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Peptic ulcers


Expert reviewer, Mr Peter Lamb, Consultant Surgeon, December 2020
Next review due December 2023

Peptic ulcers are sores that can develop in your gastrointestinal tract (GI tract), including your stomach. They usually happen when stomach acid damages the lining of your stomach and GI tract.

About peptic ulcers

The GI tract consists of your oesophagus, stomach and intestines and is where you break down and absorb food. You can develop peptic ulcers when the protective lining of this tract (the mucosa) is damaged or inflamed.

Normally the GI tract lining protects it from the stomach acid that helps you digest food. But if the amount of acid increases, or the lining is weakened, the acid can damage your GI tract. This can then cause a peptic ulcer.

People of all ages can get peptic ulcers, but they are generally more common in older people.

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Types of peptic ulcers

Peptic ulcers can occur in various parts of your GI tract. So they may be:

  • oesophageal (along the tube that carries food from your mouth into your stomach)
  • gastric (in your stomach)
  • duodenal (in the first part of your small intestine, where food goes once it leaves your stomach)

Image showing the digestive system

Symptoms of peptic ulcers

You may not have symptoms straightaway with an ulcer. You’re more likely to have a so-called ‘silent ulcer’ if you are male, older, smoke, or are taking NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen.

If you do have symptoms, a common one is abdominal (tummy) pain or discomfort. You may also have pain in the middle of your back. If you have a duodenal ulcer (at the start of your small intestine), the pain tends to come on a couple of hours after a meal. Generally, it goes away when you eat again. You may also have pain that wakes you up at night when you have an empty stomach.

A gastric ulcer (in your stomach) generally causes pain shortly after eating. Lying flat may relieve it. An oesophageal ulcer (in the tube that carries food to your stomach) may cause abdominal or lower chest pain and make it difficult to swallow.

Indigestion is often a sign of a peptic ulcer. You may:

  • feel or be sick
  • feel bloated
  • burp
  • have heartburn (gastro-oesophageal reflux) – when the contents of your stomach go back up your oesophagus

Some symptoms may mean you have peptic ulcer complications. Or they can be caused by another medical condition, including cancer. You should see your GP urgently if you:

  • are losing weight without dieting
  • see blood in your vomit or your poo looks black and tar-like
  • are very tired, as this may be caused by anaemia (lack of iron)
  • have trouble swallowing
  • feel full soon after you’ve started eating

Causes of peptic ulcers

There are two main causes of peptic ulcers – an infection called helicobacter pylori and taking medicines such as ibuprofen and aspirin, which irritate the lining of your digestive tract.

Helicobacter pylori

This stomach infection is the most common cause of peptic ulcers. Lots of people in the UK are infected with H. pylori and generally it doesn’t cause problems. You may get it from other people or through food. If you’re infected, it’s likely that this happened during childhood. However, the proportion of people infected increases with age.

These days, with less overcrowding and better hygiene, H. pylori is less common than it was. Good personal hygiene and care when handling food also help.

H. pylori infection causes around nine out of 10 duodenal ulcers and eight out of 10 stomach ulcers. The infection damages the lining of your GI tract by:

  • causing inflammation
  • causing your stomach to produce too much acid – H pylori can disrupt the mechanism that switches acid production off

Non-steroidal anti-inflammatory drugs (NSAIDs)

The second most common cause of a peptic ulcer is taking NSAIDs such as ibuprofen frequently or over a long period of time. Along with aspirin, they are the main medications associated with peptic ulcers. Taking them also increases the risk of having complications from your ulcer.

Most people can take NSAIDs safely, but up to one in three people have problems if they take them regularly. They are useful for treating pain, but can damage the lining of your GI tract, so a peptic ulcer may develop. You are more likely to develop an ulcer if you are older, take multiple NSAIDs or have used them for a long time.

Other causes

You may have an increased ulcer risk if they run in your family. Other factors that may increase risk include:

  • smoking
  • getting older
  • having a long stay in hospital intensive care
  • surgery or serious injury
  • certain medicines, including bisphosphonates (used to treat osteoporosis) and steroids
  • infections and conditions such as HIV and Crohn’s disease 

Diagnosis of peptic ulcers

Your GP will want to find out if you’ve got a peptic ulcer and what’s causing it, as this will help them decide on the right treatment. Treating your ulcer as soon as possible will reduce the risk of complications.

Your GP will ask about your symptoms and medical history. They may also feel your abdomen, to check for tenderness or pain.

Your GP will want to find out if your ulcer is caused by H. pylori or by taking NSAIDs. You should tell the doctor if you’ve been taking over-the-counter painkillers such as aspirin and ibuprofen regularly.

H. pylori tests

There are different types of test that can show whether or not you have a H. pylori infection.

  • Stool test – a small sample of your poo (about the size of a pea) is tested for H. pylori.
  • Blood test – a small blood sample is sent to a lab and tested for antibodies against the H. pylori bacteria. Antibodies are produced by your immune system when it detects something that may be harmful. This test is not used so much now as it has been replaced by the stool test.
  • Breath test – at the hospital, you swallow a liquid containing a harmless radioactive chemical. If you’re infected, this chemical will be broken down by H. pylori bacteria to produce carbon dioxide gas. After drinking the liquid, the level of radioactivity in your breath is measured and can show if you’re infected with H. pylori.

You may not be able to have a breath or stool test if you’ve had antibiotics in the previous four weeks or proton-pump inhibitors (PPIs) such as omeprazole in the previous two weeks.

Endoscopy

Your doctor may refer you for an endoscopy (also called a gastroscopy). This is a way of examining the inside of your stomach and duodenum using a thin, flexible tube with a light and camera on the end. You may have this if you’re over 55 and:

  • you regularly use NSAIDs
  • you’ve had a stomach ulcer before
  • you’ve had stomach cancer
  • someone in your family has had stomach cancer 

Whatever your age, your GP may suggest an endoscopy if you’ve got worrying symptoms such as:

  • anaemia (low red blood cell count)
  • difficulty swallowing
  • unexplained weight loss
  • persistent vomiting (being sick)

The doctor may want you to have the procedure straightaway if you have any complications, such as vomiting blood.

After giving consent, you have the endoscopy in hospital or at a treatment centre. It takes about 20 minutes, so you don’t normally need to stay overnight. You have an anaesthetic spray into your throat to help you swallow the tube and your doctor will offer you medication beforehand to help you relax. If you have this, you won’t be able to drive for a while afterwards, so will need someone to take you home.

If the doctor sees signs of an ulcer, they will take a tissue sample (a biopsy). This is tested to see if your ulcer is caused by H. pylori. Rarely, the ulcerated area may be cancerous, so endoscopy provides a good opportunity to check for this. See our FAQ for more about peptic ulcers and cancer.

Self-help

There are helpful lifestyle changes you can make if you have a peptic ulcer.

Smoking can cause a peptic ulcer or make it worse. So if you smoke, trying to quit may help your symptoms. Alcohol may also increase peptic ulcer risk, so cutting down on that may help too.

It’s best to keep to a healthy weight as being overweight can make your symptoms worse. Salt is also a risk factor for stomach ulcers, so best to cut down on salty foods too. This means choosing low salt versions of processed foods, limiting the amount of salty foods you eat, and not adding salt to your food at the table.

Try to avoid ‘triggers’ that make your symptoms worse. Keeping a diary (PDF, 1.36 MB) of what you’ve eaten and when you have symptoms may help you to identify these. It depends on the individual, but common triggers are:

  • spicy foods
  • fatty foods
  • chocolate
  • tomatoes
  • coffee

You may have been told that a diet of bland or milky foods can help. But dairy foods are not recommended these days, as they may make your symptoms worse. Eating smaller portions and having your evening meal at least three hours before you go to bed might help.

Treatment of peptic ulcers

It’s really important to get the right treatment if you’re diagnosed with a peptic ulcer. If treated properly, duodenal ulcers will heal in around four weeks and stomach ulcers in eight.

Treating the underlying cause lowers the chance of your ulcer coming back. This usually means getting rid of the H. pylori (Helicobacter pylori) or stopping taking NSAIDs.

Medicines

You can take antacids to help relieve indigestion and other symptoms. You will usually be prescribed a medicine called a PPI (proton-pump inhibitor) to reduce the amount of acid your stomach produces. Like most medicines, these can cause side-effects in some people, including diarrhoea or feeling sick.

Your doctor may also prescribe medicines to treat the cause of your ulcer.

H. pylori-related ulcers

If your peptic ulcer is caused by a H. pylori infection, a course of two different antibiotics will usually clear the infection. You take these for a week.

Taking the PPI alongside the antibiotics helps to prevent further damage to your GI tract and gives your ulcer a chance to heal. If PPIs don’t work well for you, you may have a medicine called an H2-receptor antagonist.

NSAID (non-steroidal anti-inflammatory drug)-related ulcers

If your ulcer is caused by using NSAIDs, your doctor may ask you to stop taking them, so your ulcer can heal. They’ll also give you a PPI to decrease acid production.

Your GP may suggest an alternative painkiller, or different type of NSAID, you could take that is less likely to cause an ulcer.

Follow-up

Your doctor will want to monitor you to check that your ulcer is healing. If it was caused by H. pylori, they’ll want to make sure the infection has cleared up. So, you’ll have H. pylori tests again if they previously showed that was the cause of your ulcer.

If you have a stomach ulcer, you’ll also have another endoscopy to make sure everything has healed. If you had a duodenal ulcer, you won’t usually need an endoscopy.

Your GP may refer you to a specialist if your ulcer is not responding to treatment or keeps coming back.

Complications of peptic ulcers

If a peptic ulcer is treated, the outcome is usually very good, and complications aren’t very common. But if you haven’t had any treatment, or your ulcer has gone unnoticed for a while, complications may develop. There’s a particular risk if you’re older and if you’re taking medicines that stop your blood clotting, such as aspirin or warfarin. Complications include:

  • bleeding
  • perforation
  • obstruction

The most common of these is bleeding, especially if your ulcer is linked to NSAIDs. It happens if your ulcer grows into (erodes) any underlying arteries or veins (blood vessels). If your ulcer is bleeding, you may:

  • throw up (vomit) blood – this can be bright red, or dark like coffee grounds
  • pass poo that is black and sticky
  • develop iron deficiency anaemia, if you’ve been losing blood for some time

You should get urgent medical help if you have any of these symptoms. The surgeon may be able to stop the bleeding using an endoscope rather than open surgery. It’s also possible to treat bleeding with a high dose of PPIs. Less commonly, you may need emergency surgery, but this can depend on how much blood you’ve lost.

If your ulcer eats through the lining of your stomach or duodenum, you may develop perforation. Perforation means the ulcer has broken through the wall of your stomach or duodenum, causing inflammation of your abdominal lining (peritonitis) and a potentially serious infection. Your stomach will feel rigid and sore. You should go to hospital if you think this has happened as you may need emergency surgery.

Obstruction means that food is blocked from passing from your stomach into your duodenum during digestion. This is called pyloric stenosis. It is rare but happens if scar tissue develops around your ulcer. Obstruction may cause:

  • feeling sick
  • being sick after eating
  • weight loss
  • dehydration

Depending on the cause of the obstruction, it can be treated using endoscopy, PPIs (proton-pump inhibitors) or surgery.

Frequently asked questions about peptic ulcers

  • Peptic ulcers are sores that can develop in your gastrointestinal tract (GI tract), including your stomach. They usually happen when stomach acid damages the lining of your stomach and GI tract.

  • There are two main causes of peptic ulcers.

    • an infection called helicobacter pylori
    • taking medicines such as ibuprofen and aspirin, which irritate the lining of your digestive tract

    See ‘causes of peptic ulcers’ for more information.

  • Peptic ulcers don’t turn into or cause cancer. But they do share some of the same risk factors, including smoking, H. pylori infection and diet. So, if you have an ulcer, you may have an increased risk of stomach cancer.

    Some of the symptoms of a peptic ulcer, like indigestion, unexplained weight loss, vomiting and problems swallowing, can also be signs of stomach cancer. Your doctor will look for signs of cancer during your endoscopy. It can be difficult to tell the difference between an ulcer and cancer by looking, so they will also take a biopsy.

  • It’s hard to say. Strenuous exercise and some vigorous movements of your abdomen (tummy) may cause the same sort of symptoms you can get from a peptic ulcer. Heartburn, nausea, vomiting and stomach pains are commonly reported by athletes. So certain activities could add to your symptoms. It’s not a good idea to eat just before you exercise. Athletes are generally advised to eat a low fat, high carbohydrate meal about three to four hours beforehand, as this will reduce the risk of any stomach irritation.

    There’s some evidence that moderate activity can reduce the risk of developing a peptic ulcer, especially if it’s part of a healthy lifestyle.



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  • Reviewed by Liz Woolf, Freelance Health Editor, December 2020
    Expert reviewer, Mr Peter Lamb, Consultant Surgeon, December 2020
    Next review due December 2023

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