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Introduction 

Stomach ulcers, also known as gastric ulcers, are open sores that develop on the lining of the stomach.

Ulcers can also occur in part of the intestine just beyond the stomach - these are known as duodenal ulcers.

Both stomach and duodenal ulcers are sometimes referred to as peptic ulcers. Here the term “stomach ulcer” will be used, although the following information applies equally to duodenal ulcers.

The most common symptom of a stomach ulcer is a burning or gnawing pain in the centre of the abdomen.

 

When to seek medical advice

You should always visit your GP if you suspect you have a stomach ulcer. Seek urgent medical advice if you experience any of the following symptoms:

  • vomiting blood – the blood can appear bright red or have a dark brown, grainy appearance similar to coffee grounds

  • passing black tar-like stools

  • a sudden, sharp pain in your stomach that gets steadily worse and does not improve

These could be a sign of a complication, such as internal bleeding.

 

What causes stomach ulcers?

There are two main causes of stomach ulcers:

  • Helicobacter pylori (H. pylori) bacteria, which can irritate the stomach or upper intestine lining, causing an ulcer to form

  • non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin, which can have a similar effect

 

Who is affected?

Stomach ulcers are common. In England, it is estimated about 1 in 10 people will have a stomach ulcer at some point in their life.

Stomach ulcers can affect people of any age, including children, but mostly people aged 60 or over.

Treating stomach ulcers

Medication can be used to treat stomach ulcers. A type of medication known as a proton pump inhibitor can usually reduce the amount of acid in your digestive system, allowing the ulcer to heal.

If an H. pylori infection is responsible for the ulcers, a combination of antibiotics can be used to kill the bacteria which should prevent the ulcer coming back.

If the ulcers are related to the use of NSAIDs, they are usually stopped and proton pump inhibitors used. In the case of aspirin-induced ulcers the aspirin sometimes needs to be continued, depending on why it is being given.

Your doctor will advise you on your particular case.

If the underlying causes of a stomach ulcer are addressed, the ulcer usually goes away after treatment. It's important to address the underlying cause as new ulcers can sometimes form.

 

Complications of stomach ulcers

Complications of a stomach ulcer are uncommon, affecting around 1 in 50 people.

However, they can be serious and include:

  • bleeding at the site of the ulcer

  • the stomach lining at the site of the ulcer splitting open – known as perforation

  • the ulcer blocking the movement of food through the digestive system – known as gastric obstruction

Some complications are regarded as medical emergencies, though are rarely life-threatening. Older people aged over 70 are most at risk of experiencing a fatal complication of a stomach ulcer.

 

Symptoms of stomach ulcer 

The most common symptom of a stomach ulcer is a burning or gnawing pain that develops in your abdomen (tummy). The pain can also travel up to your neck, down to your navel (belly-button) or through to your back.

The pain associated with a stomach ulcer is caused by the ulcer itself and stomach acid that comes into contact with the ulcer and irritates it.  

The pain can last from a few minutes to a few hours.

You may find pain starts soon after eating a meal. If the ulcer is in your small intestine (duodenal ulcer), pain may start two to three hours after eating so it may wake you up during the night.

Eating more food and taking antacids (indigestion medication) can often help relieve the pain of a duodenal ulcer, but not usually the pain of a stomach ulcer.

Less common symptoms of a stomach ulcer include:

  • indigestion

  • heartburn

  • loss of appetite

  • being sick 

Some people also find they can no longer tolerate eating fatty foods.

Stomach ulcers often do not cause typical symptoms and occasionally do not cause any pain at all. Which means it's possible to get a complication, such as bleeding, without feeling pain beforehand. 

 

When to seek medical advice

You should always visit your GP if you suspect you have a stomach ulcer. While there are treatments available over the counter from pharmacies that provide temporary relief, they will not treat the underlying causes.

When to seek urgent medical advice

Symptoms can develop if a stomach ulcer suddenly causes serious complications, such as internal bleeding. These include:

  • vomiting blood – the blood can appear bright red or have a dark brown, grainy appearance similar to coffee grounds

  • passing black tar-like stools

  • a sudden, sharp pain in your stomach that gets steadily worse and does not improve

If you experience these symptoms, you should contact your GP immediately.

 

Causes of stomach ulcers 

Stomach ulcers are usually caused by either H. pylori bacteria or non-steroidal anti-inflammatory drugs (NSAIDs).

Acid and mucus

The stomach produces acid to digest food.

The lining of the stomach is coated with mucus, which protects the lining from harmful effects of the acid.

H. pylori bacteria and anti-inflammatory drugs (NSAIDs) can break down the stomach's defence against acid, allowing the acid to cause an ulcer. Even though most people with ulcers are not producing too much acid, blocking the acid will allow the ulcer to heal and then the cause of the ulcer can be removed to prevent it coming back.

H. pylori

Helicobacter pylori (H. pylori) infections are very common, and it's possible to be infected without realising it because the infection doesn't usually cause symptoms.

It's not known why some people are vulnerable to the effects of H. pylori when the majority of people are not. However, smoking seems to increase the risk.

Also, stomach ulcers are known to run in families, so genetics may make certain people more sensitive to H. pylori. Some strains of H.pylori are more damaging than others.

 

NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs) are medicines commonly used to treat:

  • pain – such as toothache, headache, joint pain and period pain

  • high temperature (fever)

  • inflammatory conditions – conditions that cause painful inflammation of the joints, such as rheumatoid arthritis

Some people with cardiovascular disease (conditions that affect the heart and the blood) also take aspirin on a regular basis because it can reduce the risk of blood clots which can cause heart attacks and strokes.

NSAIDs  available over the counter include:

  • ibuprofen

  • aspirin

  • naproxen

NSAIDs only available on prescription include:

  • diclofenac

  • etodolac

  • fenoprofen

Because of the risk of getting stomach ulcers, you may be advised not to use NSAIDs if you currently have a stomach ulcer or if you have had one in the past. 

Paracetamol can often be used as an alternative painkiller as it is safer.

However, there may be cases where the benefits of taking NSAIDs is thought to outweigh the risk of developing stomach ulcers. For example, if you have recently had a heart attack, low-dose aspirin may be required to prevent you having another one.

In such circumstances, a medication called a proton pump inhibitor (PPI) can be used to reduce the amount of acid in your digestive system, which should help prevent ulcers from forming and reduce the risk of complications.

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Lifestyle factors

In the past it was thought that stomach ulcers were caused by certain lifestyle factors, such as spicy foods, stress, smoking and alcohol. However, there is little hard evidence to confirm that this is the case.

It may be that although these types of lifestyle factors do not cause ulcers, they may make the symptoms of ulcers worse.

 

Does H pylori cause cancer?

H pylori is associated with a very slightly increased risk of stomach cancer. However, treating H pylori for this reason alone is not recommended. The risk of anyone getting stomach cancer is small and no one knows whether treating H pylori will actually reduce your risk of developing stomach cancer.

 

Diagnosing a stomach ulcer 

Your GP may suspect you have an ulcer based on your symptoms. In most cases they will treat you with an acid-suppressing medication and/or test and treat you for an H. pylori infection.

You may be referred for an endoscopy to look inside your stomach directly to see whether you have a stomach ulcer.

The procedure (called a diagnostic gastroscopy) is carried out in hospital and involves passing a thin, flexible tube (an endoscope) with a camera at one end into your mouth, through your gullet and into your stomach and duodenum.

The images taken by the camera will usually confirm or rule out an ulcer without the need for further tests.

During the procedure the specialist may also take a tissue sample from your stomach or duodenum. The sample can then be tested for the H. pylori bacteria.

A diagnostic gastroscopy isn't painful but some people find the experience uncomfortable. You can have your throat numbed with a local anaesthetic spray or you can be sedated.

Sedation makes you drowsy so you have little or no awareness of the gastroscopy being carried out. However, even with sedation, some people may still gag or find the procedure uncomfortable.

If you choose to have sedation, you will need someone to give you a lift home after the procedure and to stay with you for at least 24 hours.

If you have a local anaesthetic, you can leave hospital as soon as the procedure has been completed. You can resume normal activities within one-to-two hours.

 

Diagnosing H. pylori infection

If your GP thinks your symptoms may be due to an H. pylori infection (which would usually be the case if you don't have a recent history of taking non-steroidal anti-inflammatory drugs), you may need one of several further tests. These are described below.

  • A urea breath test – you will be given a special drink containing a chemical that is digested by H. pylori. Your breath is then analysed to see whether or not you have an H. pylori infection.

  • A stool antigen test – a pea-sized stool sample is tested.

  • blood test – a sample of your blood is tested for antibodies to the H. pylori bacteria. Antibodies are proteins produced naturally in your blood and help fight infection.

If you test positive for H. pylori, you will need treatment to clear the infection. This can heal the ulcer and prevent it from coming back.

 

Treating a stomach ulcer 

If you have a stomach ulcer, your treatment will depend on whether the cause is an H. pylori infection or non-steroidal anti-inflammatory drugs (NSAIDs) or both.

If your stomach ulcer is caused by an H. pylori infection, a course of antibiotics is recommended. This is known as eradication therapy because it will kill the bacteria.

If your stomach ulcer is caused by NSAIDs and you don't have a H. pylori infection, a one-to two-month course of proton pump inhibitors (PPIs) is recommended. Your use of NSAIDs will also need to be reviewed and an alternative painkiller, such as paracetamol, may be recommended.

If it's thought your stomach ulcer is caused by a combination of NSAID use and an H. pylori infection, you will be given a two-month course of PPIs and a course of antibiotics (eradication therapy).

An alternative type of medication, known as H2-receptor antagonists, is sometimes used instead of PPIs.

 

Eradication therapy

Eradication therapy involves taking a combination of two or three different antibiotics and a proton pump inhibitor (PPI), at the same time. Taking one antibiotic alone is insufficient to kill the bacteria. You will usually be asked to take each antibiotic twice a day for 7-14 days. The antibiotics most commonly used in eradication therapy are:

  • amoxicillin

  • clarithromycin

  • metronidazole

The side effects are usually mild and include:

  • feeling sick

  • diarrhoea

  • a metallic taste in your mouth

  • grey colouring of saliva or your stools

You will be re-tested at least four weeks after eradication therapy has been completed to see whether there are any H. pylori bacteria left in your stomach. If there are, a further course of eradication therapy using different antibiotics will be given.

 

Proton pump inhibitors (PPIs)

Proton pump inhibitors (PPIs) work by blocking the actions of proteins called proton pumps, which are partially responsible for producing stomach acid. Reducing the amount of stomach acid prevents further damage to the ulcer, allowing it to heal naturally.

Lansoprazole and omeprazole are the two PPIs most commonly used to treat stomach ulcers. Side effects of these are usually mild but include:

  • headache

  • diarrhoea

  • nausea

  • abdominal pain

  • constipation

  • dizziness

  • skin rashes

These should pass once treatment has been completed.

 

H2-receptor antagonists

H2-receptor antagonists work by blocking the actions of a protein called histamine, which is also responsible for stimulating the production of acid.

Ranitidine is the most widely used H2-receptor antagonist for treating stomach ulcers.

Side effects are uncommon but may include:

  • diarrhoea

  • headaches

  • dizziness

  • skin rashes

  • tiredness

 

Antacids and alginates

All of the above treatments can take several hours before they start to work, so it's likely your GP will recommend additional medication to help provide short-term symptom relief. This is likely to be either:

  • antacids – to help neutralise stomach acid on a short-term basis

  • alginates – which produce a protective coating on the lining of your stomach

Both antacids and alginates are available to buy over the counter at pharmacies. Your pharmacist will be able to advise you about the types most suitable for you.

Antacids are best taken when you experience symptoms or when you expect them, such as after meals or at bedtime. Alginates are best taken after meals.

Don't take these medications within an hour of taking proton pump inhibitors or ranitidine as they may block the effects.

Side effects for both medications are uncommon but include:

  • diarrhoea

  • vomiting

  • wind (flatulence)

Bananas are also thought to be effective at protecting against stomach acid, and can be an alternative way to relieve your symptoms, if you don't want to take antacids or alginates.

 

Reviewing NSAID use

If your stomach ulcer has been caused by taking NSAIDs, your GP will want to review your use of them.

You will usually be advised to use an alternative painkiller not linked to stomach  ulcers, such as paracetamol or a low-dose opiate-based painkiller.

If you are taking low-dose aspirin to reduce your risk of getting blood clots, your GP will help you decide whether you need to continue taking it. In most cases it is continued or only stopped for a few days.

In these cases a PPI is given as well as the aspirin to try to prevent further ulceration. If you or your GP feel the continued use of NSAIDs is absolutely necessary, you will be prescribed a long-term course of a PPI or H2-receptor antagonist.

It's important to understand the potential risks associated with continued NSAID use. You are more likely to develop another stomach ulcer and the risks of experiencing serious complications, such as internal bleeding, are higher.

 

Stress

Stress does not cause stomach ulcers but it may make them worse. An expert explains what stress is, the physical and mental effects of being stressed, when it becomes a problem and when to seek help.

Media last reviewed: 21/09/2014

Next review due: 21/09/2016

 

Lifestyle advice

Diet and stress are not thought to be directly responsible for stomach ulcers but they may make the symptoms of ulcers worse.

The following advice may be of some help:

  • Cut down on the amount of coffee and tea you drink. This can increase the amount of acid your stomach produces. Try herbal teas instead.

  • Drink milk and eat milk-based foods, such as yoghurt and cheese. Milk is thought to coat the stomach and neutralise the effects of stomach acid.

  • Lose any extra weight you are carrying.

  • Eat little and often. This could help reduce the build-up of stomach acid between meals.

  • Limit your intake of alcohol. Too much alcohol can irritate the areas of inflammation in your stomach. 

  • Avoid spicy or excessively rich foods if they make your symptoms worse.

  • Quit smoking. It may put you at greater risk of developing an ulcer and slow down your recovery.

 

Complications of stomach ulcer 

The introduction of eradication therapy means that complications of stomach ulcers related to H. pylori infections are now uncommon.

Complications are more common with stomach ulcers associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs). This is because these types of ulcers do not always cause obvious symptoms, so are left untreated.

It is estimated that around 1 in 50 people with a NSAID-related stomach ulcer will develop a complication.

Internal bleeding

Internal bleeding is the most common complication of stomach ulcers. Internal bleeding can occur when an ulcer develops at a site of a blood vessel. You are at an increased risk of bleeding if you:

  • are on continued use of non-steroidal anti-inflammatory drugs (NSAIDs)

  • are 60 years old or over

Depending on the location and type of blood vessel, you may have long-term bleeding that could lead to anaemia (where the body has a lack of oxygen-carrying red blood cells).

Symptoms of anaemia include:

  • fatigue

  • breathlessness

  • pale skin

  • irregular heartbeats

Alternatively, the bleeding can be rapid and massive, causing you to vomit blood or pass stools that are black and tar-like.

An endoscopy is needed to identify the cause of this sort of internal bleeding. Often bleeding can be stopped by treatment performed through the endoscope.

Injections of proton pump inhibitors (PPIs) are also given around the site of the bleeding. Lowering the amount of acid around the site is thought to make the blood more likely to clot, which helps stop the bleeding.

Massive bleeding can be treated using blood transfusions to replace any blood loss. Surgery is occasionally needed to repair the blood vessels.

 

Perforation

A rarer complication of stomach ulcers is the lining of the stomach splitting open (a perforation). It affects around 1 in 350 people with a stomach ulcer.

Perforation can be very serious because it enables the bacteria that live in your stomach to escape and infect the lining of your abdomen (peritoneum). This is known as peritonitis.

The most common symptom of peritonitis is sudden abdominal pain, which gets steadily worse.

In peritonitis, an infection can rapidly spread into the blood (sepsis) before spreading to other organs. This carries the risk of multiple organ failure, and can be fatal if left untreated.

Peritonitis is a medical emergency that requires admission to hospital.

 

Gastric outlet obstruction

In some cases, an inflamed or scarred stomach ulcer can obstruct the normal passage of food through your digestive system. This is known as gastric outlet obstruction.

Gastric outlet obstruction is relatively uncommon. Each year it affects around 1 in 1,000 people with a stomach ulcer.

Symptoms of gastric outlet obstruction include:

  • repeated episodes of vomiting, with large amounts of vomit that contain undigested food

  • a persistent feeling of bloating or fullness

  • feeling very full after eating less food than usual

  • unexplained weight loss

An endoscopy will confirm the type and site of the obstruction. If the obstruction is caused by inflammation, PPIs or H2-receptor antagonists can be used to help reduce it.

If the obstruction is caused by scar tissue, surgery may be needed to treat it, although sometimes it can be treated by passing a small balloon through an endoscope and inflating it to widen the site of the obstruction.

In more severe cases of scarring, it may be necessary to surgically remove the affected section of stomach, before reattaching the remainder of the stomach.