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Peptic Ulcer Disease
What is a peptic ulcer?
A peptic ulcer is a sore in the inner lining of the stomach or upper small intestine.
Ulcers form when the intestine or stomach's protective layer is broken down. When this happens, digestive juices—which contain hydrochloric acid and an enzyme called pepsin—can damage the intestine or stomach tissue.
Treatment cures most ulcers. And symptoms usually go away quickly.
Peptic ulcers that form in the stomach are called gastric ulcers. Those that form in the upper small intestine are called duodenal (say "doo-uh-DEE-nul" or "doo-AW-duh-nul") ulcers.
What causes peptic ulcers?
The two most common causes of peptic ulcers are:
- Infection with Helicobacter pylori ( H. pylori) bacteria.
- Use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, and naproxen.
H. pylori and NSAIDs break down the stomach or intestine's protective mucus layer.
What are the symptoms?
- A burning, aching, or gnawing pain between the belly button (navel) and the breastbone. Some people also have back pain. The pain can last from a few minutes to a few hours and may come and go for weeks.
- Pain that usually goes away for a while after you take an antacid or acid reducer.
- Loss of appetite and weight loss.
- Bloating or nausea after eating.
- Vomiting blood or material that looks like coffee grounds.
- Passing black stools that look like tar, or stools that contain dark red blood.
Different people have different symptoms, and some people have no symptoms at all.
How are peptic ulcers diagnosed?
Your doctor will ask you questions about your symptoms and your general health, and he or she will do a physical exam.
If your symptoms aren't severe and you are younger than 55, your doctor may do some simple tests (using your blood, breath, or stool) to look for signs of H. pylori infection.
The only way for you and your doctor to know for sure if you have an ulcer is to do a more complicated test, called an endoscopy, to look for an ulcer and to test for H. pylori infection. An endoscopy allows the doctor to look inside your esophagus, stomach, and small intestine. An endoscopy is usually done by a gastroenterologist, a doctor who specializes in digestive diseases.
How are they treated?
To treat peptic ulcers, most people need to take medicines that reduce the amount of acid in the stomach. If you have an H. pylori infection, you will also need to take antibiotics.
You can help speed the healing of your ulcer and prevent it from coming back if you quit smoking and limit alcohol. Continued use of medicines such as aspirin, ibuprofen, or naproxen may increase the chance of your ulcer coming back.
Ignoring symptoms of an ulcer is not a good idea. This condition needs to be treated. While symptoms can go away for a short time, you may still have an ulcer. Left untreated, an ulcer can cause life-threatening problems. Even with treatment, some ulcers may come back and may need more treatment.
The two most common causes of peptic ulcers are:
- Infection with Helicobacter pylori ( H. pylori ) bacteria. Although many people are infected with H. pylori bacteria, only a few get ulcers.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) . When used for weeks or months, NSAIDs can damage the lining of the digestive tract, causing an ulcer or making an existing ulcer worse. NSAIDs include aspirin, ibuprofen, and naproxen.
A rare cause of peptic ulcers is Zollinger-Ellison syndrome. In this condition, the stomach makes too much acid, damaging the stomach lining.
Common ulcer symptoms include:
- A burning, aching pain—or a pain that feels like hunger—between the navel and the breastbone. The pain sometimes extends to the back.
- Belly pain that can last from a few minutes to a few hours and that usually goes away for a while after you take an antacid or acid reducer.
- Weeks of pain that comes and goes and may alternate with pain-free periods.
- Loss of appetite and weight loss.
- Bloating or nausea after eating.
Less common symptoms
Less common but more serious symptoms of ulcers include:
- Vomiting after meals.
- Vomiting blood and/or material that looks like coffee grounds.
- Black stools that look like tar, or stools that contain dark red blood.
Ulcers and pains
Symptoms of ulcers in the upper small intestine (duodenal ulcers) and in the stomach (gastric ulcers) are similar, except for when pain occurs.
- Pain from a duodenal ulcer may occur several hours after you eat (when the stomach is empty) and may improve after you eat. Pain also may wake you in the middle of the night.
- Pain from a gastric ulcer may occur shortly after you eat (when food is still in your stomach).
Some ulcers don't cause symptoms. These are known as silent ulcers. Silent ulcers are more common in:
- Older adults.
- People who have diabetes.
- People who use nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, ibuprofen (such as Advil), and naproxen (such as Aleve).
Symptoms in children
In children, symptoms vary with age:
- Toddlers and young children may complain of general stomach pain.
- Teenagers may have symptoms more like those of adults.
Many people who have peptic ulcers may not see a doctor when their symptoms begin. Their symptoms, such as belly pain, may come and go. Even without treatment, some ulcers will heal by themselves.
And even with treatment, ulcers sometimes come back. Certain factors such as cigarette smoking and continued use of nonsteroidal anti-inflammatory drugs (NSAIDs) increase the risk of ulcers coming back.
Sometimes ulcers can cause complications, such as bleeding, perforation, penetration, or obstruction. That's why it's important to treat an ulcer, even if you have one that isn't causing any symptoms.
Most peptic ulcers without complications heal, regardless of the cause. But an ulcer is likely to come back if you have an H. pylori infection that is not successfully treated. Recurring ulcers caused by reinfection with H. pylori are not common in the United States, except in areas that are overcrowded or have poor sanitation.
Ulcers in the stomach (gastric ulcers) often heal more slowly than ulcers in the upper small intestine (duodenal ulcers).
What Increases Your Risk
Risk factors you can control
The following things can increase your chance of getting a peptic ulcer and may slow the healing of an ulcer you already have:
- Taking nonsteroidal anti-inflammatory drugs (NSAIDs). These include aspirin, ibuprofen (such as Advil), and naproxen (such as Aleve).
- Drinking too much alcohol. This is more than 2 drinks a day for men and more than 1 drink a day for women.
In the past, spicy foods, caffeine, and moderate amounts of alcohol were thought to increase ulcer risk. This is no longer believed to be true.
Risk factors you cannot control
Some things that you cannot control may increase your risk of getting an ulcer. These include:
- A Helicobacter pylori ( H. pylori) infection, the most common cause of ulcers.
- Physical stress caused by a serious illness or injury (such as a major trauma, surgery, or the need to be on a ventilator to assist breathing).
- Hypersecretory condition, in which your stomach produces too much acid.
- A personal or family history of ulcers.
When should you call your doctor?
If you have been diagnosed with a peptic ulcer, call 911 or other emergency services immediately if you have:
- Symptoms that could indicate a heart attack or shock.
- Sudden severe, continuous belly pain or vomiting.
Call your doctor or seek medical attention right away if you have:
- Frequent feelings of dizziness or lightheadedness, especially when moving from lying down to a seated or standing position.
- Blood in your vomit or something that looks like coffee grounds (partially digested blood) in your vomit.
- Stools that are black or that look like tar, or stools that contain dark red or maroon blood.
Call your doctor if you have been diagnosed with a peptic ulcer and:
- Your symptoms continue or become worse after 10 to 14 days of treatment.
- You begin to lose weight without trying.
- You are vomiting.
- You have new belly pain or belly pain that does not go away.
If you have been diagnosed with a peptic ulcer and medical treatment is not helping, call your doctor. Waiting until your symptoms get worse can be serious.
If you don't know if you have a peptic ulcer and you don't have any of the emergency symptoms listed above, you may try taking an antacid or nonprescription acid reducer and other home treatment, such as making changes to your diet.
- If your symptoms don't get better after 10 to 14 days, call your doctor.
- If your symptoms go away after you take antacids or acid reducers and try home treatment, but then the symptoms come back, call your doctor.
Who to see
To evaluate your symptoms, see your:
- Family medicine doctor.
- General practitioner.
- Nurse practitioner.
- Physician assistant.
- Pediatrician (for children and teens).
If further testing or treatment is needed, you may need to see someone who specializes in the treatment of diseases of the digestive tract (gastroenterologist).
If surgery is needed, your doctor may refer you to a general surgeon. But surgery is rarely needed to treat ulcers.
Exams and Tests
Although not all peptic ulcers are caused by bacteria, it's getting more common to do a test for Helicobacter pylori whenever someone has ulcer symptoms. This includes testing your blood, breath, stool, or a sample of tissue from your digestive tract (biopsy).
An endoscopy may be done so that a doctor can:
- Look at the inside of your stomach and your upper small intestine to check for an ulcer.
- Collect a tissue sample (biopsy) that can be tested for H. pylori or cancer.
If you are older than 55, you may need an endoscopy because of a higher risk for stomach cancer. This is especially true if you have:
- Ulcer symptoms for the first time.
- Ulcer symptoms that return before or after treatment is completed.
- A family history of stomach cancer.
- Other symptoms that may point to a more serious problem, such as stomach cancer. These include:
- Blood in the stool.
- Weight loss of more than 10% of body weight.
- Difficulty swallowing (dysphagia).
- Abdominal mass.
Other tests that may be done include:
- Fecal occult blood test (FOBT). This test may be done to detect blood in the stool, which may be caused by a peptic ulcer or another serious problem, such as colon cancer. By itself, an FOBT cannot diagnose peptic ulcer disease, but it may show if an ulcer is bleeding.
- Complete blood count (CBC). This blood test may be done to look for anemia, which may be caused by a bleeding ulcer.
- Upper GI series. This X-ray exam of the esophagus and stomach may be used to diagnose peptic ulcer disease, although this test is being used less frequently.
Left untreated, many ulcers eventually heal. But ulcers often recur if the cause of the ulcer is not eliminated or treated. If ulcers keep coming back, you have an increased risk of developing a serious complication, such as bleeding or a hole in the wall of your stomach or intestine.
Most of the time, treatment means taking medicines—such as H2 blockers and proton pump inhibitors (PPIs)—and making lifestyle changes, including:
- Not taking nonsteroidal anti-inflammatory drugs (NSAIDs), if possible. These include aspirin, ibuprofen (such as Advil), and naproxen (such as Aleve).
- Quitting smoking.
- Not drinking too much alcohol (no more than 2 drinks a day for men and 1 drink a day for women).
H. pylori infection
If your ulcer is caused by Helicobacter pylori ( H. pylori) bacteria, treatment usually involves a combination of medicines, including antibiotics.
If treatment isn't working, you may need more tests to look for bacteria. If you still have an H. pylori infection, your doctor will likely try a different combination of medicines. He or she may also suggest that you see a gastroenterologist. This specialist will do an endoscopy to look at your ulcer and to take a tissue sample (biopsy).
Treatment if ulcers get worse
If you have serious complications from a peptic ulcer, such as bleeding or obstruction, you may need an endoscopy, even if you have already had one.
If your stomach or intestine has a perforation or your ulcer continues to bleed despite treatment, you may need surgery. But surgery is rarely used to treat an ulcer.
You can greatly reduce the chance that you will get a peptic ulcer if you:
- Don't smoke. Smokers are much more likely than nonsmokers to get ulcers. For ways to quit smoking, see the topic Quitting Smoking.
- Avoid NSAIDs. Avoid taking aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs (NSAIDs) for longer than a few days at a time. If you are taking one of these medicines daily, for example taking aspirin for heart problems, ask your doctor about taking medicine to help protect your stomach and intestines from ulcers.
- Drink alcohol only in moderation. Limit alcohol to 2 drinks a day for men and 1 drink a day for women.
Many people who have mild ulcer symptoms first try home treatment for a short time without seeing a doctor.
But see your doctor if your symptoms don't get better after 10 to 14 days of home treatment, or if you have other symptoms such as weight loss, nausea after eating, or consistent pain. This is even more important if you are middle-aged or older, because the risk for cancer or other illnesses that cause symptoms similar to peptic ulcer disease increases with age.
Try these home treatment steps to stop symptoms and help an ulcer heal:
- Stop smoking.
- Try nonprescription medicines that reduce stomach acid. Make sure you tell your doctor about any medicines you are taking.
- Make changes to your diet, such as eating smaller, more frequent meals. (These changes may improve your symptoms, but they won't help your ulcer heal.)
- Drink alcohol only in moderation, or not at all. Limit alcohol to 2 drinks a day for men and 1 drink a day for women. Drinking too much alcohol may make an ulcer heal more slowly and may make your symptoms worse.
Medicines are used to:
- Treat peptic ulcers by reducing the amount of acid produced by the stomach.
- Kill Helicobacter pylori ( H. pylori) bacteria if they are infecting the stomach lining.
- Protect the lining of the stomach and upper small intestine from injury caused by nonsteroidal anti-inflammatory drugs (NSAIDs). These include aspirin, ibuprofen (such as Advil), and naproxen (such as Aleve).
Medicines to reduce stomach acid
Medicines that reduce the amount of acid produced by the stomach are used to treat all forms of peptic ulcer disease.
- Antacids (such as Tums)
- Acid reducers
- H2 blockers (such as Pepcid). Some H2 blockers are available without a prescription.
- Proton pump inhibitors (PPIs) (such as Prilosec). Some PPIs are available without a prescription.
Be careful when you take over-the-counter antacid medicines. Many of these medicines have aspirin in them. Read the label to make sure that you are not taking more than the recommended dose. Too much aspirin can be harmful.
Medicines to kill H. pylori bacteria
Doctors prescribe combination drug therapy to cure infection with H. pylori bacteria. This usually includes at least two antibiotics, a proton pump inhibitor, and sometimes a bismuth compound.
Medicines to protect the stomach
Medicines used to protect the stomach from damage caused by frequent use of aspirin or other NSAIDs include:
- Acid reducers. These include:
- H2 blockers (such as Tagamet).
- Proton pump inhibitors (PPIs) (such as Prilosec).
- Prostaglandin analogs (such as Cytotec).
You can get some H2 blockers and PPIs without a prescription (over the counter or OTC). If you are using OTC acid reducers (such as Prilosec or Pepcid) to help with your symptoms for more than 10 to 14 days at a time, or if your symptoms are very bad, be sure to see your doctor.
Surgery is rare, but it is needed sometimes to treat:
- Ulcers that don't heal (intractable peptic ulcers).
- Life-threatening complications of an ulcer, such as severe bleeding, perforation, or obstruction.
If surgery is suggested, you may want to:
- Seek a second opinion and ask whether all medicine treatment options have been tried.
- Compare the cost of long-term medicine treatment to the one-time cost of surgery.
- Remember that no surgery can completely prevent ulcers from returning.
- Find a surgeon who has a lot of experience with surgery for ulcers.
When surgery is done, it usually involves one or more of the following:
- Cutting one or more of the nerves to the stomach (vagotomy).
- Widening the opening of the bottom of the stomach (pyloroplasty).
- Removing part of the stomach (partial gastrectomy).
Other Works Consulted
- Yang YX, et al. (2006). Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA, 296(24): 2947–2953.
Current as of: April 15, 2020
Author: Healthwise Staff
E. Gregory Thompson MD - Internal Medicine
Adam Husney MD - Family Medicine
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