hemorrhage occurs in about half of the cases. The bleeding may be profuse and the blood bright red, or it may be less severe and the color of the blood changed by contact with the gastric juices to a dark brown like coffee grounds.

Excess Acid.—Hyperacidity is present in the majority of the cases, the percentage of HCl rising at times fifty per cent. or more. Other cases occur in which all of the just mentioned symptoms except dyspepsia are missing, the first intimation of the ulcer being hemorrhage or perforation.

The patient with gastric ulcer may recover entirely and never have a return of the trouble, but care and close attention are necessary, since the ulcers are apt to recur, at times a series of ulcers developing one after another. Death may occur from exhaustion or from perforation and peritonitis. Surgical intervention is as a rule necessary when the ulcers persist, as they generally develop at or near the pyloric opening; and the constant development of cicatricial tissue brings about an obstruction of the pylorus, which if not relieved would allow the patient to starve.

Diet Treatment.—There are a number of treatments used in overcoming this condition. After the test meal and the diagnosis, the patient is placed upon a diet directed to overcome the chief symptom; for example, if the ulcer developed as a result of hyperacidity, the diet would be directed toward the relieving of that symptom. Boas[93] divides the treatment into three stages: (1) hemorrhage; (2) the intermediate stage; (3) the convalescent stage.

Starvation Treatment.—The majority of physicians institute a total abstinence period for the first stage, allowing no food or water to be taken by mouth. If the patient is very weak and anemic from the extended course of the disease, nutrient enemas are given from four to six times a day, alternating with saline enemas. This total abstinence continues from three to six days. Some cases have been known to be fed in this way for a month or six weeks with obvious success. However, this is not the rule but the exception. The diet must be adjusted to the needs of each individual, but a few general rules may be found helpful.

Dietetic Treatment.—Milk is the food generally utilized in the beginning. This may require peptonizing to be digested, or it may have to be modified with limewater. Protein foods require HCl for their digestion. If these foods are fed they will absorb some of the excess acid, and in this way save the already irritated wall of the organ from additional irritation. When protein foods are given they must be in the form of soft-cooked eggs, scraped raw beef or beef juice, milk soups, and like protein foods.

When there is a dilatation of the organ there is more or less danger of fermentation taking place, with the formation of organic acids. These acids are exceedingly irritating, and every care must be observed to prevent their production. The following dietetic régime may be used as a guide in many cases of gastric ulceration:

Milk Diet.—½ glass (4 ounces) of milk peptonized at 115° F. for 20 minutes, every hour for three or four days. After this the interval between feedings is lengthened to two hours and the amount of milk increased to ¾ of a glass (6 ounces). This is continued from a week to ten days. The patient may be given a cup of well-strained meat broth, reënforced with an egg, once or twice a day, to vary the monotony of the diet. During the third week the milk may be given in the form of milk soups. These may be slightly thickened with barley, rice, or farina flour. The soups may be flavored with beef extract, but only a small quantity must be used, owing to the stimulating properties of these substances.

Water as a Stimulus to Gastric Secretion.—Water is exceedingly stimulating to the acid secreting cells of the stomach, hence it is advisable to limit the amount of water taken by mouth, allowing the patient just enough to wash out the mouth without swallowing any. The thirst is relieved by saline enemas.

It has been found, in many cases of gastric ulceration, especially those accompanied by hemorrhage, that glucose gives better results when used in rectal alimentation, than any other substance. The strength of the solution varies from a five to a twenty-five per cent. solution. The number of glucose enemas given each day must be regulated by the physician. The method used is the same as in other rectal feedings, the enema is given “high,” and the flow regulated (drip-method).

Convalescent Diet.—During the fourth week, if the pain and discomfort are decreasing, soft-cooked or creamed eggs may be added to the diet, together with thoroughly boiled rice, farina, cream of wheat, wheatena and other finely ground wheat foods, wine or fruit jelly, sweetened slightly, or by using a small amount of saccharin for the purpose, junket and plain vanilla ice cream. At the end of the fourth week a very small portion of meat may be given once a day. It may be scraped raw beef spread upon toast or zwieback, or very lightly broiled beefsteak, broiled lamb chop or chicken (breast only), or boiled or broiled sweetbreads or brains. Spinach or green peas pressed through a sieve are the first vegetables allowed. After these young tender carrots and string beans may be given. Tea, coffee, and chocolate are eliminated from the diet. Milk flavored with coffee or cocoa may serve as a hot drink in the morning when the desire or need for such a drink is manifested. Butter is the best form of fat to be used in cases of gastric ulceration, but this must be given with the greatest caution. In cases where this fat is used in the form of cream, the amount must be cut down or entirely abandoned when there are evidences of butyric fermentation. Buttermilk, koumiss, and other fermented milk drinks are often found very satisfactory adjuncts to the diet. These may be given between meals, or at meals they may be substituted entirely for the milk when other foods are being given. They are not sufficiently nourishing to take the place of the milk diet otherwise. Albumenized orange juice and cream, egg and vichy may be given to add variety to the diet.

Anemia.—When anemia is severe, as is often the case in gastric ulceration, the diet must be reënforced to overcome it. Some of the concentrated milk foods such as plasmon, encasin, sanatogen, etc., as well as the predigested meat foods, such as panopepton, liquid beef peptonoids, and like preparations, may be used to reënforce the diet.

Bland Diet.—In certain cases of gastric ulceration it has been found more advisable to use what is known as a bland diet. This consists of farinaceous foods such as farina, arrowroot, cream of wheat, corn meal, wheatena, malted breakfast foods cooked thoroughly and given in the form of gruels, and some of the proprietary infant foods, such as Mellin’s Food, Eskay’s Food, Racahout. These foods may require the addition of Taka diastase to make them more readily digested. They leave the stomach more rapidly than any of the others, and for this reason will be found to give less discomfort than the foods containing a high percentage of protein and fat. This diet, however, cannot be prolonged on account of its lack of balance. If the gruels are made with milk instead of with all water they become more evenly balanced. Samples of the stomach contents may be taken for analyses from time to time.

Lavage.—When lavage is necessary the patient must be allowed to rest after the process before being given food, otherwise it is apt to be vomited.

Instructions to Nurse.—The treatment for gastric ulceration is thus seen to be strenuous. In the beginning the patient is placed on a liquid or semi-solid diet, or is not fed at all for a time. This is done that the diseased organ may have a chance to adjust itself as far as possible and to give the physician an opportunity of studying the changes taking place in that organ. During the course of the disease the general symptoms which develop from time to time, causing more or less pain and discomfort to the patient, are nervousness, which in some individuals amounts to melancholia, extreme anemia and an utter distaste for food, all of which require patience on the part of the physician, the nurse, and the patient herself to overcome. The nurse must see that the patient is not disturbed or made unhappy by having business or home cares talked over in her presence; she must be kept as cheerful and as comfortable as her condition permits and urged to use care in her diet. After the ulcer is healed, to prevent a return of the trouble she must be warned against eating too fast or when over-tired, and she must be advised against very hot and highly seasoned foods, for, in the observance of these simple common-sense precautions only is she even in a measure saved further attacks.

Special Diets Used for Gastric and Duodenal Ulcer.—There are several well-known diets used in these conditions. Among those that have been found most satisfactory may be mentioned the Sippi diet, the Lenhartz diet.

All of these diets require the most careful adjustment as to regulation of intervals of feeding, type of food material used, and method of preparation and administration of food.

The treatment is directed toward the reduction of the free hydrochloric acid in the stomach in order that the ulcer may have an opportunity for healing.

Sippi Diet.—Equal quantities of heavy cream and whole milk, beginning with ½ ounce each every hour during the day. Alkaline powders are given with the meal and one-half hour after the meal. These consist of 15 grains each of sodium bicarbonate and bismuth subcarbonate with the feeding, and 10 grains of light oxide of magnesia and 15 grains of sodium bicarbonate between feeding. The cream and milk are increased at the rate of one-half ounce each at each feeding for two days, the powders are continued as on the first day. On the fourth day an egg is added to the diet, the milk and cream are given in quantities of one and one-half ounce each, every hour. On the fifth day two eggs are added. On the sixth day one helping of oatmeal or other soft cereal is added to the above diet. The diet is in this way increased until the patient is taking three eggs and nine ounces of cooked cereal each day in addition to the cream and milk mixture. The amount given at one time must be small, never exceeding six ounces (according to Carter, Howe and Mason).

An accurate control of the acidity of the stomach should be maintained, this is accomplished by withdrawing a certain amount of the gastric contents by means of the stomach tube.

The Lenhartz Diet.—This diet is likewise given in hourly feedings, consisting of milk and raw eggs in the beginning, then a small portion of sugar is added, next scraped beef is added to the milk, eggs and sugar, already given, then boiled rice. Next a small quantity of zwieback (or soft toast), and continuing in this way, chicken, and butter are admitted. In the beginning the quantity of milk is 100 c.c. and the number of eggs 2, given raw. It is served iced, and with a teaspoon. When the sugar is added it is beaten up with the eggs (20 gm.). The milk and eggs are divided into separate feedings and given at hourly intervals from 7 A.M. to 7 P.M. It is rarely possible to give the amounts called for in the Lenhartz diet after the sixth day, but as much as possible should be given without risking an acute disturbance. Women, as a rule, find it more difficult to take the full amount ordered than men.

The following outlines represent the diet for the first, third, sixth, seventh and tenth day:

FIRST DAY

7 A.M.Egg
8 A.M.Milk, 20 c.c.
9 A.M.Egg
10 A.M.Milk, 20 c.c.
11 A.M.Egg
12 noonMilk, 15 c.c.
1 P.M.Egg
2 P.M.Milk, 15 c.c.
3 P.M.Egg
4 P.M.Milk, 15 c.c.
5 P.M.Egg
6 P.M.Milk, 15 c.c.
Total: Milk, 100 c.c. Eggs (raw), 2.

THIRD DAY

7 A.M.Egg; sugar, 2 gm.
8 A.M.Milk, 50 c.c.
9 A.M.Egg; sugar, 3 gm.
10 A.M.Milk, 50 c.c.
11 A.M.Egg; sugar, 3 gm.
12 noonMilk, 50 c.c.
1 P.M.Egg; sugar, 3 gm.
2 P.M.Milk, 50 c.c.
3 P.M.Egg; sugar, 3 gm.
4 P.M.Milk, 50 c.c.
5 P.M.Egg; sugar, 3 gm.
6 P.M.Milk, 50 c.c.
7 P.M.Egg; sugar, 3 gm.
Total: Milk, 300 c.c. Eggs (raw), 4. Sugar, 20 gm.

SIXTH DAY

7 A.M.Egg; sugar, 4 gm.
8 A.M.Milk, 100 c.c.
9 A.M.Egg; sugar, 4½ gm.; scraped beef, 12 gm.
10 A.M.Milk, 100 c.c.
11 A.M.Egg; sugar, 4½ gm.
12 noonMilk, 100 c.c.
1 P.M.Egg; sugar, 4½ gm.; scraped beef, 12 gm.
2 P.M.Milk, 100 c.c.
3 P.M.Egg; sugar, 4½ gm.
4 P.M.Milk, 100 c.c.
5 P.M.Egg; sugar, 4 gm.; scraped beef, 12 gm.
6 P.M.Milk, 100 c.c.
7 P.M.Egg; sugar, 4½ gm.
Total: Eggs (raw), 7. Milk, 600 c.c. Sugar, 30 gm. Scraped beef, 36 gm.

SEVENTH DAY

7 A.M.1 soft-cooked egg
8 A.M.Milk, 100 c.c.
9 A.M.Egg; sugar, 13 gm.
10 A.M.Milk, 100 c.c.; scraped beef, 23 gm.; boiled rice, 33 gm.
11 A.M.1 soft-cooked egg
12 noonMilk, 125 c.c.
1 P.M.Egg; sugar, 13 gm.
2 P.M.Milk, 125 c.c.; scraped beef, 23 gm.; boiled rice, 33 gm.
3 P.M.1 soft-cooked egg
4 P.M.Milk, 125 c.c.
5 P.M.Egg; sugar, 14 gm.
6 P.M.Milk, 125 c.c.; scraped beef, 24 gm.; boiled rice, 34 gm.
7 P.M.1 soft-cooked egg
Total: Eggs (raw), 4; (soft-cooked), 4. Milk, 700 c.c. Sugar, 40 gm. Scraped beef, 70 gm. Boiled rice, 100 gm.

TENTH DAY

7 A.M.1 soft-cooked egg
8 A.M.Milk, 166 c.c.
9 A.M.Egg; sugar, 13 gm.
10 A.M.Milk, 168 c.c.; scraped beef, 23 gm.; boiled rice, 66 gm.; butter, 4 gm.
11 A.M.1 soft-cooked egg; zwieback (or soft toast), 20 gm.; butter, 4 gm.
12 noonMilk, 166 c.c.; minced chicken, 25 gm.
1 P.M.Egg; sugar, 13 gm.
2 P.M.Milk, 166 c.c.; scraped beef, 25 gm.; boiled rice, 66 gm.; butter, 4 gm.
3 P.M.1 soft-cooked egg; butter, 4 gm.; toast or zwieback, 20 gm.
4 P.M.Milk, 168 c.c.; minced chicken, 25 gm.
5 P.M.Egg; sugar, 14 gm.
6 P.M.Milk, 166 c.c.; scraped beef, 24 gm.; boiled rice, 67 gm.; butter, 4 gm.
7 P.M.1 soft-cooked egg
Total: Eggs (raw), 4; (soft-cooked), 4. Milk, 1000 c.c. Sugar, 40 gm. Scraped beef, 70 gm. Minced chicken, 50 gm. Butter, 20 gm. Boiled rice, 200 gm. Toast or zwieback, 40 gm.