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Peptic Ulcer

Also indexed as: Duodenal Ulcer, Gastric Ulcer, Stomach Ulcer

Illustration

Ulcer pain? Undo the damage. Peptic ulcers can cause serious discomfort and damage to the digestive system if left untreated. According to research or other evidence, the following self-care steps may be helpful:

What you need to know

  • Avoid irritants
  • Avoid smoking, aspirin and related drugs (nonsteroidal anti-inflammatory drugs), alcohol, coffee (including decaf), and tea to improve ulcer healing
  • Fight recurrences with fiber
  • Reduce the risk of new duodenal ulcers by getting enough fiber
  • Try a little licorice
  • Chew 250 to 500 mg of deglycyrrhizinated licorice (DGL) before meals and bedtime to support mucous membrane healing
  • Give zinc a go
  • Take 25 to 50 mg of this mineral a day to speed the repair of damaged tissue
  • Get a checkup
  • See a doctor to find out whether your ulcer is related to Helicobacter pylori infection

These recommendations are not comprehensive and are not intended to replace the advice of your doctor or pharmacist. Continue reading the full peptic ulcer article for more in-depth, fully-referenced information on medicines, vitamins, herbs, and dietary and lifestyle changes that may be helpful.

About peptic ulcer

Peptic ulcers are erosions or open sores in the mucous lining of the stomach or duodenum (the first part of the small intestine). The term “peptic” distinguishes peptic ulcers from ulcerations that affect other parts of the body (e.g., diabetic leg ulcers). 

Peptic ulcer should never be treated without proper diagnosis. They are usually caused by infection from Helicobacter pylori (H. pylori). People with peptic ulcer due to infection should discuss conventional treatment directed toward eradicating the organism—various combinations of antibiotics, acid blockers, and bismuth—with a medical doctor. Ulcers can also be caused or aggravated by stress, alcohol, smoking, and dietary factors.

Product ratings for peptic ulcer

Science Ratings Nutritional Supplements Herbs
3Stars  

Deglycyrrhizinated licorice (chewable)

Mastic

2Stars

Vitamin A

Zinc

Zinc-L-Carnosine

Banana powder

Neem

1Star

Carnosine

DMSO

Fiber (for duodenal ulcer)

Flavonoids (quercetin, catechin, apigenin)

Glutamine

Vitamin C

Calendula

Chamomile

Comfrey

Corydalis

Garlic

Marshmallow

Plantain

3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support and/or minimal health benefit.

What are the symptoms?

Peptic ulcers are occasionally painless. However, the most common symptom is a dull ache in the upper abdomen that usually occurs two to three hours after a meal; the ache is relieved by eating. Other common symptoms include weight loss, bloating, belching, and nausea. Untreated, peptic ulcers often bleed and may cause sharp burning pain in the area of the stomach or just below it.

Medical options

Over the counter antacids, such as magnesium hydroxide (Phillips’ Milk of Magnesia®), aluminum hydroxide (Amphojel®), calcium carbonate (Tums®), and the combination magnesium-aluminum hydroxide (Mylanta®, Maalox®), help relieve the symptoms associated with peptic ulcers. The histamine H2 antagonists, such as cimetidine (Tagamet®), ranitidine (Zantac®), and famotidine (Pepcid®), as well as the proton pump inhibitor omeprazole (Prilosec-OTC), are also beneficial.

Prescription drug therapy might involve antibiotics that eliminate H. pylori infection, such as amoxicillin (Amoxil®), clarithromycin (Biaxin®), metronidazole (Flagyl®), and tetracycline (Sumycin®), in combination with the proton pump inhibitors lansoprazole (Prevacid®) and omeprazole (Prilosec®). Bismuth subsalicylate (Pepto Bismol®) may be added as well. Other medications may be prescribed to control stomach acidity, including prescription strength histamine H2 inhibitors, such as cimetidine (Tagamet®), ranitidine (Zantac®), and famotidine (Pepcid®), as well as the prescription strength proton pump inhibitors omeprazole (Prilosec®), lansoprazole (Prevacid®), pantoprazole (Protonix®), and rabeprazole (Aciphex®).

Dietary changes that may be helpful

People with ulcers have been reported to eat more sugar than people without ulcers,1 though this link may only occur in those with a genetic susceptibility toward ulcer formation.2 Sugar has also been reported to increase stomach acidity,3 which could aggravate ulcer symptoms.

Salt is a stomach and intestinal irritant. Higher intakes of salt have been linked to higher risk of stomach (though not duodenal) ulcer.4 As a result of these reports, some doctors suggest that people with ulcers should restrict the use of both sugar and salt, although the benefit of such dietary changes remains unknown.

Many years ago, researchers reported that cabbage juice accelerated healing of peptic ulcers.5 6 7 8 Drinking a quart of cabbage juice per day was necessary for symptom relief in some reports. Although only preliminary modern research supports this approach,9 many doctors claim considerable success using one quart per day for 10 to 14 days, with ulcer symptoms frequently decreasing in only a few days. Carrot juice may be added to improve the flavor.

Fiber slows the movement of food and acidic fluid from the stomach to the intestines, which should help those with duodenal, though not stomach, ulcers.10 When people with recently healed duodenal ulcers were put on a long-term (six-month), high-fiber diet, the rate of ulcer recurrence was dramatically reduced in one controlled study,11 though short-term (four-week) use of fiber in people with active duodenal ulcers led to only negligible improvement.12

The relationship between food allergies and peptic ulcers has been reported at least as far back as the 1930s.13 Exposing the lining of the stomach to foods to which a person is allergic has been reported to cause bleeding in the stomach.14 Although additional research is needed, avoiding food allergens may be helpful for people with peptic ulcers. Consult with a doctor to determine food sensitivities.

Lifestyle changes that may be helpful

Aspirin and related drugs (non-steroidal anti-inflammatory drugs),15 alcohol,16 coffee17 (including decaf),18 and tea19 can aggravate or interfere with the healing of peptic ulcers. Smoking is also known to slow ulcer healing.20 Whether or not an ulcer is caused by infection, people with peptic ulcer should avoid use of these substances.

Vitamins that may be helpful

Vitamin A is needed to heal the linings (called mucous membranes) of the stomach and intestines. In one controlled trial, vitamin A supplementation facilitated healing in a small group of people with stomach ulcer.21 The amount used in that study (150,000 IU per day) can be toxic and may also cause birth defects. Such a high dose should not be taken by a pregnant woman, by a woman who could become pregnant, or by anyone else without careful supervision from a doctor. Objective evidence of ulcer healing from taking vitamin A has been reported by the same research group.22 The effect of lower amounts of vitamin A has not been studied in people with peptic ulcer.

Zinc is also needed for the repair of damaged tissue and has protected against stomach ulceration in animal studies.23 In Europe, zinc combined with acexamic acid, an anti-inflammatory substance, is used as a drug in the treatment of peptic ulcers.24 In a small controlled trial, high amounts of zinc accelerated the healing of gastric ulcers compared with placebo.25 Some doctors suspect that such an exceptionally high intake of zinc may be unnecessary, suggesting instead that people with ulcers wishing to take zinc supplements use only 25 to 50 mg of zinc per day. Even at these lower levels, 1 to 3 mg of copper per day must be taken to avoid copper deficiency that would otherwise be induced by the zinc supplementation.

Experimental animal studies have shown that a zinc salt of the amino acid carnosine exerts significant protection against ulcer formation and promotes the healing of existing ulcers.26 27 However, because zinc by itself has been shown to be helpful against peptic ulcer, it is not known how much of the beneficial effect was due to the carnosine.28 29 Clinical studies in humans demonstrated that this compound can help eradicate H. pylori, an organism that has been linked to peptic ulcer and stomach cancer.30 The amount of the zinc carnosine complex used in research studies for eradication of H. pylori is 150 mg twice daily.

Glutamine, an amino acid, is the principal source of energy for cells that line the small intestine and stomach. More than 40 years ago, glutamine was reported to help people with peptic ulcer in a preliminary trial.31 Glutamine has also prevented stress ulcers triggered by severe burns in another preliminary study.32 Despite the limited amount of published research, some doctors suggest 500 to 1,000 mg of glutamine taken two to three times per day to help people overcome peptic ulcers.

Oral supplementation with dimethyl sulfoxide (DMSO) reduced relapse rates for peptic ulcer significantly better than did placebo or the ulcer drug cimetidine (Tagamet®) in one study.33 Previous research showed that DMSO in combination with cimetidine was more effective than cimetidine alone.34 These trials used 500 mg of DMSO taken four times per day. The authors of these trials believe the antioxidant activity of DMSO may have a protective effect. Oral supplementation with DMSO should not be attempted without the supervision of a doctor.

Little is known about the effects of vitamin C supplementation for people with peptic ulcer. People with gastritis, a related condition, have been found to have low levels of vitamin C in their stomach juice. Vitamin C may also help eradicate H. pylori in people with gastritis. Vitamin C may one day prove to have a therapeutic effect for people with peptic ulcer; however, further research in this area is needed.

Are there any side effects or interactions?
Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful

Licorice root has a long history of use for soothing inflamed and injured mucous membranes in the digestive tract. Licorice may protect the stomach and duodenum by increasing production of mucin, a substance that protects the lining of these organs against stomach acid and other harmful substances.35 According to laboratory research, flavonoids in licorice may also inhibit growth of H. pylori.36

For people with peptic ulcer, many doctors who use herbal medicine use the deglycyrrhizinated form of licorice (DGL). In making DGL, the portion of licorice root that can increase blood pressure and cause water retention is almost completely removed, while the mucous-membrane-healing part of the root is retained. In some reports, DGL has compared favorably to the popular drug cimetidine (Tagamet®) for treatment of peptic ulcer,37 while in other trials cimetidine has appeared initially more effective.38 After DGL and cimetidine were discontinued, though, one study reported fewer recurrences in the DGL group than in the cimetidine group.39

Though not every trial has reported efficacy,40 most studies find DGL to facilitate healing of peptic ulcer. A review of the DGL research shows that the studies not reporting efficacy used capsules, and the trials finding DGL to be helpful used chewable tablets.41 Doctors typically suggest taking one to two chewable tablets of DGL (250 to 500 mg) 15 minutes before meals and one to two hours before bedtime.

The gummy extract of Pistachia lentiscus, also known as mastic or gum mastic, has been shown in one preliminary study and one double-blind study to heal peptic ulcers.42 43 This may be related to its ability to kill H. pylori in test tubes.44

Ayurvedic doctors in India have traditionally used dried banana powder (Musa paradisiaca) to treat ulcers. In animal studies, banana powder protects the lining of the stomach from acid.45 A human trial has also found dried banana helpful in those with peptic ulcer. In that report, two capsules of dried raw banana powder taken four times per day for eight weeks led to significant improvement.46 Bananas and unsweetened banana chips may be good substitutes, although ideal intake remains unknown.

Administration of 30 to 60 mg of freeze-dried neem bark extract twice per day led to a significant reduction in stomach acid levels and near complete healing of all people with duodenal ulcers over ten weeks time in a preliminary clinical trial.47

Chamomile has a soothing effect on inflamed and irritated mucous membranes. It is also high in the flavonoid apigenin—another flavonoid that has inhibited growth of H. pylori in test tubes.48 Many doctors recommend drinking two to three cups of strong chamomile tea each day. The tea can be made by combining 3 to 5 ml of chamomile tincture with hot water or by steeping 2 to 3 tsp of chamomile flowers in the water, covered, for 10 to 15 minutes. Chamomile is also available in capsules; two may be taken three times per day.

Calendula is another plant with anti-inflammatory and healing activities that can be used as part of a traditional medicine approach to peptic ulcers. The same amount as chamomile can be used.

Marshmallow is high in mucilage. High-mucilage-containing herbs have a long history of use for irritated or inflamed mucous membranes in the digestive system, though no clinical research has yet investigated effects in people with peptic ulcer.

Garlic has been reported to have anti-Helicobacter activity in test-tube studies.49 50 In a preliminary trial, garlic supplementation (300 mg in tablets three times daily for eight weeks) failed to eradicate H. pylori in participants with active infections.51 In another preliminary trial, participants with active H. pylori infections added 10 sliced cloves of garlic to a meal.52 The addition of garlic failed to inhibit the growth of the organism. Further trials using garlic extracts are needed to validate the anti-Helicobacter activity of garlic observed in test tubes. Until then, evidence to support the use of garlic for H. pylori-related peptic ulcers remains weak.

Extracts of the herb corydalis are not only helpful as pain-relief agents but also may be useful in the treatment of stomach ulcers. In a study of people with stomach and intestinal ulcers or chronic inflammation of the stomach lining, 90 to 120 mg of corydalis extract per day (equal to 5 to 10 grams of the crude herb) was found to be effective in 76% of the participants.53

Comfrey has a long tradition of use as a topical agent for improving healing of wounds and skin ulcers.54 55 It is also used for people with gastrointestinal problems, including stomach ulcers, though these traditional uses have yet to be tested in scientific studies. People should only use comfrey preparations made from the leaves and avoid those made from the root.

Because of the anti-inflammatory and healing effects of plantain, it may be beneficial in some people with peptic ulcer. Clinical trials have not been done to confirm this possibility.

Are there any side effects or interactions?
Refer to the individual herb for information about any side effects or interactions.

Holistic approaches that may be helpful

Emotional stress has been shown to increase acid production in the stomach.56 The reported association between stress and peptic ulcer might be attributable to a stress-induced increase in gastric acidity.57 58 During the air raids of London in World War II, British physicians observed an increase of more than 50% in the incidence of ruptured peptic ulcers.59 60 More recently, an increased incidence of bleeding stomach ulcers was seen in survivors of the Hanshin-Awaji earthquake in Japan.61 Whether stress reduction techniques or psychological counseling helps prevent ulcers or ulcer recurrence has not been adequately studied in medical trials.

References:

1. Katchinski BD, Logan RFA, Edmond M, Langman MJS. Duodenal ulcer and refined carbohydrate intake: a case-control study assessing dietary fiber and refined sugar intake. Gut 1990;31:993–6.

2. Suadicani P, Hein HO, Gyntelberg F. Genetic and life-style determinants of peptic ulcer. A study of 3387 men aged 54 to 74 years: The Copenhagen Male Study. Scand J Gastroenterol 1999;34:12–7.

3. Yudkin J. Eating and ulcers. BMJ 1980;Feb 16:483 [letter].

4. Sonnenberg A. Dietary salt and gastric ulcer. Gut 1986;27:1138–42.

5. Cheney G. Rapid healing of peptic ulcers in patients receiving fresh cabbage juice. Cal Med 1949;70:10.

6. Doll R, Pygott F. Clinical trial of Robaden and of cabbage juice in the treatment of gastric ulcer. Lancet 1954;2:1200.

7. Thaly H. A new therapy of peptic ulcer: The anti-ulcer factor of cabbage. Gaz Med Fr 1965;72:1992–3.

8. Dunaevskii GA, Migonova DK, Rozka IM, Chibisova SM. Value of preserved juice of white cabbage in the complex therapy of peptic ulcer. Vopr Pitan 1970;29:29–33.

9. Noess K. Ulcer-fiber-cabbage and vitamin U. Tidsskr Nor Laegeforen 1986;106:693–4.

10. Grimes DS, Goddard J. Gastric emptying of wholemeal and white bread. Gut 1977;18:725–9.

11. Rydning A, Berstad A, Aadland E, Odegaard B. Prophylactic effect of dietary fiber in duodenal ulcer disease. Lancet 1982;2(8301):736–9.

12. Ryndning A, Berstad A. Fiber diet and antacids in the short-term treatment of duodenal ulcer. Scand J Gastroenterol 1985;20:1078–82.

13. Kern RA, Stewart G. Allergy in duodenal ulcer: incidence and significance of food hypersensitivities as observed in 32 patients. J Allergy 1931;3:51.

14. Reimann HJ, Lewin J. Gastric mucosal reactions in patients with food allergy. Am J Gastroenterol 1988;83:1212–9.

15. Allison MC, Howatson AG, Caroline MG, et al. Gastrointestinal damage associated with the use of nonsteroidal antiinflammatory drugs. N Engl J Med 1992;327:749–54.

16. Lenz HJ, Ferrari-Taylor J, Isenberg JI. Wine and five percent ethanol are potent stimulants of gastric acid secretion in humans. Gastroenterology 1983;85:1082–7.

17. Cohen S, Booth GH Jr. Gastric acid secretion and lower-esophageal-sphincter pressure in response to coffee and caffeine. N Engl J Med 1975;293:897–9.

18. Feldman EJ, Isenberg JI, Grossman MI. Gastric acid and gastrin response to decaffeinated coffee and a peptone meal. JAMA 1981;246:248–50.

19. Dubey P, Sundram KR, Nundy S. Effect of tea on gastric acid secretion. Dig Dis Sci 1984;29:202–6.

20. Korman MG, Hansky J, Eaves ER, Schmidt GT. Influence of cigarette smoking on healing and relapse in duodenal ulcer disease. Gastroenterology 1983;85:871–4.

21. Patty I, Benedek S, Deak G, et al. Controlled trial of vitamin A therapy in gastric ulcer. Lancet 1982;2(8303):876 [letter].

22. Patty I, Tarnok F, Simon L, et al. A comparative dynamic study of the effectiveness of gastric cytoprotection by vitamin A, De-Nol, sucralfate and ulcer healing by pirenzepine in patients with chronic gastric ulcer (a multiclinical and randomized study). Acta Physiol Hung 1984;64:379–84.

23. Pfeiffer CJ, Cho CH, Cheema A, Saltman D. Reserpine-induced gastric ulcers: protection by lysosomal stabilization due to zinc. Eur J Pharmacol 1980;61:347–53.

24. Jimenez E, Bosch F, Galmes JL, Banos JE. Meta-analysis of efficacy of zinc acexamate in peptic ulcer. Digestion 1992;51:18–26.

25. Frommer DJ. The healing of gastric ulcers by zinc sulphate. Med J Aust 1975;2:793–6.

26. Nishiwaki H, Kato S, Sugamoto S, et al. Ulcerogenic and healing impairing actions of monochloramine in rat stomachs: effects of zinc L-carnosine, polaprezinc. J Physiol Pharmacol 1999;50:183–95.

27. Arakawa T, Satoh H, Nakamura A, et al. Effects of zinc L-carnosine on gastric mucosal and cell damage caused by ethanol in rats. Correlation with endogenous prostaglandin E2. Dig Dis Sci 1990;35:559–66.

28. Cho CH, Ogle CW. A correlative study of the antiulcer effects of zinc sulphate in stressed rats. Eur J Pharmacol 1978;48:97–105.

29. Frommer DJ. The healing of gastric ulcers by zinc sulphate. Med J Aust 1975;2:793–6.

30. Kashimura H, Suzuki K, Hassan M, et al. Polaprezinc, a mucosal protective agent, in combination with lansoprazole, amoxicillin, and clarithromycin increases the cure rate of Helicobacter pylori infection. Aliment Pharmacol Ther 1999;13(4):483–7.

31. Shive W, Snider RN, DuBilier B, et al. Glutamine in treatment of peptic ulcer. Texas State J Med 1957;Nov:840.

32. Yan R, Sun Y, Sun R. Early enteral feeding and supplement of glutamine prevent occurrence of stress ulcer following severe thermal injury. Chung Hwa Cheng Hsing Shao Shang Wai Ko Tsa Chih 1995;11:189–92.

33. Salim AS. The relationship between Helicobacter pylori and oxygen-derived free radicals in the mechanism of duodenal ulceration. Internal Med 1993;32:359–64.

34. Salim AS. Allopurinol and dimethyl sulfoxide improve treatment outcomes in smokers with peptic ulcer disease. J Lab Clin Med 1992;119:702–9.

35. Goso Y, Ogata Y, Ishihara K, Hotta K. Effects of traditional herbal medicine on gastric mucin against ethanol-induced gastric injury in rats. Comp Biochem Physiol 1996;113C:17–21.

36. Beil W, Birkholz W, Sewing KF. Effects of flavonoids on parietal cell acid secretion, gastric mucosal prostaglandin production and Helicobacter pylori growth. Arzneimittelforschung 1995;45:697–700.

37. Brogden RN, Speight TM, Avery GS. Deglycyrrhizinated licorice: A report of its pharmacological properties and therapeutic efficacy. Drugs 1974;8:330–9.

38. D’imperio N, Piccari GG, Sarti F, et al. Double blind trial in duodenal and gastric ulcers. Cimetidine and deglycyrrhizinized liquorice. Acta Gastro-Enterologica Belgica 1978;41:427–34.

39. Morgan AG, Pacsoo C, McAdam WAF. Maintenance therapy: a two year comparison between Caved-S and cimetidine treatment in the prevention of symptomatic gastric ulcer recurrence. Gut 1985;26:599–602.

40. Bardhan KD, Cumberland DC, Dixon RA, Holdsworth CD. Clinical trial of deglycyrrhizinised liquorice in gastric ulcer. Gut 1978;19:779–82.

41. Gaby AR. Deglycyrrhizinated licorice treatment of peptic ulcer. Townsend Letter for Doctors 1988;July:306 [editorial/review].

42. Al-Said MS, Ageel AM, Parmar NS, Tariq M. Evaluation of mastic, a crude drug obtained from Pistacia lentiscus for gastric and duodenal anti-ulcer activity. J Ethnopharmacol 1986;15:271–8.

43. Huwez FU, Al-Habbal MJ. Mastic in treatment of benign gastric ulcers. Gastroenterol Japon 1986;21:273–4.

44. Huwez FU, Thirlwell D, Cockayne A, Ala’Aldeen DA. Mastic gum kills Helicobacter pylori. New Engl J Med 1998;339:1946 [letter].

45. Hills BA, Kirwood CA. Surfactant approach to the gastric mucosal barrier: Protection of rats by banana even when acidified. Gastroenterology 1989;97:294–303.

46. Sikka KK, Singhai CM, Vajpcyi GN. Efficacy of dried raw banana powder in the healing of peptic ulcer. J Assoc Phys India 1988;36(1):65 [abstract].

47. Bandyopadhyay U, Biswas K, Sengupta A, et al. Clinical studies on the effect of Neem (Azadirachta indica) bark extract on gastric secretion and gastroduodenal ulcer. Life Sci 2004;75:2867–78.

48. Beil W, Birkholz C, Sewing KF. Effects of flavonoids on parietal cell acid secretion, gastric mucosal prostaglandin production and Helicobacter pylori growth. Arzneimittelforschung 1995;45:697–700.

49. Sivam GP, Lampe JW, Ulness B, et al. Helicobacter pylori--in vitro susceptibility to garlic (Allium sativum) extract. Nutr Cancer 1997;27:118–21.

50. Chung JG, Chen GW, Wu LT, et al. Effects of garlic compounds diallyl sulfide and diallyl disulfide on arylamine N-acetyltransferase activity in strains of Helicobacter pylori from peptic ulcer patients. Am J Chin Med 1998;26:353–64.

51. Ernst E. Is garlic an effective treatment for Helicobacter pylori infection? Arch Intern Med 1999;159:2484–5 [letter].

52. Graham DY, Anderson SY, Lang T. Garlic or jalapeno peppers for treatment of Helicobacter pylori infection. Am J Gastroenterol 1999;94:1200–2.

53. Chang HM, But PPH. Pharmacology and Applications of Chinese Materia Medica vol 1. Singapore: World Scientific Inc., 1986, 521.

54. Mills SY. Out of the Earth: The Essential Book of Herbal Medicine. New York: Viking Arkana, 1991, 544–7.

55. Weiss RF. Herbal Medicine. Gothenburg, Sweden: Ab Arcanum and Beaconsfield, UK: Beaconsfield Publishers Ltd, 1988, 334–5.

56. Bresnick WH, Rask-Madsen C, Hogan DL, et al. The effect of acute emotional stress on gastric acid secretion in normal subjects and duodenal ulcer patients. J Clin Gastroenterol 1993;17:117–22.

57. Lam SK, Hui WM, Shiu LP, Ng MM. Society stress and peptic ulcer performation. J Gastroenterol Hepatol 1995;10:570–6.

58. Piper DW, Tennant C. Stress and personality in patients with chronic peptic ulcer. J Clin Gastroenterol 1993;16:211–4.

59. Stewart DN, de R. Winser DM. Incidence of perforated peptic ulcer. Effect of heavy air raids. Lancet 1942;2:259–61.

60. Spicer CC, Stewart DN, de R. Winser DM. Perforated peptic ulcer during the period of heavy air raids. Lancet 1944;1:14.

61. Aoyama N, Kinoshita Y, Fujimoto S, et al. Peptic ulcers after the Hanshin-Awaji earthquake: Increased incidence of bleeding gastric ulcers. Am J Gastroenterol 1998;93:311–6.

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