Stomach (Gastric) Ulcer
Stomach ulcers are open sores that develop when the lining of the stomach has become damaged. Stomach ulcers are also called gastric ulcers.
How common is it?
It's not known exactly how common stomach ulcers are. They have become much less common since the 1980s because of much more effective treatments. So people with stomach ulcers now usually get better much more quickly.
The term 'peptic ulcer' is used to describe ulcers that are caused by too much acid in the stomach. This includes stomach ulcers and also ulcers in the first part of the gut (small intestine) known as the duodenum. Stomach ulcers are less common than duodenal ulcers.
What are the causes?
The acid in your stomach can damage the stomach lining but this is usually prevented by a protective layer over the lining of your stomach. Sometimes this protective layer doesn't work properly and this allows a stomach ulcer to develop.
- We now know that a germ (bacterium) called Helicobacter pylori (H. pylori) is often the cause of a stomach ulcer.
- Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen and diclofenac can allow the stomach acid to cause an ulcer.
- Most stomach ulcers are not cancerous (that means they are benign) but a few stomach ulcers are caused by stomach (gastric) cancer.
Read more about the causes of stomach ulcers.
What are the symptoms?
The main symptom caused by a stomach ulcer is having a pain in the upper tummy (abdomen). Other symptoms may include:
- Bloating. This means your tummy swells because your stomach is full of gas or air.
- Retching. Also known as 'heaving'. This means sounding and looking as though you're about to be sick (vomit) but not actually vomiting.
- Feeling sick (nausea).
- Feeling very 'full' after a meal.
A stomach ulcer may cause bleeding into the stomach, which may cause blood in your vomit (called haematemesis). Blood may also pass through your gut (bowel) and make your stools (faeces) very dark in colour or black (melaena).
A stomach ulcer may also cause a hole to form through the whole wall of the stomach (this is called a perforation) but this is rare. Food and acid can then leak out of the stomach and cause severe pain and make you very unwell. This is a medical emergency and needs hospital treatment as soon as possible.
Find out more about the symptoms of stomach ulcers.
What tests may be done?
Your doctor will arrange blood tests, including to see if any bleeding from the ulcer has made you anaemic. You will also have a blood test, stool (faeces) test or a breath test to see if you have the H. pylori germ (bacterium).
To confirm whether or not you have a stomach ulcer, you will usually be referred to a specialist to have a gastroscopy (endoscopy). This involves having a thin, flexible telescope passed down your gullet (oesophagus) to look for any inflammation or ulcers in the stomach. Samples (biopsies) of the stomach wall are also taken to check for any cancer in the stomach ulcer.
Read more about the tests for a stomach ulcer.
What are the treatments?
- The initial treatment for a stomach ulcer is a 4- to 8-week course of a medicine to reduce the amount of acid in your stomach. This will help to heal the ulcer.
- If it is found that you are infected with H. pylori, you will need a course of treatment with medicines to clear this infection. This usually involves treatment with two different antibiotics and a medicine to reduce the amount of acid in your stomach.
- If your ulcer was caused by an anti-inflammatory medicine then the best option is to stop taking the medicine and use a different type of medicine if needed.
- Surgery is now usually only needed if a complication of a stomach ulcer develops, such as severe bleeding or a hole (perforation) in the stomach wall.
Learn more about the treatments for a stomach ulcer.
What is the outlook?
For most people with a stomach ulcer, the outlook (prognosis) is excellent. Depending on the cause of the stomach ulcer, treatment of H. pylori infection or avoiding non-steroidal anti-inflammatory medicines greatly reduces the risk of having any more stomach ulcers in the future.
What are the symptoms of a stomach ulcer?
Pain in the upper tummy (abdomen) just below the breastbone (sternum) is the most common symptom. It usually comes and goes. It may be eased if you take antacid tablets. Sometimes food makes the pain worse. The pain may wake you from sleep.
Other symptoms which may occur include bloating, retching, feeling sick (nausea) and being sick (vomiting). You may also feel more 'full' than usual after a meal.
What are the symptoms of any complications?
Stomach ulcers can cause various complications but these are much less common now because of more effective treatments. However, complications can be very serious and include:
Bleeding from the ulcer
- This can range from a 'trickle' to a life-threatening bleed.
- If there is sudden heavy bleeding then this will cause you to vomit blood (this is called a haematemesis) and make you feel very faint.
- Less sudden bleeding may cause you to vomit and the vomit looks coffee-coloured because the stomach acid has partly broken down the blood.
- A more gradual trickle of blood will pass through your gut (bowel) and cause your stools (faeces) to look very dark in colour or even black (this is called melaena).
This is the term used to describe the ulcer having gone all the way through (perforated) the wall of the stomach. Food and acid in the stomach then leak out of the stomach. This usually causes severe pain and makes you very unwell. Stomach perforation is a medical emergency and needs hospital treatment as soon as possible.
This is now rare. An ulcer at the end of the stomach can cause the outlet of the stomach (the part of the stomach that goes into the duodenum) to narrow and cause an obstruction. This can cause frequent severe vomiting.
What causes stomach ulcers?
Your stomach normally produces acid to help with the digestion of food and to kill germs (bacteria). This acid is corrosive, so some cells on the inside lining of the stomach and the first part of the gut (small intestine) known as the duodenum produce a natural mucous barrier. This protects the lining of the stomach and duodenum.
There is normally a balance between the amount of acid that you make and the mucous defence barrier. An ulcer may develop if there is an alteration in this balance, allowing the acid to damage the lining of the stomach or duodenum. Causes of this include the following:
Infection with Helicobacter pylori
Infection with H. pylori is the cause in about 8 in 10 cases of stomach ulcer. More than a quarter of people in the UK become infected with H. pylori at some stage in their lives. Once you are infected, unless treated, the infection usually stays for the rest of your life.
In many people, it causes no problems and a number of these bacteria just live harmlessly in the lining of the stomach and duodenum. However, in some people, this bacterium causes an inflammation of the lining of the stomach or duodenum. This causes the defence mucous barrier to be disrupted (and in some cases the amount of acid to be increased) which allows the acid to cause inflammation and ulcers.
Anti-inflammatory medicines - including aspirin
Anti-inflammatory medicines are sometimes called non-steroidal anti-inflammatory drugs (NSAIDs). There are various types and brands. For example, aspirin, ibuprofen, diclofenac, etc. Many people take an anti-inflammatory medicine for arthritis, muscular pains, etc. Aspirin is also used by many people to protect against blood clots forming. However, these medicines sometimes affect the mucous barrier of the stomach and allow acid to cause an ulcer. About 2 in 10 stomach ulcers are caused by anti-inflammatory medicines.
Other causes and factors
Other causes are rare. For example, some viral infections can cause a stomach ulcer. Crohn's disease may cause a stomach ulcer in addition to other problems of the gut.
Stomach cancer may at first look similar to an ulcer. Stomach cancer is uncommon but may need to be 'ruled out' if you are found to have a stomach ulcer.
What tests are there for a stomach ulcer?
If your doctor thinks you may have a stomach ulcer, the initial tests will include some blood tests. These tests will help to check whether you have become anaemic because of any bleeding from the ulcer. The blood test will also check to see that your liver and pancreas are working properly.
The main tests that are then used to diagnose a stomach ulcer are as follows:
- A test to detect the H. pylori germ (bacterium) is usually done if you have a stomach ulcer. If H. pylori infection is found then it is likely to be the cause of the ulcer. The H. pylori bacterium can be detected in a sample of stools (faeces), or in a 'breath test', or from a blood test, or from a biopsy sample taken during a gastroscopy. See separate leaflet called Helicobacter Pylori and Stomach Pain for more details.
- Gastroscopy (endoscopy) is the test that can confirm a stomach ulcer. Gastroscopy is usually done as an outpatient 'day case'. You may be given a sedative to help you to relax. In this test, a doctor looks inside your stomach by passing a thin, flexible telescope down your gullet (oesophagus). The doctor will then be able to see any inflammation or ulcers in your stomach.
- Small samples (biopsies) are usually taken of the tissue in and around the ulcer during gastroscopy. These are sent to the laboratory to be looked at under the microscope. This is important because some ulcers are caused by stomach cancer. However, most stomach ulcers are not caused by cancer.
What are the treatments for a stomach ulcer?
A 4- to 8-week course of a medicine that greatly reduces the amount of acid that your stomach makes is usually advised. The most commonly used medicine is a proton pump inhibitor (PPI). PPIs are a group (class) of medicines that work on the cells that line the stomach, reducing the production of acid. They include esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole and they come in various brand names. Sometimes another class of medicines called H2 blockers is used. These are also called histamine H2-receptor antagonists but are commonly called H2 blockers. H2 blockers work in a different way on the cells that line the stomach, reducing the production of acid. They include cimetidine, famotidine, nizatidine and ranitidine and they come in various brand names. As the amount of acid is greatly reduced, the ulcer usually heals. However, this is not the end of the story.
If your ulcer was caused by H. pylori
Most stomach ulcers are caused by infection with H. pylori. Therefore, a main part of the treatment is to clear this infection. If this infection is not cleared, the ulcer is likely to return once you stop taking acid-suppressing medication. Two antibiotics are needed to clear H. pylori. In addition, you need to take an acid-suppressing medicine to reduce the acid in the stomach. This is needed to allow the antibiotics to work well. You need to take this 'combination therapy' (sometimes called 'triple therapy') for a week. One course of combination therapy clears H. pylori infection in up to 9 in 10 cases. If H. pylori infection is cleared, the chance of a stomach ulcer returning is greatly reduced. However, in a small number of people H. pylori infection returns at some stage in the future.
If your ulcer was caused by an anti-inflammatory medicine
If possible, you should stop taking the anti-inflammatory medicine. This allows the ulcer to heal. You will also normally be prescribed an acid-suppressing medicine for several weeks. This stops the stomach from making acid and allows the ulcer to heal. However, in many cases, the anti-inflammatory medicine is needed to ease symptoms of arthritis or other painful conditions, or aspirin is needed to protect against blood clots. In these situations, one option is to take an acid-suppressing medicine each day indefinitely. This reduces the amount of acid made by the stomach and greatly reduces the chance of an ulcer forming again.
What about surgery?
In the past, surgery was commonly needed to treat a stomach ulcer. This was before it was discovered that H. pylori infection was the cause of most stomach ulcers, and before modern acid-suppressing medicines became available. Surgery is now usually only needed if a complication of a stomach ulcer develops, such as severe bleeding or a hole (perforation).
What happens after treatment?
A repeat gastroscopy (endoscopy) is usually advised a few weeks after treatment has finished. This is mainly to check that the ulcer has healed. It is also to be doubly certain that the 'ulcer' was not due to stomach cancer. If your ulcer was caused by H. pylori then a test is advised to check that the H. pylori infection has gone. This is done at least four weeks after the course of combination therapy has finished. In most cases, the test is 'negative' meaning that the infection has gone. If it has not gone then a repeat course of combination therapy with a different set of antibiotics may be advised.
Further reading & references
- Dyspepsia and gastro‑oesophageal reflux disease: Investigation and management of dyspepsia - symptoms suggestive of gastro‑oesophageal reflux disease - or both; NICE Clinical Guideline (Sept 2014)
- Dyspepsia - proven peptic ulcer; NICE CKS, July 2015 (UK access only)
- Cai S, Garcia Rodriguez LA, Masso-Gonzalez EL, et al; Uncomplicated peptic ulcer in the UK: trends from 1997 to 2005. Aliment Pharmacol Ther. 2009 Nov 15;30(10):1039-48. Epub 2009 Aug 26.
- Sachs G, Scott DR, Wen Y; Gastric infection by Helicobacter pylori. Curr Gastroenterol Rep. 2011 Dec;13(6):540-6. doi: 10.1007/s11894-011-0226-4.
- Niv Y; H. pylori/NSAID--negative peptic ulcer - the mucin theory. Med Hypotheses. 2010 Nov;75(5):433-5. Epub 2010 May 4.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Colin Tidy
Prof Cathy Jackson