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Peptic ulcers

Ulcers of the lower part of the gullet (oesophageal ulcers), the stomach (gastric ulcers) and the first part of the small intestine (duodenal ulcers) are also known as peptic ulcers. Peptic ulcers can affect people of any age, but they are more common as you get older. They affect men and women equally.

Your stomach produces acid to help you digest and sterilise food. The lining of your stomach and first part of your small bowel have a layer of mucus that protects them from the acid. If this protection mechanism doesn't work properly, or if acid refluxes back up into your gullet, the acid can eat into the lining of your oesophagus, stomach or duodenum and cause an ulcer.

The size of peptic ulcers can vary from five millimetres (mm) to several centimetres (cm) across. If the damaged area is smaller than 5mm across then it’s called an erosion.

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How a peptic ulcer develops
Peptic ulcers are ulcers of the stomach and small bowel
Image showing the digestive system

Details

  • Symptoms Symptoms of peptic ulcers

    You may not have any symptoms at all if you have a peptic ulcer. However, the most common symptom is pain in your abdomen (tummy), just below your breastbone. This pain is often described as burning or gnawing. It may extend to your back. It usually comes on after eating – often one to two hours after a meal – and may come and go for several days or weeks. The pain is worse at night when your stomach is empty.

    Other symptoms may include:

    • heartburn
    • a poor appetite
    • feeling bloated
    • feeling sick or vomiting food or blood
    • burping

    It's important to see your GP if you have:

    • lost weight without dieting
    • seen blood in your vomit or bowel movements
    • sudden, severe abdominal pain

    These symptoms may be caused by other problems than a peptic ulcer. If you have any of these symptoms, see your GP for advice.

  • Diagnosis Diagnosis of peptic ulcers

    Your GP will ask about your symptoms and medical history. If your doctor thinks you may have a peptic ulcer, you may be asked to have the following tests.

    H. pylori test

    Your doctor may take a blood test, or ask you to provide a sample of your faeces. The samples will be sent to a laboratory for testing.

    Alternatively, your doctor may arrange for you to have a breath test (called the carbon-13 urea breath test). You will be asked to swallow a liquid containing a low level of harmless radioactive material. H. pylori breaks down the substance into radio-labelled carbon dioxide gas. You will be asked to breathe into a special machine which measures the levels of carbon dioxide gas. High carbon dioxide levels indicate H. pylori infection.

    Endoscopy

    Your GP may arrange for you to have a gastrointestinal endoscopy (also called a gastroscopy). This procedure is done using a narrow, flexible, camera called an endoscope that you swallow and is passed through into your oesophagus, stomach and duodenum. It allows your doctor to look inside your oesophagus, stomach and duodenum and take a biopsy (a small sample of tissue). This sample can be tested for H. pylori and to check that the lump or ulcer isn’t cancerous.

  • Treatment Treatment of peptic ulcers

    Self-help

    There are lifestyle changes that you can make to help your ulcers heal and prevent them coming back. These include:

    • not having food and drink that makes your symptoms worse, such as spicy foods and alcohol
    • stopping smoking
    • stop taking NSAIDS, your GP or pharmacist can suggest alternative medicines

    Medicines

    Your doctor will prescribe medicines called proton pump inhibitors (PPIs) to reduce the amount of acid your stomach produces and help the ulcer to heal. This is the main medicine prescribed to treat ulcers.

    Medicines include omeprazole, esomeprazole, lansoprazole, pantoprazole and rabeprazole.
    PPIs reduce acid production in your stomach, allowing your ulcer to heal. You will need to take the medicines for about six to eight weeks.

    Your doctor may prescribe other medicines such as H2 blockers if you don’t respond to treatment with PPIs. Discuss your treatment options with your GP.

    If you’re taking NSAIDS for medical reasons (for example, you need to take a daily aspirin to prevent heart disease), your doctor may prescribe PPIs long-term to control your symptoms and prevent gastric ulcers.

    Treating H. pylori infection

    If tests confirm that you have H. pylori, you will also be prescribed a course of antibiotics. This is given in combination with a PPI and usually consists of two antibiotics (such as amoxicillin or clarithromycin and metronidazole) that you take for seven to 14 days. Treating the H. pylori infection should allow your ulcer to heal and prevent it from coming back. Your GP will test you again about four weeks later to make sure the infection has gone.

    Always read the patient information leaflet that comes with your medicine and take your antibiotics as directed by your doctor. Don't stop taking them early, even if your symptoms improve. If you have any questions, ask your pharmacist or GP for advice.

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  • Causes Causes of peptic ulcers

    Helicobacter pylori infection

    The most common cause of peptic ulcers is a stomach infection caused by a bacterium called Helicobacter pylori (H. pylori). The infection inflames your stomach lining and interferes with the mechanism which switches off acid production, causing your stomach to produce too much acid. The infection is quite common; around nine out of 10 people with duodenal ulcers and more than seven out of 10 people with gastric ulcers have H. pylori infection.

    Non-steroidal anti-inflammatory drugs (NSAIDs)

    The second most common cause of peptic ulcers is taking steroids or non-steroidal anti-inflammatory drugs (NSAIDs). Examples of NSAIDs include aspirin, ibuprofen, naproxen and diclofenac. Most people can take these safely, but if you take NSAIDs over a long period of time, they can damage the mucus lining in your stomach. Gastric ulcers are almost always linked with NSAID use.

    Other causes

    You’re more likely to get a peptic ulcer if you smoke, drink excessive alcohol or have a family history of peptic ulcers. Family risk is probably caused by H. pylori passing from one family member to another rather than an inherited risk.

    Experts previously thought that stress could cause a peptic ulcer. However, stress is now only considered to be important if it's the result of a major operation or trauma.

  • Complications Complications of peptic ulcers

    Complications of a peptic ulcer include the following.

    • Bleeding. A peptic ulcer can erode into the wall of a blood vessel and bleed. If this happens suddenly, you may vomit blood, which may be bright red or look like coffee grounds (dark brown bits of clotted blood). You might also have dark faeces that look like tar and have a strong odour.
    • Anaemia. If the ulcer causes light bleeding that lasts for a long time, it can lead to iron-deficiency anaemia.
    • Perforation. A peptic ulcer may push through the wall of your stomach or duodenum. This is called a perforation – it causes severe pain and you will need emergency surgery.
    • Obstruction. Rarely, long-term inflammation in the wall of your oesophagus causes scarring and narrowing, making it difficult to swallow food. Scarring from a duodenal ulcer can cause an obstruction which may cause nausea, weight loss or cause you to vomit.
  • FAQs FAQs

    Do I need to make any changes to what I eat if I have a peptic ulcer?

    Answer

    There are certain foods and drinks that can make your symptoms worse if you have a peptic ulcer. It may be best not to eat these until your ulcer heals.

    Explanation

    Your stomach produces acid to help with digestion. Too much acid can damage the lining of your stomach and duodenum, and cause peptic ulcers. Foods that encourage acid production will usually make the symptoms of peptic ulcers worse. These may include spicy foods, alcohol, fizzy drinks and citrus foods.

    If you're diagnosed with a peptic ulcer or regularly get heartburn or pain in your upper abdomen after meals, it's important that you make some changes to your diet. These measures include cutting out food and drink that give you more severe symptoms.

    It’s also best to stop smoking to help improve your symptoms. If you need help to stop smoking, ask your GP for advice.

    Do peptic ulcers cause cancer?

    Answer

    A cancer can form a lump in the wall of your stomach or an ulcer in your stomach. However, cancerous ulcers are different from peptic ulcers and peptic ulcers aren’t believed to turn into or cause cancer. They do share some of the same risk factors for some types of cancer though. The underlying causes of ulcers, such as acid reflux into your oesophagus or infection with H pylori, may cause changes to the cells of your oesophagus and stomach. These changes may lead to cancer. It’s important that a sample or biopsy is taken from any stomach ulcers to make sure that it isn’t cancer.

    Explanation

    Acid reflux (when acid from your stomach goes back up into your oesophagus) can cause inflammation. Over time, the cells in the lining of your oesophagus may change and become damaged. This may cause a condition called Barrett’s Oesophagus, which is a risk factor for oesophageal cancer.

    If you’re infected with H. pylori for a long time, your risk of developing stomach cancer increases. People infected with chronic (long-term) H. pylori are four to six times more at risk of getting stomach cancer. If you’re infected, you may have no symptoms, or you may have indigestion – with or without an associated peptic ulcer. People with H. pylori are also at risk of getting a rare B-cell tumour (called MALT lymphoma).

    However, it’s important to note that millions of people in the world are infected with H. pylori – the majority of whom don’t develop stomach cancer. There may be many other factors that determine whether cancer is a risk. For example, it may be that the infection interacts with other factors, such as smoking and diet, and may cause stomach cancer.

    The evidence isn’t yet clear, but it’s been suggested that H. pylori may even protect against other types of cancer, such as oesophageal cancer.

    Although there is no scientific evidence that treating a H. pylori infection reduces the risk of stomach cancer, your GP is likely to advise you to have treatment as it may be causing other symptoms such as indigestion. The infection is usually treated with a combination of a proton pump inhibitor medicine and two antibiotics that you take for seven to 14 days. Your GP will then test you about four weeks after you started your treatment to make sure the infection has gone.

    How long does it take before peptic ulcers improve?

    Answer

    How soon you recover from a peptic ulcer depends on the size of the ulcer and its cause. You will probably need to take medicines to relieve your symptoms. It can take several weeks for your ulcer to heal after the cause has been identified and treated.

    Explanation

    The main goals for treating a peptic ulcer include:

    • removing the underlying cause (treating a H. pylori infection or stopping taking NSAIDs – ask your GP or pharmacist if an alternative is available)
    • preventing further damage and complications
    • reducing the risk of the ulcer coming back

    Medicines are usually needed to provide relief from your symptoms and to treat a H. pylori infection. Lifestyle factors such as stopping smoking and making changes to your diet are also important.

    Once the cause of your peptic ulcer has been identified and treated, it may still take several weeks for it to heal. To help reduce the risk of it coming back, it's important that you follow your GP’s advice and complete the full course of any treatment you're prescribed.

    I need to take NSAIDs for another health problem – will I get a peptic ulcer?

    Answer

    Non-steroidal anti-inflammatory drugs (NSAIDs) can cause peptic ulcers so, if possible, it’s best to take an alternative medicine. However, if you do need to continue to take them, your GP can prescribe a medicine to help prevent gastric (peptic) ulcers.

    Explanation

    NSAIDs are generally safe to use. However, if you take them for a long time, they can damage the mucus lining in your stomach and cause a peptic ulcer. It’s best not to take NSAIDs if you have a peptic ulcer or have had one in the past.

    If you have a health condition that requires you to take NSAIDs (for example, if you need to take a daily aspirin to prevent heart disease), your GP will prescribe you proton pump inhibitors to help reduce acid production and prevent peptic ulcers. You may need to take these medicines long-term. Other medicines may include H2 blockers if you can’t take PPIs. Discuss your treatment options with your GP.

    If you need to take NSAIDs for a long time, ask your doctor to test you for a H. pylori infection. H. pylori is the biggest cause of peptic ulcers. Treating an existing H. pylori infection and taking PPIs or H2-blocker medicines for as long as you take NSAIDS will help lower your risk of getting a peptic ulcer. Ask your GP for more information.

    Where does H. pylori come from?

    Answer

    Where H. pylori comes from, how it's spread or why some people become ill from it and others don't isn’t known. It probably spreads from one person to another through close contact in early childhood or through poor hygiene. It's also possible that contaminated food and water may cause infection.

    Explanation

    H. pylori infection is common – about half of the world's population is infected. These bacteria cause your stomach to make too much acid. The acid damages the lining of your stomach and duodenum and causes peptic ulcers. H. pylori is the main cause of peptic ulcers.

    If you're diagnosed with a peptic ulcer, your GP may recommend you have tests to find out if you have H. pylori. If you’re infected, your GP will usually prescribe a combination of a proton pump inhibitor and two antibiotics (such as amoxicillin or clarithromycin and metronidazole) to treat the infection. It's important that you take the full course of antibiotic treatment to make sure that you completely get rid of the bacteria from your digestive system.

  • Resources Resources

    Further information

    Sources

    • Peptic ulcer disease. BMJ Best Practice. www.bestpractice.bmj.com, published 25 April 2012
    • Helicobacter Pylori Test. Lab Tests Online UK. www.labtestsonline.org.uk, published November 2011
    • Peptic ulcer disease. eMedicine. www.emedicine.medscape.com, published June 2012
    • H. pylori and peptic ulcers. National Digestive Diseases Information Clearinghouse. www.digestive.niddk.nih.gov, published April 2010
    • Review of the evidence for H. pylori treatment regimens. 18th Expert Committee on the Selection and Use of Essential Medicines. March 2011. www.who.int
    • Diagnosis of Helicobacter pylori quick reference guide for primary care. Public Health England. www.hpa.org.uk, reviewed July 2012
    • Helicobacter pylori and cancer. Cancer Research UK. www.cancerresearchuk.org, updated January 2012
    • Mabe K, Takahashi M, Oizumi H, et al. Does Helicobacter pylori eradication therapy for peptic ulcer prevent gastric cancer? World J Gastroenterol 2009; 15(34):4290–97. doi:10.3748/wjg.15.4290
    • Duodenal ulcer – Helicobacter pylori (H. pylori) test. Map of Medicine. www.mapofmedicine.com, published 23 October 2012
    • Bleeding in the Digestive Tract. National Digestive Diseases Information Clearinghouse. www.digestive.niddk.nih.gov, published January 2010
    • Jackson PG, Raiji M. Evaluation and Management of Intestinal Obstruction. Am Fam Physician 2011; 83(2):159–65. www.aafp.org
    • Peptic ulcers. British Society of Gastroenterology. www.bsg.org.uk, accessed 15 July 2013
    • Stomach Cancer. Better Health Channel. www.betterhealth.vic.gov.au, published August 2011
    • Peptic ulcers. University of Maryland Medical Center, www.umm.edu, published 2 October 2012
    • Stomach cancer risks and causes. Cancer Research UK. www.cancerresearchuk.org, accessed 15 July 2013
    • Risks and causes of oesophageal cancer. Cancer Research UK. www.cancerresearchuk.org, accessed 15 July 2013
    • Helicobacter pylori and cancer. National Cancer Institute. www.cancer.gov, accessed 15 July 2013
  • Related information Related information

  • Author information Author information

    Reviewed by Natalie Heaton, Bupa Health Information Team, August 2013.

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