Peptic Ulcer Disease

How ulcers form

The stomach makes strong acid to digest food. A layer of mucus, bicarbonate and good blood flow normally protects its lining. An ulcer forms when this protection is weakened and acid eats into the lining.

• H. pylori lives in the stomach lining, causes chronic inflammation (gastritis) and disrupts acid regulation. See H. pylori.
• NSAIDs block prostaglandins, which maintain the protective mucus and blood flow. Risk rises with higher doses, older age, previous ulcers, and combination with blood thinners, steroids or SSRIs. See NSAID gastropathy.

Stress and spicy food do not cause ulcers, although severe physical stress in critically ill patients can cause "stress ulcers". Smoking and heavy alcohol use slow healing.

Gastric vs duodenal ulcers

These patterns are unreliable, and endoscopy is needed to tell them apart.

Symptoms

• burning or gnawing pain in the upper middle belly
• pain that comes and goes over weeks
• bloating and belching
• nausea and sometimes vomiting
• feeling full quickly
• loss of appetite
• symptoms relieved temporarily by antacids

Many people, especially older adults and people taking NSAIDs, have no pain until they develop bleeding.

Complications

• Bleeding: the most common complication. Signs include black, tarry stools (melena), vomiting blood or coffee-ground material, dizziness and anemia. See gastrointestinal bleeding.
• Perforation: the ulcer burns through the wall, causing sudden, severe pain and peritonitis. A surgical emergency.
• Gastric outlet obstruction: scarring narrows the outlet, causing vomiting and early fullness.
• Penetration into nearby organs such as the pancreas, causing back pain.

Diagnosis

• H. pylori testing: urea breath test, stool antigen test or biopsy. Stop proton pump inhibitors 2 weeks before testing (and antibiotics and bismuth 4 weeks before) if possible, as they cause false negatives.
• Upper endoscopy: a camera examines the stomach and duodenum, confirms the ulcer, takes biopsies and treats bleeding. Recommended for people over about 60 with new symptoms, or anyone with alarm features such as bleeding, weight loss, anemia, vomiting or difficulty swallowing.
• Blood count to check for anemia.
• Gastrin level if ulcers are multiple, unusual or recurrent, to look for Zollinger-Ellison syndrome.

Treatment

Medicines

• Proton pump inhibitors (PPIs) such as omeprazole or pantoprazole reduce acid and heal most ulcers in 4 to 8 weeks.
• H. pylori eradication: a 14-day course of combination therapy, such as bismuth quadruple therapy (a PPI, bismuth, tetracycline and metronidazole) or newer regimens with vonoprazan. Testing afterward, at least 4 weeks after finishing antibiotics, confirms cure.
• H2 blockers (famotidine) are a less potent alternative.

Stop or reduce NSAIDs

If you need an NSAID or aspirin for a medical reason, your doctor may continue it with a PPI for protection, or switch to an alternative. Do not stop prescribed low-dose aspirin for heart disease without medical advice.

Lifestyle

• stop smoking
• limit alcohol
• eat regular meals; no specific diet is required, but avoid foods that worsen your symptoms
• use acetaminophen (paracetamol) instead of NSAIDs for pain when possible

Bleeding ulcers

Bleeding ulcers are treated in hospital with IV PPIs, endoscopic therapy (clips, heat or injections) and blood transfusion if needed. Rarely, radiological embolization or surgery is required.

Surgery

Surgery is now uncommon, reserved for perforation, uncontrolled bleeding or obstruction.

Prevention

• treat H. pylori when found, and test family members if advised
• use the lowest effective dose of NSAIDs for the shortest time
• take a PPI with long-term NSAIDs or aspirin if you are at high risk
• avoid combining NSAIDs with steroids, blood thinners or SSRIs without medical advice
• do not smoke

Frequently asked questions

What does a stomach ulcer feel like?

Most people describe a burning or gnawing pain in the upper middle belly, often between meals or at night, sometimes eased by eating or antacids. Bloating, nausea and early fullness are common. Some ulcers cause no pain until they bleed.

What causes peptic ulcers?

The two main causes are infection with H. pylori bacteria and regular use of NSAIDs such as ibuprofen, naproxen and aspirin. Smoking and heavy alcohol use add to the risk and slow healing. Rarely, conditions that cause excess acid, such as Zollinger-Ellison syndrome, are responsible.

What are the signs of a bleeding ulcer?

Signs include black, tarry or sticky stools, vomiting blood or material that looks like coffee grounds, dizziness, fainting, weakness, a fast heartbeat and pale skin. A bleeding ulcer is a medical emergency.

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

With a proton pump inhibitor and treatment of the cause, most ulcers heal within 4 to 8 weeks. Large gastric ulcers may take longer. Eradicating H. pylori and avoiding NSAIDs greatly reduces the chance of the ulcer coming back.

What should I eat with a stomach ulcer?

No special diet is needed to heal an ulcer, because medicines do the main work. Eat regular, balanced meals and avoid foods and drinks that worsen your symptoms, such as alcohol, coffee or spicy foods for some people. Avoid smoking.