Gastroduodenal Ulcer (Stomach and Duodenal Ulcers)

Gastric vs duodenal ulcer

Pain patterns are not reliable enough to tell the two apart, so endoscopy is used when the type matters.

Causes

H. pylori infection

Helicobacter pylori is a bacterium that lives in the stomach lining in a large share of the world's population, usually acquired in childhood. It causes inflammation and weakens the protective mucus layer. Most infected people never develop ulcers, but it is a leading cause of both gastric and duodenal ulcers, and also raises the risk of stomach cancer.

NSAIDs and aspirin

Ibuprofen, naproxen, diclofenac, aspirin (even low-dose) and other NSAIDs reduce the protective prostaglandins in the stomach lining. The risk is higher with:

• age over 60 to 65
• higher doses or long-term use
• a previous ulcer
• combining NSAIDs with steroids, blood thinners or SSRIs

See NSAID gastropathy.

Other causes and risk factors

• smoking slows healing and raises recurrence
• heavy alcohol use
• severe physical stress, such as major burns, head injury or intensive care (stress ulcers)
• Zollinger-Ellison syndrome: a rare tumor that makes excess acid, causing multiple or recurrent ulcers
• Crohn's disease, some cancers and other rare causes

Spicy food and everyday stress do not cause ulcers, though they may worsen symptoms in some people.

Symptoms

• burning or gnawing pain in the upper middle belly, between the breastbone and belly button
• pain that comes and goes over weeks
• bloating, belching and feeling full quickly
• nausea
• heartburn
• loss of appetite

Many people, especially older adults and those taking NSAIDs, have no pain until a complication such as bleeding occurs.

Complications

• Bleeding: the most common complication. It can be slow, causing anemia and tiredness, or sudden, causing vomiting blood or black, tarry stools (melena).
• Perforation: the ulcer breaks through the wall, leaking stomach contents into the abdomen. Causes sudden severe pain and needs emergency surgery.
• Gastric outlet obstruction: scarring and swelling block the passage from the stomach, causing vomiting and weight loss.
• Penetration into nearby organs such as the pancreas, causing back pain.

Diagnosis

• H. pylori tests: urea breath test, stool antigen test, or biopsy during endoscopy. Stop PPIs for 2 weeks and antibiotics for 4 weeks beforehand if possible, as they can cause false negatives.
• Upper endoscopy (EGD): a thin camera through the mouth to see the ulcer, take biopsies and treat bleeding. Recommended for people over 60, with warning signs, or when symptoms persist.
• Blood tests for anemia.
• CT scan if perforation is suspected.

Treatment

Acid suppression

Proton pump inhibitors (PPIs) such as omeprazole, esomeprazole and pantoprazole reduce acid and allow ulcers to heal, usually over 4 to 8 weeks. H2 blockers such as famotidine are an alternative.

H. pylori eradication

If H. pylori is present, a 14-day combination of antibiotics with a PPI, and often bismuth, is used. Common regimens include bismuth quadruple therapy and newer combinations. Because antibiotic resistance is increasing, a follow-up test at least 4 weeks after finishing treatment confirms the infection is gone. Clearing H. pylori greatly reduces the chance of the ulcer coming back.

Stopping NSAIDs

Stop NSAIDs if possible. If they are essential, your doctor may switch to a less harmful option and add a PPI. Acetaminophen (paracetamol) is usually safer for the stomach. Do not stop low-dose aspirin prescribed for your heart without talking to your doctor.

Treating complications

• Bleeding: endoscopy to inject, clip or cauterize the bleeding vessel, IV PPIs, and blood transfusion if needed.
• Perforation: usually surgery.
• Obstruction: endoscopic dilation or surgery.

Lifestyle

• stop smoking
• limit alcohol
• eat regular meals and avoid foods that worsen your symptoms

Outlook

With treatment, most ulcers heal within 2 months. Eradicating H. pylori and avoiding NSAIDs make recurrence uncommon. Gastric ulcers are usually rechecked with endoscopy to confirm healing and rule out cancer.

Frequently asked questions

What is the difference between a gastric and a duodenal ulcer?

A gastric ulcer is in the stomach and often hurts during or soon after eating. A duodenal ulcer is in the first part of the small intestine and tends to hurt on an empty stomach or at night, often easing with food. Both are treated similarly.

What causes gastroduodenal ulcers?

Most are caused by H. pylori infection or by NSAIDs such as ibuprofen, naproxen and aspirin. Smoking, heavy drinking and severe illness add to the risk. Stress and spicy food do not cause ulcers but can worsen symptoms.

How long does it take for a stomach ulcer to heal?

Most ulcers heal within 4 to 8 weeks of acid-reducing medicine such as a PPI, combined with H. pylori treatment if needed. Larger ulcers may take longer. Gastric ulcers are often rechecked with endoscopy to confirm healing.

What are the signs of a bleeding ulcer?

Signs include vomiting blood or coffee-ground material, black and tarry stools, feeling faint or dizzy, a racing heart and pale skin. A slow bleed may only cause tiredness and anemia. Sudden bleeding is an emergency.