FACTORS ASSOCIATED WITH PEPTIC ULCERS AMONG ADULT

FACTORS ASSOCIATED WITH PEPTIC ULCERS AMONG ADULT

PATIENTS ATTENDING ST. MICHAEL DIGESTIVE DISEASES AND

MEDICAL CARE IN UPPER HILL, NAIROBI COUNTY

BY:

MUSYOKA LILIAN KATUNGE

ADMISSION NO: A90/28864/2009

SUPERVISOR:

PROF.J.K.IMUNGI

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Research project submitted in partial fulfilment of the requirements for the degree ofBachelor of Science in food, nutrition and dietetics of the University of Nairobi.Department of food science, nutrition and technology.

2013

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DECLARATION

This research report is my original work and has not been presented for a degree or diploma inany other university. Therefore duplication, publication of this research report to any university,collage or institution is prohibited. No part of this research may be reproduced without the priorpermission of the author and the University Of Nairobi- Upper Kabete campus.

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Name A illan ~a.+V(n c.Project Researcher/ Author 3

This research report has been submitted for review with my approval as a university supervisor

Signature:Q ::__=: m •••• Date: 6,.EJDl'1fY?.!.} m •••

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DEDICATION

I dedicate this project to God, to my parents who were with me in every step of the way and toall those who contributed in one way or another towards my education life.

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ACKNOWLEDGEMENTS

First of all, I thank the almighty for giving me the strength to face all the challenges in my studyperiod.

My special thanks go to my mother for her guidance during the entire period of my project.

I am greatly indebted to my supervisor professor 1.K. IMUNGI of food science and technologyfor his invaluable input in this work, beginning of the proposal to the final write up.

I would like to acknowledge St. Michael digestive diseases and medical care for granting mepermission to do my study at their medical care.

To many people who made important contributions to the success ofthis study. Those who willremain unnamed, I wish to express my gratitude for all the assistance rendered so generously.

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ABSTRACT

OBJECTIVE: The objective of this study was to establish factors associated with peptic ulcersamong adult patients attending St. Michael digestive diseases and medical care in upper hill,

airobi County. METHOD: A cross sectional descriptive and analytical study was used to gatherinformation on different qualitative and quantitative data and information on important healthrelated issues likely to be associated with peptic ulcers. The data was collected between Marchand April 2013. The study targeted a population consisting of all adults patients aged 18 yearsand above attending the medical centre. Sampling frame consisted of adult patients diagnosedwith peptic ulcers

The sampling size consisted of 40 patients through which exhaustive sampling were donep'robabjy for a week to determine the peptic ulcer patients as this involved recruiting the patientsfor the study until the sample size was achieved.

The findings showed that a majority of the peptic ulcer patients were older people of age 44 and45 years. These were mostly university graduates 57.5% and secondary school graduates 30%.The study also shows most of the patients were married people 60% and were professionals intheir career indicating they belonged to the high socio-economic class. The findings also showthat most of the patients who had peptic ulcers were males 62.5% this then shows that maleswere more affected by the disease compared to females. The result of the study shows that therewas a strong association between patients who had the "H.pylori" infection, consumed alcoholand smoked tobacco and peptic ulcer disease. This therefore means that tobacco smoking,alcohol consumption and "H pylori" infection were the main associated factors for PUD in adultpatients who attended the medical Care and that usage ofNSAID drugs was the major factor thatcontributed to peptic ulcers among the patients.

The study recommends the formulation and implementation of an education programme that willtarget peptic ulcer patients in hospitals and other people in the community and different parts ofthe country especially men to create awareness of the prevalence of peptic ulcers and the factorsthat are associated with peptic ulcers for proper nutritional management of their condition andmeasures to undertake in prevention of the disease.

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TABLE OF CONTENTS Page

Declaration I

Dedication II

Acknowledgement III

Abstract IV

CHAPTER ONE- INTRODUCTION 1

Background of the study

Statement of the problem 2

Justification of the study 3

Research objectives 4

Statement of hypothesis 4

Expected benefits 4

Assumptions 5

CHAPTER TWO- LITERATURE REVIEW 6

History 6

Prevalence of peptic ulcers 6

Complications in peptic ulcers 9

Summary of existing gaps 11

CHAPTER THREE- RESEARCH METHODOLOGY 12

Study design 12

Study setting 12

Study population 13

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Sample and sampling procedure

Research instruments

Data collection procedures

Data handling and analysis

Ethical considerations

Time plan

CHAPTER FOUR-RESULTS

CHAPTER FIVE- CONCLUSIONS AND RECOMMENDATIONS

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Conclusions

Recommendations

References

Appendixes

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1.8: DEFINITION OF KEY TERMS/CONCEPTS

Peptic ulcer painful, open sores that develop on the inside lining of your oesophagus, stomach,----and the upper portion of your small intestine called the duodenum.'--

Prevalence A frequently used epidemiological measure of how commonly a disease or conditionoccurs in a population. Prevalence measures how much of some disease or condition there is in apopulation at a particular point in time

Infection is the invasion of a host organism's bodily tissues by disease-causing organisms, theirmultiplication, and the reaction of host tissues to these organisms and the toxins they produce.Infections are caused by microorganisms such as viruses, bacteria, and larger organismslike macro parasites and fungi.

Oesophagus is an organ in vertebrates which consists of a muscular tube through which foodpasses from the pharynx to the stomach. During swallowing, food passes from the mouth throughthe pharynx into the oesophagus and travels via peristalsis to the stomach. It's the part of thebody that carries food to the stomach

Duodenum In humans, it is shortest part of the small intestine, connecting the stomach to thejejunum, and it is where most chemical digestion takes place. Its' part of the small intestine thatis below the stomach

Hydrochloric acid in the stomach is an acid that provides an optimum pH for normalfunctioning of the enzymes present there. For example, hydrochloric acid helps convertpepsinogen to pepsin, which is responsible for breaking down proteins in the stomach.

No-steroidal Anti- inflammatory drugs NSAIDs are drugs used to reduce inflammation andrelieve fever and pain by blocking enzymes and proteins made by the body. They relieve painand fever. They also reduce swelling and inflammation caused by an injury or a disease. Antiinflammatory refers to the property of a substance or treatment that reduces inflammation.

Gastrointestinal tract is the stomach and intestine, sometimes including all the structures fromthe mouth to the anus. (The "digestive system" is a broader term that includes other structures,including the accessory organs of digestion)

Morbidity is a diseased state, disability, or poor health due to any cause. The term may be usedto refer to the existence of any form of disease, or to the degree that the health condition affectsthe patient.

Mortality is the state of being mortal, or susceptible to death

Phospholipids are a class of lipids that are a major component of all cell membranes as they canform lipid bilayers.

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CHAPTER ONE: INTRODUCTION

1.1: BACKGROUND OF THE STUDY

A peptic ulcer also known as peptic ulcer disease (PUD) is the most common ulcer of anarea of the gastrointestinal tract that is usually acidic and thus extremely painful. It is definedas mucosal erosions equal to or greater than 0.5 em. (Wikipedia)

A peptic ulcer is a sore in the lining of your stomach or duodenum. The duodenum is thefirst part of your small intestine. A peptic ulcer in the stomach is called a gastric ulcer. Onethat is in thedUodenum is called a duodenal ulcer. A peptic ulcer also may develop justabove your stomach in the oesophagus the tube that connects the mouth to the stomach. Butmost peptic ulcers develop in the stomach or duodenum (national digestive diseasesinformation clearinghouse, NDDIC)

How ulcers develop

The stomach and duodenal lining have several mechanisms that help prevent ulcers fromdeveloping, including the following:

1. A coating of mucus (mucous layer) protects the stomach lining from the effects ofacidic digestive juices.

2. Food and other substances in the stomach neutralize acid. Certain chemicalsproduced by the stomach protect the cells lining the stomach.

3. If the mucous layer is damaged or if acid neutralizing substances are not present innormal amounts, digestive juices can cause irritation and breakdown of the stomachor duodenal lining, allowing an ulcer to form

Causes

The most common cause for peptic ulcer disease is "Helicobacter pylori" infection, alsocalled H. pylori infection. "Helicobacter pylori" are spiral-shaped bacteria that are found incontaminated food and water. These bacteria, which were formerly called "Campylobacterpylori", spread through close contact (e.g., sharing drinking glasses and eating utensils) andpoor hygiene. "Pylori" infection occurs when these bacteria attach to the lining of thestomach or small intestine, multiply, and release toxins that cause mucosal inflammation anddamage. "Helicobacter pylori" infection can cause peptic ulcer disease, gastritis(inflammation of the stomach lining), and other complications (e.g., stomach [gastric]cancer).

Long-term use of non steroidal anti-inflammatory drugs (NSAIDs), such as aspirin,ibuprofen, and naproxen, also can damage the lining of the GI tract and cause peptic ulcerdisease. These medications, which are used to reduce pain and inflammation, should be usedonly as directed. When used in combination with NSAIDs, corticosteroids (e.g., prednisone)further increase the risk for peptic ulcers. In most cases, peptic ulcer disease caused by"Helicobacter pylori" infection or non steroidal anti-inflammatory drugs resolves once theinfection is treated or the medication is discontinued.

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Serious illnesses (e.g., liver disease, chronic obstructive pulmonary disease, kidney failure)can increase the risk for developing peptic ulcer disease. Trauma resulting from physicalstress (e.g., severe burns, traumatic brain injury, and surgery) also can increase the risk forPUD. (Health communities.com)

Additional factors that increase the risk for peptic ulcer disease include the following:

• Age (more common in people over the age of 50)• Alcohol use• Family history of peptic ulcers• Smoking• physical and mental stress

Classification

By Region/Location

1. Duodenum (called duodenal ulcer)2. Oesophagus (called oesophageal ulcer)3. Stomach (called gastric ulcer)

Symptoms.

People with peptic ulcers may have a wide variety of symptoms, have no symptoms, or,rarely, develop potentially life-threatening complications such as bleeding. Ulcers manifestthemselves as intermittent pain under the sternum after a meal or when one is hungry and atnight. You may also experience some nausea, vomiting, indigestion and bloody stool and

--vwithout treatment, the ulcer can expand and result in internal bleeding in extreme cases ahole forms in the duodenum, leaking the contents of your digestive tract into your abdominalcavity. The timing ofthe symptoms in relation to the meal may differentiate between gastricand duodenal ulcers: A gastric ulcer would give epigastric pain during the meal, as gastricacid production is increased as food enters the stomach. Symptoms of duodenal ulcers wouldinitially be relieved by a meal, as the pyloric sphincter closes to concentrate the stomachcontents; therefore acid is not reaching the duodenum. Duodenal ulcer pain would manifestmostly 2-3 hours after the meal, when the stomach begins to release digested food and acidinto the duodenum (Wikipedia)

Also, the symptoms of peptic ulcers may vary with the location of the ulcer and the patient'sage. Furthermore, typical ulcers tend to heal and recur and as a result the pain may occur forfew days and weeks and then wane or disappear. Usually, children and the elderly do notdevelop any symptoms unless complications have arisen. Burning or gnawing feeling in thestomach area lasting between 30 minutes and 3 hours commonly accompanies ulcers. Thispain can be misinterpreted as hunger, indigestion or heartburn. Pain is usually caused by theulcer but it may be aggravated by the stomach acid when it comes into contact with theulcerated area. The pain caused by peptic ulcers can be felt anywhere from the navel up tothe sternum, it may last from few minutes to several hours and it may be worse when thestomach is empty. Also, sometimes the pain may flare at night and it can commonly be

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temporarily relieved by eating foods that buffer stomach acid or by taking anti-acidmedication. However, peptic ulcer disease symptoms may be different for every sufferer.

1.2: PROBLEM STATEMENT

Peptic ulcer disease represents a serious medical problem in Kenya. Approximately 500,000new cases are reported each year. It is a disease that is predominantly affecting the youngand old but mostly the adult group. Factors associated with peptic ulcers have beensuggested in many researches and main causes have been identified but it is not knownwhether the situation is true for Kenya.

The disease is attributable to:

1. Infection with a type of bacteria called "helicobacter pylori" (H. Pylori)2. Hydrochloric Acid and pepsin a digestive stomach enzyme. Ulcers form when the

intestine or stomach's protective layer is broken down and this digestive juicesdamage the intestine or stomach tissue

3. Use of pain killers called nonsteroidal anti- inflammatory drugs (NSAIDS) such asaspirin, naproxen or diclofenac, ibuprofen these are drug used by many for arthritis,rheumatism, backache, head ache and period pains. Break down the stomach orintestine's protective mucus layer.

4. Drinking too much alcohol5. Smoking cigarettes or chewing tobacco6. People weakened by severe disease such as chronic respiratory disease or major

trauma) and under physiological stress are especially prone to form ulcers may resultfrom poor oxygenation to the lining of the stomach

7. Having radiation treatment8. Stress and consumption of acid foods

1.3: JUSTIFICATION OF THE STUDY

Importance of this study is to provide information, designed to give people the basic factsabout peptic ulcers to help them better understand this condition and to serve as a startingpoint for patients for discussion with their doctors.

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1.4: OBJECTIVES

1.4.1: Main Objective

To establish factors associated with peptic ulcer disease in adult patients attending St.Michael digestive diseases and medical care in upper hill, Nairobi.

1.4.2: Specific Objectives

To identify the socio-demographic and the socio-economic status ofthe patients.

To determine the main factors associated with peptic ulcer disease.

To determine the main factor that contributes to peptic ulcers among adult patients attendingthe medical care

1.5: STATEMENT OF HYPOTHESIS

Although peptic ulceration can occur at any age, it typically develops in adulthood with apeak incidence above the age of forty.

Ulcers are more common in men and cigarette smokers ant tend to run in families

Adults who over consume alcohol, take cigarettes, use NSAID drugs and eat poorly aremostly at risk of getting peptic ulcer disease

1.6: EXPECTED BENEFITS

First, the study findings would benefit all persons especially those diagnosed with thedisease through creating awareness of the disease its causes, signs and symptoms and how itcan be managed through a nutrition intervention. The findings and recommendations wouldbe helpful to the health workers in that they would give proper information on what causespeptic ulcers and how to treat and prevent it.

Secondly, the study would be able to address the risk factors that influence the cause ofpeptic ulcers and with this information the patients and the health workers will be moreeducated about the disease and would pass the information out there to other people.

The study would also contribute new knowledge to the existing knowledge of peptic ulcerdisease. This study would provide information that will be useful to academicians for theywould gain additional knowledge on peptic ulcers. Lastly, the study is an eye opener forfurther research.

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1.7: ASSUMPTIONS

Assumptions were that:

The patients would be able to remember and give honest information on the researchvariables such as age, gender, socio-economic status etc.

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CHAPTER TWO: LITERATURE REVIEW

1.8: HISTORY

For thousands of years healthy people have had acute abdominal pain, nausea, vomiting anddiarrhoea followed by death in few hours or days. Often these symptoms were contributed topoisoning and people have been sent to prison for this. King Charles 1's daughter, Henriette-Anne, died suddenly in 1670 (at age of26) after a day of abdominal pain and tenderness.Since poisoning was suspected autopsy was performed and revealing peritonitis and a smallhole in the interior wall of the stomach. However doctors had never had of a perforatedpeptic ulcer and attributed the hole in the stomach to the knife of the dissector. Necropsieswere first allowed since 1500 and became more routine between 1600 and 1800. As aconsequence more often perforation of the stomach was observed. Johan Radecki (1850-1905), often refer to as the first surgeon who closed a perforated ulcer by simple closuresaid: "every doctor, faced with perforated duodenal ulcer of the stomach or intestine, mustconsider opening the abdomen, sewing up the hole, and averting a possible in animation bycareful cleansing ofthe abdominal cavity" surprisingly enough treatment since has notchanged much, still consisting ofthe primary closure of the perforation by single stitchsuture and a convenient tag of adjacent omentum on the top of this. Although the theorysounds simple still perforated peptic ulcer remains a dangerous surgical condition, associatedwith high morbidity and mortality, not to be underestimated. ( Prof. Dr. H.G. Schmidt)

In 1843 Edward Crisp was the first to report 50 cases ofPPU and accurately summarized theclinical aspects of perforation. Patients with PPU had a typical history of sudden onset ofacute, sharp pain usually located in the epigastric area and sometimes with referred shoulderpain, indicating free air under the diaphragm. Bases on collected data from 52 papers onPPU clinical characteristics were summarized. The typical patient with PPU was male withan average age of 48 years who may have had a history of peptic ulcer disease (29%) or nonsteroidal usage (20%). Vomiting and nausea was present in 50 of the cases. (Prof. Dr. H.G.Schmidt)

1.9: PREVALENCE OF PEPTIC ULCER

Peptic ulcer disease refers to a disruption of the mucosal integrity of the stomach, duodenum,or both, mucosal causal by local inflammation, which leads to a well-defined mucosal defect.This results from an imbalance between the damaging effects of the noxious substances andthe ability of the mucosa to defend against them. The time trends in the epidemiology ofpeptic ulcer disease reflect complex, multifactorial aetiologies. Peptic ulcers were rare beforethe 1800s. The pathology of gastric ulcers (GUs) was first described in 1835 during the late1800s the prominent form was GUs in young women. Duodenal ulcers (DUs) were rare untilabout 1900 and then became a prevalent condition during the first half of the 20th century

It is estimated that 2% ofthe adult population in the United States has active peptic ulcers,and that about 10% will develop ulcers at some point in their lives. There are about 500,000new cases of peptic ulcer in the United States every year, with as many as 4 millionrecurrences. The male/female ratio for ulcers of the digestive tract is 3:1. The risk ofdeveloping PUD is higher among men and among those with lower socioeconomic status.

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The most common forms of peptic ulcer are duodenal and gastric. About 80% of all ulcers inthe digestive tract are duodenal ulcers. This type of ulcer may strike people in any age groupbut is most common in males between the ages of20 and 45. The incidence of duodenalulcers has dropped over the past 30 years. Gastric ulcers account for about 16% of pepticulcers. They are most common in males between the ages of 55 and 70.Peptic ulcer diseaseis a relatively common condition. According to the National Institute of Diabetes andDigestive and Kidney Diseases (NIDDK), about 10% of people in the United States (25million people) will develop peptic ulcer disease during their lifetimes (called lifetimeincidence ).PUD develops about as often in women as men. Peptic ulcer disease is morecommon in people over the age of 50.

The prevalence of the infection varies, however both among countries and within differentracial group and resident within the same country. In both developed and developingcountries. The lifetime risk for developing a peptic ulcer is approximately 10%. In Westerncountries the prevalence of "helicobacter pylori" infections roughly matches age (i.e., 20% atage 20,30% at age 30, 80% at age 80 etc.). Prevalence is higher in third world countrieswhere it is estimated at about 70% of the population, whereas developed countries show amaximum of 40% ratio

Today over 810 million people suffer with peptic ulcers and there are many more at risk ofgetting the disease. In the past it was believed that stress and diet caused peptic ulcers. Later,researchers stated stomach acids (hydrochloric acid and pepsin) contributed to the majorityof ulcer formation. Today however research shows that most ulcers develop as a result ofinfection with a spiral shaped bacterium called "helicobacter pylori". As many as 70-90% ofsuch ulcers are associated with "helicobacter pylori". Research shows that the bacteriumenters the stomach through the oral route and is usually acquired at a young age and cansurvive in the stomach for long periods without being killed off by the stomach acid. Inadulthood as the stomach lining is weakened due to stress, lack of sleep and excessivealcohol consumption the H. Pylori is able to attack the cells more aggressively. Helicobacterpylorus is quite common as it infects more than half ofthe world's population. It causesmore than 90% of the duodenal ulcers and up to 80% of the gastric stomach ulcers (BarryMarshall and robin warren).

2.1: COMPLICATIONS OF PEPTIC ULCER DISEASE

Peptic ulcer can heal spontaneously and may come and go. They can also be associated withserious, potentially life threatening complications, sometimes without warning signs. This ismost common in elderly patients and those who take NSAIDs. The most commoncomplication of ulcers is bleeding and perforation.

B1eeding- bleeding can be gradual or abrupt, abrupt bleeding often causes black, tarry, loosestools, and a drop in blood pressure. Most ulcer bleeding can be controlled with endoscopy,which allows a physician to cauterize the ulcer or inject it with epinephrine to stop thebleeding. Only about 2 to 5 percent of people with a peptic ulcer require surgery.

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Perforation- perforation is the medical term for a puncture in the stomach lining or theduodenum caused by the ulcer. Perforation usually causes sudden severe abdominal pain thatrequires surgery.

Gastric outlet obstruction- is the narrowing of pyloric canal by scarring and swelling ofgastric antrum and duodenum due to peptic ulcers. Patients often present with severevomiting

Cancer- cancer is included in the differential diagnosis (elucidated by biopsy), H.pylorias the etiological factor making it 3 to 6 times more likely to develop stomach cancer fromthe ulcer.

2.2: DIAGNOSIS AND TREATMENT

2.2.1: DIAGNOSIS

Not everyone with ulcer symptoms has an ulcer. Similar symptoms can be caused by widevariety of conditions such as functional dyspepsia (i.e. the presence of ulcer symptomswithout a specific cause), abnormal emptying of the stomach, acid reflux, gallbladderproblems and much less commonly stomach ulcer. Thus, the process needed to diagnose anulcer depends upon the person's medical history and sometimes, use of specific tests.(Diagnostic procedures and tests used in evaluating PUD can be categorized into those thatdocument the presence of an ulcer and those that document the presence of "h. pylori"infection. Diagnosis of peptic ulcer disease involves taking a medical and family history andperforming a physical examination and diagnostic tests. In most cases, an upper GJ seriesand an upper endoscopy are performed to diagnose PUD.

In an upper GI series, the patient drinks a contrast solution (e.g., barium) and a series of x-rays are taken of the upper gastrointestinal tract (i.e., the oesophagus, stomach, and smallintestine). The contrast solution produces clearer images of the lining of the GI tract andhelps the physician detect ulcers.

Upper endoscopy involves passing a thin, lighted tube with a tiny camera attached throughthe throat and into the stomach and upper portion of the small intestine (duodenum). Upperendoscopy, which is performed under sedation, allows the physician to visualize the lining ofthe GI tract and detect ulcers. During this procedure, a small piece of tissue can be removedfor microscopic evaluation (called a biopsy).

Once a diagnosis of peptic ulcer disease has been made, other laboratory tests (e.g., breathtests, blood tests, stool tests) are performed to determine if the condition is caused bybacteria (e.g., Helicobacter pylori)

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2.2.2: TREATMENT

Most ulcers can be healed with medications. In rare cases, surgery may be performed totreat severe peptic ulcer disease that does not respond to medications or to treatcomplications ofPUD (e.g., perforation, obstruction). Types ofPUD surgery includevagotomy (used to reduce the production of stomach [gastric] acid), pyloroplasty (used towiden the lower portion of the stomach [pylorus]), and partial gastrectomy (removal of partof the stomach).

Identity cause of ulcer- this initial step in treating an ulcer is to identify the cause. NSAIDsshould be stopped, regardless of the cause. People who have "H.pylori" are treated withantibiotics and medication that reduces acid production.

Treating "H.pylori" no single drug effectively cures "H.pylori" infection. Treatment involvestaking several medications for 7 to 14 days.

Most of the treatment regimens include a medication called a proton pump inhibitor. Thismedication decreases the stomach's production of acid, which allows the tissues damaged bythe infection to heal. Examples of proton pump inhibitors include lansoprazole (prevacido),esomeprazole (nexiumo), omeprazole (prilloseco), dexiansoprazole (dexilanto), pantoprazole(protonixo) and rabeprazole (aciphexo)

Avoid consumption of alcohol when on medication, Stop smoking, and avoid NSAIDs if~ .-possible. All medications should be reviewed with a health care provider to make sure thatthey do not contain NSAIDs. If it is necessary to continue NSAIDs; one or more medicationsmay be added to aid in ulcer healing and prevent recurrence. If you had complications fromyour ulcer (bleeding or perforation) you should be retested for "H.pylori" to make sure thatantibiotics therapy was successful. Although controversial, most experts recommend that amedication to reduce acid secretion is continued, even after a complicated ulcer has healed.

Antacids are permissible during ulcer treatment if needed, although antacids should not beused within one hour before or two hours after taking ulcer medications, since they caninterfere with their absorption.

Efforts to reduce stress can benefit your overall health and may have a small benefit inhealing ulcers. However most ulcers heal with medications, even in people who continue tolive a stressful life.

2.2.3: DIETARY CHANGES

In the past, it was common practice to tell people with peptic ulcers to consume smallamounts of bland foods frequently throughout the day. Research conducted since that timehas shown that a bland diet is not effective at reducing the incidence or recurrence of ulcersand that eating numerous small meals throughout the day is no more effective than eating

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three meals a day. Large amounts of food should still be avoided, however, becausestretching the stomach can result in painful symptoms.

Fruits and Vegetables. A diet that is rich in fiber may cut the risk of developing ulcers in halfand speed the healing of existing ulcers. Fiber found in fruits and vegetables is particularlyprotective. Vitamin A contained in many ofthese foods may increase the benefit.

Milk. Milk encourages the production of acid in the stomach, although moderate amounts (2- 3 cups a day) appear to do no harm. Certain probiotics, which are "good" bacteria added toyogurt and other fermented milk drinks, may protect the gastrointestinal system.

Coffee and Carbonated Beverages. Coffee (both caffeinated and decaffeinated), soft drinks,and fruit juices with citric acid increase stomach acid production. Although no studies haveproven that any of these drinks contribute to ulcers, consuming more than 3 cups of coffeeper day may increase susceptibility to H. pylori infection.

Spices and Peppers. Studies conducted on spices and peppers have yielded conflictingresults. The rule of thumb is to use these substances moderately, and to avoid them if theyirritate the stomach.

Garlic. Some studies suggest that large amounts of garlic may have some protectiveproperties against stomach cancer, although one study concluded that garlic offered nobenefits against H. pylori and, in large amounts, can cause considerable GI distress.

Olive Oil. Studies from Spain have shown that phenolic compounds in virgin olive oil maybe effective against eight strains ofH. pylori, three of which are antibiotic-resistant.

Vitamins. Although no vitamins have been shown to protect against ulcers, H. pylori appearto impair the absorption of vitamin C, which may playa role in the higher risk of stomachcancer.

Exercise some evidence suggests that exercise may help reduce the risk for ulcers in somepeople.

2.3: PROGNOSIS AND PREVENTION OF PEPTIC ULCER DISEASE

When the underlying cause for peptic ulcer disease is successfully treated, the prognosis(expected outcome) for patients with the condition is excellent. To help prevent pepticulcers, avoid the following:

1. Alcohol2. Common sources of"Helicobacter pylori" bacteria (e.g., contaminated food and

water, floodwater, raw sewage)3. Long-term use of non steroidal anti-inflammatory drugs (NSAIDs)4. Smoking

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2.3.1: PEPTIC ULCER FOLLOW-UP

Duodenal ulcers- people with uncomplicated duodenal ulcers should have follow-up testingafter treatment, especially if symptoms recur or do not improve. Follow-up testing isrecommended for all people who have had complications (such as bleeding or perforation) toensure that "H.pylori" has been successfully cured.

Gastric ulcers-people with gastric ulcers usually undergo a repeat endoscopy to ensure thatthe ulcer has healed and to ensure that the ulcer do not contain cancer cells. Long termtreatment to suppress stomach acid is usually recommended if a person has a high risk ofulcer recurrence (e.g. a history of ulcer complications or frequent recurrences)

People with ulcers due to "H.pylori" who have been cured ofthe infection are unlikely todevelop another ulcer ifNSAIDs are avoided.

2.4: GAPS OF KNOWLEDGE

Although much research and documentation has been done on peptic ulcer disease no muchwork has been done in Kenya.

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CHAPTER THREE: STUDY DESIGN AND METHODOLOGY

2.5: STUDY DESIGN

II

This was a cross sectional descriptive and analytical study that gathered information onfactors such as patient's medical history, socio demographic and economic status ofthepatients, life style practices and information on important health related issues likely to beassociated with peptic ulcers

2.6: METHODOLOGY

2.6.1: STUDY SETTING

The study was conducted at St. Michael digestive diseases and medical care that deals withtreatment of digestive diseases such as gastritis, stomach ulcers etc which is located in y.pperHill Nairobi County, at Professor Nelson Awori Centre, Ralphe Bunche road next to Nairobihospital, off ng'ong road. The medical care is a private clinic owned by a gastroenterologist.Nairobi the capital city of Kenya is located at 1017'S 36°49'E and occupies 696 squarekilometres (270 sq mi). At 1,795 metres (5,889 ft) above sea level, Nairobi enjoys amoderate climate. Under the Koppen climate classification, Nairobi has a subtropicalhighland climate. The altitude makes for some cool evenings, especially in the June/Julyseason, when the temperature can drop to 10°C (50 OF). The sunniest and warmest part ofthe year is from December to March, when temperatures average the mid-twenties during theday. The mean maximum temperature for this period is 24 °C (75 OF).

Nairobi is basically a political, socio-economic and industrial capital with very littleagricultural practices/activities. Urban agriculture is practised in peri-urban areas and somecity estates like ruai and kahawa. Most of the food consumed in the city is brought throughchannels of trade from the surrounding agricultural lands and upcountry. Through trade andcommerce, both local and international, the residents of Nairobi have all foods at theirdisposal as long as they can afford.

The city boasts of the best health facilities in Kenya that are managed by highly qualifiedpersonnel. The Kenyatta national hospital (KNH) is located in Nairobi. It is the premiernational referral and teaching hospital in the country. Private-owned hospitals are the AgaKhan, Nairobi, Gertrude's Garden, Mater, Guru Nanak and MP Shah. Some health facilitiesare church owned and provide curative, preventive and rehabilitative health services

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2.6.2: STUDY POPULATION

The study targeted a population consisting of all adults patients aged 18 years and aboveattending the medical centre. Sampling frame consisted of adult patients diagnosed withpeptic ulcer

2.7: SAMPLING

2.7.1: SAMPLE SIZE DETERMINATION

.The study consisted of 40 patients since the population of the patients at the clinic was nothigh and the clinic receives slightly less than 10 peptic ulcer patients in any given week.

2.7.2: SAMPLING PROCEDURE

Exhaustive sampling was done for a week. This entailed recruiting the adult patients for thestudy as they came for treatment at the health centre until the sample size was achieved.There was Informed consent for assessments and use of questionnaires on the patients.

2.8: INCLUSION CRITERIA.

Adults both male and female diagnosed with peptic ulcers and also Patients with otherdiseases including peptic ulcer disease

2.9: EXCLUSION CRITERIA.

Patients under the age of 18 years

3.1: STUDY TOOLS

The following tools were used for data collection:

Pretested Semi structured questionnaire consisting of sections on diet habits and medicalhistory ofthe patients

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3.2: RECRUITMENT AND TRAINING OF RESEARCH ASSISTANTS

One research assistant was recruited to assist in the administration of the questionnaire. Theresearch assistant was trained on research ethics on the administration ofthe questionnaire.

3.3: PRE-TESTING OF QUESTIONNAIRE

Pretesting of research tools was done on random people who were diagnosed with thedisease in different locations in Nairobi to ensure questions were clearly stated and theirlanguage were easily understood

3.4: DATA COLLECTION PROCEDURES

Data was collected using a self administered questionnaire by the researcher and theassistant. A letter was obtained from the university to conduct research. With the help of theassistant, the questionnaires were administered to the patients upon being informed about thestudy.

With the self administered questionnaire the following variables were assessed:

1. Socio demographic factors: sex, age, occupation, level of education2. socioeconomic status: socio economic class and income3. genetic factors: family history ofPUD4. lifestyle practices: tobacco smoking (cumulative tobacco consumption (g/day)-

cumulative consumption of different tobacco products), alcohol (cumulative numberof drinks)

5. dietary habits6. Medications used: unspecified antirheumatic drugs (NSAIDs).7. Psychosocial factors such as stress

3.5: DATA QUALITY CONTROL

During data collection there was close monitoring and questionnaires were inspected tocheck for errors of omission and commission. Data was collected and analyzed with respectto the study objective.

14

3.6: DATA ANALYSIS

Descriptive analysis was done on the data collected. Information obtained from thequestionnaires will be checked, verified and entered into the computer. Data entry andanalysis was accomplished by use of a suitable statistical package i.e. the analytical softwarestatistical package of social sciences (SPSS). The SPSS software was utilized to generatedifferent descriptive statistics depending on the variable under consideration and the specificstudy objectives.

The graphs were done using the micro soft excel and SPSS programmes.

3.7: ETHICAL CONSIDERATIONS

A recommendation letter was obtained from university of Nairobi, faculty of agriculture inorder to be able to obtain permission from the medical centre to be able to carry on theproject. The administrators ofthe study site were informed of the intended study prior to datacollection. During data collection, consent was sought from the respondents and there wasconfidentiality of the collected information.

3.8: TIME PLAN

March A ril

15

CHAPTER FOUR: RESULTS AND DISCUSSIONS

3.9: SOCIO-DEMOGRAPHIC AND ECONOMIC CHARACTERISTICS OF THE

STUDY POPULATION

3.9.1: AGE OF THE RESPONDENTS

The below shows that the minimum age of respondents was 22 years and maximum was 65years while the average age was 44 years. The results further indicated that most of therespondents who were affected with peptic ulcers were of age 44 and 45 years.

AGE 40

40

65.00 44.025022.00

MeanN Minimum Maximum

16

3.9.2: SEX OF THE RESPONDENTS

The table below shows that 62.5% of adult patients who came for treatment were males and37.5% were females. This indicates that males are more at risk of peptic ulcers than females.

Cumulative

Frequency Percent Valid Percent Percent

MALE 25 62.5 62.5 62.5

FEMALE 15 37.5 37.5 100.0

70.00%62.50%

60.00%

50.00% +-----

40.00%

30.00% +-----

20.00%

10.00%

MALE FEMALE

17

The graph below shows that a majority of respondents were married people who formed60% of the total response. The single respondents formed 25%, divorced 5% and widowed10%. This indicates that most ofthe patients in the clinic were married people and fewerwere single people and some of them widowed and others divorced.

3.9.3: RESPONDENTS MARITAL STATUS

n11

MARITAL STATUS

-------L---

WIDOWED 10%

V'l DIVORCED 5o/c::::l

~ MARRIED

<i. I I~ SINGLE I ,

25li~~o i i

---------------'----- --------L--- --J----

60%

50 6020 30 40o 10 70

18

3.9.4: RESPONDENTS OCCUPATION LEVEL

The graph below shows that most of the respondents were either professionals in their career(37.50%) or business persons (25.00%) others were unemployed (12.50%) and Unskilledworkers were the minimum at (2.50%).This indicates that the medical care receives patientsof different socio-economic class and according to the study most of them were from thehigh socio-economic class.

403530

2520

15105 --.._ -- ---.-_ _ _.

o

37.5%

4-------I-----'L~A>-----------------

:>70-------1---' -' z I c::: c::: c::: 0<l: <l: 0 UJ UJ UJ UJZ Z VI ::.:: ::.:: ::.:: >-0 Q c:::

Ic::: c::: c::: 0

Vi UJ 0 0 0 -'VI c, 3: 3: 3: c,VI VI ~UJ UJ VI 0 0 0u, u.. VI UJ UJ UJ UJ0 0 UJ -' -' -' zc::: c::: z -' -' -' ::Jc, c, Vi :;z :;z :;z

~ ::J VI !!! VI

UJco ~ z

VI UJ::J

VI

OCCUPATION

19

Frequency Percent

Finished Primary School 2 5.0

Finished Secondary School 12 30.0

Not Finished Secondary2 5.0

School

Finished University/Collage23 57.5

Level

Non Finished University1 2.5

/Collage Level

AMOUNT EARNED IN A MONTH

20

15

-cCP<>~ 10

Q..

2.90%

5

8g b

ca

AMOUNT EARNED IN A MONTH

The graph above shows that a majority of the patients earned around ksh.20, 000 to ksh.50,000. The highest earned was 40,000 by 16.13% of the patients. This indicates that amajority of the patients at the study earned well.

4.1: TO DETERMINE THE MAIN FACTORS ASSOCIATED WITH PEPTICULCERS.

21

'.P..)

a) ASSOCIATION BETWEEN HELICOBACTER PYLORI INFECTION ANDPEPTIC ULCERS

Asymp. Sig. (2- Exact Sig. (2- Exact Sig. (1-

Value df sided) sided) sided)

Pearson Chi-Square 12.1303 1 .000

Continuity Correction'' 10.025 1 .002

Likelihood Ratio 12.842 1 .000

Fisher's Exact Test .001 .001

Linear-by-Linear Association 11.827 1 .001

N of Valid cases" 40

Chi-Square Tests

b) ASSOCIATION BETWEEN INTAKE OF NSAID DRUGS AND PEPTIC ULCERDISEASE

Chi-Square Tests



Pearson Chi-Square .4403 1 .507

Continuity Correction" .110 1 .740

Likelihood Ratio .441 1 .507


Linear -by-Linear Association .429 1 .513

N of Valid Cases" 40

c) ASSOCIATION BETWEEN FAMILY HISTORY OF PEPTIC ULCERS ANDPEPTIC ULCER DISEASE

22



Pearson Chi-Square .000a 1 1.000

Continuity Correction" .000 1 1.000

Likelihood Ratio .000 1 1.000

Fisher's Exact Test 1.000 .624

Linear-by-Linear Association .000 1 1.000


d) ASSOCIATION BETWEEN PREVIOUS ILLNESSES AND PEPTIC ULCERS



Pearson Chi-Square .742a 1 .389

Continuity Correction" .283 1 .595

Likelihood Ratio .745 1 .388


Linear-by-Linear Association .723 1 .395

N of Valid cases" 39

Chi-Square Tests

e) ASSOCIATION BETWEEN INTAKE OF HOT AND SPICY FOODS ANDPEPTIC ULCER DISEASE



Pearson Chi-Square .000a 1 1.000

Continuity Correction" .000 1 1.000

Likelihood Ratio .000 1 1.000

Fisher's Exact Test 1.000 .642

Linear-by-Linear Association .000 1 1.000


Chi-Square Tests

23

f) ASSOCIATION BETWEEN SMOKING AND PEPTIC ULCERS

Chi-Square Tests

,..



Pearson Chi-Square 4.358a 1 .037

Continuity Correction" 3.104 1 .078



Linear -by-Linear Association 4.246 1 .039


g) ASSOCIATION BETWEEN ALCOHOL CONSUMPTION AND PEPTIC ULCERS



Pearson Chi-Square 4.286a 1 .038

Continuity Correction" 2.976 1 .084



Linear-by-Linear Association 4.179 1 .041


Chi-Square Tests

24

4.1.1: A SUMMARY ON FACTORS ASSOCIATED WITH PEPTIC ULCERS

FACTORS ASSOCIATED cm SQUARE VALUEWITH PEPTIC ULCERS

HELICOBACTER 0.001INFECTION

FAMILY HISTORY OF 0.624PEPTIC ULCERS

HISTORY OF PREVIOUS 0.624ILLNESSES

TOBACCO SMOKING 0.038

USAGE OF NSAID DRUGS 0.371

ALCOHOL 0.041CONSUMPTION

INTAKE OF HOT AND 0.642SPICY FOODS

STRESS RELATED 0.374CONDITIONS

The tables above show a cross tabulation between different factors and peptic ulcers by usinga chi square test to determine the main factors that are associated with peptic ulcers amongthe peptic ulcer patients. According to the chi square test, the level of significance is set at<0.05 meaning any value more than this has no association with peptic ulcers. From thesummary table above the associated factors were: infection with H.pylori infection, alcohol

25

consumption and tobacco smoking. Among the factors H. Pylori infection showed thestrongest association with peptic ulcer disease.

4.2: TO DETERMINE THE MAIN FACTOR THAT CONTRIBUTES TO PEPTICULCERS AMONG THE ADULT PATIENTS ATTENDING THE MEDICAL CARE.

• ~~e[c~nt(no)of" ,y

"l' f ~, j{ l'

PRESENCE OF HELICOBACTER 52.5 47.5INFECTION

FAMILY HISTORY OF PEPTIC 45.5 55.5ULCERS

HISTORY OF PREVIOUS 37.5 60.5ILLNESSES

TOBACCO SMOKING 40.0 57.5

USAGE OF NSAID DRUGS 65.5 35.5

ALCOHOL CONSUMPTION 70.0 30.0

AFFECTED BY INTAKE OF HOT 75.5 25.5AND SPICY FOODS

STRESS RELATED CONDITIONS 60.0 40.0

Table above shows that 75.5% of peptic ulcer patients had a habit of taking NSAID drugs,45% had a family history of peptic ulcers, 37% had a history of previous illnesses, 40%smoked tobacco, 70% consumed alcohol, 75% were affected by intake of hot and spicy food,60% had suffered from stress related conditions and 52.5% had been infected with "H.pyloriinfection". This therefore indicates that the factor that played a high role in peptic ulcercondition in the patients was intake ofNSAID drugs (75.5%)

26

CHAPTER FIVE: CONCLUSION AND RECOMMENDATION

4.3: CONCLUSION

Results indicate that a majority of the peptic ulcer patients were older people of age 44 and45 years. These were mostly university graduates and secondary school graduates. The studyalso shows most of the patients were married people who were professionals in their careerindicating they belonged to the high socio-economic class.

It is also seen that most of the patients who had peptic ulcers were males this shows thatmales were more affected by the disease as compared to females .There was a strongassociation between patients who were treated with H.pylori infection, consumed alcoholand smoked tobacco and peptic ulcer disease. This therefore means that Tobacco smoking;alcohol consumption and "H pylori" infection were the main associated factors for pepticulcer disease in adult patients who attended the medical Care.

The results also show that usage ofNSAID drugs was the major factor that contributed topeptic ulcers in adult patients attending the medical care.

4.4: RECOMMENDATION.

The study recommends the formulation and implementation of an education programme thatwill target peptic ulcer patients in hospitals and the population in different parts of thecountry especially men to create awareness of the prevalence of peptic ulcers and the factorsthat are associated with peptic ulcers for proper nutritional management of their conditionand measures to undertake in prevention of the disease.

There is need for the government to include peptic ulcer disease among the public healthconcerns in the country to create awareness and to help the population prevent and managethe disease.

Designing and implementing of an education programme targeting to educate men on goodlifestyle practices to prevent peptic ulcers as they are more at risk of getting peptic ulcers ascompared to women

27

CHAPTER SIX:REFERENCES1. Kurata JH,2006, epidemiology: peptic ulcer risk factors ..

2. Sung JJ, kuipers EJ,EI-serag HB, 2009, systemic review: global incidence andprevalence of peptic ulcer disease " _

3. Peura, P.A. (2007) patient information: peptic ulcer disease http://www.Mckinley.Illinois.edu

4. National institute for diabetes and digestive and kidney diseases, 2010, NSAID andpeptic ulcers, http://digestive.niddk.nih.gov

s. Kurata Ph.D., M.P.H., John H.; Nogawa, Aki N. M.S. (Jan 1997). Smoking". Journalof Clinical Gastroenterology

6. digestive.niddk.nih.gov/eases/pubs/peptic ulcers ez

7. Chey WD, et al. (2007). American College of Gastroenterology guideline of themanagement of "Helicobacter pylori" infection. American Journal ofGastroenterology, 102(8): 1808-1825.

8. Lanza FL, et al. (2009). Guidelines for prevention ofNSAID-related ulcercomplications. American Journal of Gastroenterology, 104(3): 728-738.

9. Malagelada J-R, Kuipers Martin EJ, Blaser 1. Acid Peptic Disease: Clinicalmanifestations, Diagnosis, Treatment, and Prognosis. In.Goldman: Cecil Medicine,23rd ed. Philadelphia, PA: WB Saunders, 2007

10. Amakrishnan K, Salinas RC. Peptic ulcer disease. Am Fam Physician. 2007;76(7): 1005-12.

11. Chey WD, Wong Be. American College of Gastroenterology guideline on themanagement of Helicobacter pylori infection. Am J Gastroenterol. Aug 2007; 102(8):1808-25.

12. Malagelada JR, Kuipers EJ, Blaser MJ. Acid peptic disease: clinical manifestations,diagnosis, treatment, and prognosis. In: Goldman L, Ausiello D, eds. Cecil Medicine.23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 142

28

APPENDIX

ANNEX 1: SAMPLE QUESTIONNAIRE

INTERVIEWER: LILIAN KATUNGE.

I'm a fourth year student at the University of Nairobi currently doing a project onfactors associated with peptic ulcers and I would like to ask you some questions. Thepurpose of this study is to provide information that would be used by the policymakers, planners, programme managers and others in redesigning andreimplementation of the programme. The information collected will be confidential.

REG.NO.A90/0269/2009Bsc. Food science Nutrition and Dietetics, University of Nairobi

FOR PATIENTS WITH ULCERS

QUESTIONNAIRE NO:

INTERVIEWERS NO:

DATE OF INTERVIEW: 1. /2013

SOCIO- DEMOGRAPHIC CHARACTERISTICS:

I. Age: --- years.

2. Sex: 1=male D 2= female D3. Marital status: (tick inside the circle)

o I=Singleo 2=Marriedo 3=Divorcedo 4=widowed

4. Place of residence/ home:

(Town, estate, area)

5. Occupation: (tick inside the circle)o 1=Professionalo 2=Semi professionalo 3=ClericaI, shop owner, farmero 4=Skilled workero 5=Semiskilled workero 6=Unskilled worker

29

o 7=Unemployed

6. Education: (tick inside the circle)o 1=Finished primary schoolo 2=Not finished primary schoolo 3=Finished secondary schoolo 4=Not finished secondary schoolo 5=Finished university or collage levelo 6=Not finished university or collage level

SOCIO-ECONOMIC STATUS

7. How much do you earn ( say specific amount per month in shillings):

8. Socio-economic class: (tick inside the circle)o 1=Upper classo 2=Middle classo 3=Lower class

MEDICAL HISTORY: (tick inside the box)

9. Have you been diagnosed with peptic ulcers?1=yes 0 2=no D

10. Have you ever been treated for "helicobacter pylori" infection:

l=Yes D 2=No D

11. Is there any family history of Peptic Ulcer Disease:I=Yes 0 2=No D

12. Are you in the habit of taking NSAID drugs (Aspirin, Paracetamol etc.):

I=Yes D 2=No DIf yes: 1= Prescribed by a doctor D 2=self administered 0

13. How many times do you take the NSAID drugs(pain killers):

14. Time of intake of the NSAID drug: 1=Before foodD 2= After food D

15. Do you often take steroid drugs: I=Yes D 2= No DIf yes, is it taken in combination with NSAID: I=Yes D 2=NoD

30

16. Do you have a history of any previous illnesses such as arthritis or respiratorydiseases: I=YesD 2=No D

If yes, specify which disease:

17. Have you ever suffered from stress related conditions l=Yes D 2= No D

DIETARY PRACTICES: (tick inside the box)

18. Do hot and spicy foods affect your health: 1=Yes D 2= No D

If yes, how does it affect you (do you have pains or discomfort when eating them):

19. What kinds of foods don't you consume due to peptic ulcers:(Name them)

DIET ARY HABIT: (tick inside the box)

20. Eating habits: 1=Normal D 2=Fast D 3= Slo~

21. Appetite pattern: Normal D 1= Increased D 2=Reduced D

22. Do you consume food at regular intervals (breakfast, lunch, supper): I=Yes D2=NoD

LIFESTYLE: (tick inside the box)

23.Doyousmoke:l=Yes D 2=NoD

If yes, how many cigarettes do you smoke per day?

Say specific No. of years:

24. Does anyone else smoke in the family: 1=Yes D 2=NoD

25. Do you consume alcohol: I=Yes D 2= NoDIf yes, what amount of alcohol is consumed at a time (in a day orweek)?

26. Any other addictions: 1=Yes DIf yes, specify:

2= NoD

31

Documents

FACTORS ASSOCIATED WITH PEPTIC ULCERS AMONG ADULT