Stomach ulcer

What causes stomach ulcers?

A stomach ulcer forms when the layer that protects the stomach lining from stomach acid breaks down. Once that protection is gone, the acid can damage the lining itself.

This usually happens for one of two reasons:

• an infection with a bacterium called Helicobacter pylori (H. pylori)
• taking non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin, especially if they are taken for a long time or at high doses

There is little evidence that stress or particular foods cause stomach ulcers.

More about the causes of stomach ulcers

Stomach ulcer causes

Most stomach ulcers are caused either by H. pylori bacteria or by NSAIDs.

Both of these can wear down the stomach's natural defence against the acid it produces to digest food. The lining then becomes damaged and an ulcer forms.

H. pylori bacteria

H. pylori bacteria live in the lining of the stomach. They can irritate the lining and make it more vulnerable to damage from stomach acid.

Infection with H. pylori is common. Many people carry it without ever knowing, because the infection usually causes no symptoms at all.

People of any age can be infected. It is not fully understood why some people are affected more by H. pylori than others.

Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are medicines widely used to treat pain, fever (high temperature) and inflammation (swelling).

Commonly used NSAIDs include:

• ibuprofen
• aspirin
• naproxen
• diclofenac

Many people take NSAIDs with no side effects at all. Even so, there is always a risk that these medicines can cause problems such as stomach ulcers, particularly when taken for a long time or at high doses.

If you have a stomach ulcer now, or have had one in the past, you may be advised not to use NSAIDs. Paracetamol is a safer painkiller to use instead.

More about NSAIDs

Lifestyle factors

There is little evidence that stomach ulcers are caused by:

• spicy foods
• stress
• alcohol

These things can, however, make the symptoms worse.

Smoking is different. Smoking can:

• increase your risk of developing a stomach ulcer
• make treatment less effective

Ulcers caused by NSAIDs

If your stomach ulcer was caused by taking NSAIDs:

• you will be given a course of PPI medication
• your use of NSAIDs will be reviewed, and you may be advised to switch to a different painkiller

Alternative painkillers

You may be advised to use a painkiller that is not linked to stomach ulcers, such as paracetamol.

Sometimes COX-2 inhibitors are recommended. These are a different type of NSAID that is less likely to cause stomach ulcers.

Low-dose aspirin

If you take low-dose aspirin to lower your risk of blood clots, your doctor will tell you whether you need to keep taking it.

If you do need to continue, you may also be prescribed long-term treatment with a PPI or an H2-receptor antagonist to prevent further ulcers.

Proton pump inhibitors (PPIs)

PPIs work by reducing the amount of acid your stomach produces. This protects the ulcer from further damage while it heals naturally.

The most commonly used PPIs are:

• omeprazole
• pantoprazole
• lansoprazole

They are usually prescribed for 4 to 8 weeks.

H2-receptor antagonists

Sometimes a type of medicine called an H2-receptor antagonist is used instead of a PPI.

These also reduce the amount of acid your stomach produces.

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

Antacids and alginates

Because PPIs and H2-receptor antagonists can take several hours to start working, your doctor may suggest taking an antacid as well.

Antacids:

• neutralise your stomach acid
• give immediate relief from symptoms, though only for a short time
• should be taken when you have symptoms, or when you expect them, such as after meals or at bedtime

Some antacids also contain a medicine called an alginate, which forms a protective coating over the lining of your stomach. Antacids that contain alginates are best taken after meals.

You can buy these medicines at pharmacies. Your pharmacist can tell you which one is most suitable for you.

Lifestyle changes

There are no special lifestyle measures you must follow during treatment.

Even so, avoiding stress, alcohol, spicy foods and smoking may reduce your symptoms while your ulcer heals.

Diagnosis

Your doctor will want to know whether you have been taking non-steroidal anti-inflammatory drugs (NSAIDs), and may test you for an infection with the bacteria Helicobacter pylori (H. pylori). In some cases, you may be referred for a gastroscopy so a specialist can look for an ulcer inside your stomach.

Testing for H. pylori infection

If your doctor thinks your symptoms could be caused by an H. pylori infection, you will be offered one of these tests:

• a urea breath test
• a stool antigen test, where a small stool sample is checked for the bacteria
• a blood test

Urea breath test

You will be given a special drink containing a chemical that H. pylori breaks down. Your breath is then analysed to see whether or not you have the infection.

Blood test

A sample of your blood is checked for antibodies to the H. pylori bacteria. Antibodies are proteins your body makes naturally to help fight infection. This test has now largely been replaced by the stool antigen test.

Gastroscopy

A gastroscopy is a procedure in which a thin, flexible tube with a camera at one end (an endoscope) is passed through your mouth and down into your stomach and the first part of your small intestine (the duodenum).

Before the procedure, you may:

• be given a mild sedative injection
• have your throat sprayed with a local anaesthetic, which makes passing the endoscope more comfortable

The pictures from the camera will usually confirm or rule out an ulcer. A small tissue sample may also be taken from your stomach or duodenum to test for the H. pylori bacteria.

You will have this procedure as an outpatient at a hospital, which means you will not need to stay overnight. After 4 to 6 weeks, you may have a repeat gastroscopy to check that the ulcer has healed.

If your ulcer was caused by an H. pylori infection, you will be treated with antibiotics. These kill the bacteria and should stop the ulcer from coming back.

If your ulcer was caused by NSAIDs (common painkillers such as ibuprofen or diclofenac), you will be treated with a proton pump inhibitor (PPI). Your doctor will prescribe this and talk with you about whether you should keep taking NSAIDs. An alternative to NSAIDs, such as paracetamol, may be suggested.

Most stomach ulcers take a few months to heal after treatment. Ulcers can come back after treatment, but this is less likely if the underlying cause has been dealt with.

More about treating stomach ulcers

Stomach ulcer treatment

If you have a stomach ulcer, your treatment depends on what caused it. With treatment, most ulcers heal within a month or two.

Treating Helicobacter pylori (H. pylori) infection

If your stomach ulcer is caused by a Helicobacter pylori (H. pylori) bacterial infection, you will be given:

• a course of antibiotics
• a medicine called a proton pump inhibitor (PPI)

The same approach is recommended if it is thought your ulcer was caused by a combination of an H. pylori infection and non-steroidal anti-inflammatory drugs (NSAIDs).

Antibiotics

If you have an H. pylori infection, you will usually be prescribed a course of 2 or 3 antibiotics.

The antibiotics used most often are:

• amoxicillin
• clarithromycin
• metronidazole

You should take these twice a day for a week.

Side effects

The side effects of these antibiotics are usually mild, but can include:

• feeling sick and vomiting
• diarrhoea
• a metallic taste in your mouth

Side effects of PPIs are usually mild, but can include:

• headaches
• diarrhoea or constipation
• feeling sick
• abdominal (tummy) pain
• dizziness
• rashes

These should pass once treatment is finished.

Side effects of H2-receptor antagonists are uncommon, but can include:

• diarrhoea
• headaches
• dizziness
• rashes
• tiredness

Side effects of both of these medicines are usually mild, but can include:

• diarrhoea or constipation
• passing wind
• stomach cramps
• feeling sick and vomiting

Further testing

You will be tested again at least 4 weeks after finishing your antibiotic course to check whether any H. pylori bacteria remain in your stomach. If they do, a further course of eradication therapy using different antibiotics may be given.

Treating a gastric outlet obstruction

An endoscopy can be used to confirm the obstruction.

If the obstruction is caused by inflammation, proton pump inhibitors (PPIs) or H2-receptor antagonists can be used to reduce stomach acid levels until the swelling settles.

If the obstruction is caused by scar tissue, surgery may be needed. This can involve passing a small balloon through an endoscope and inflating it to widen the narrowed area.

Complications

Complications are rare but can be very serious and potentially life-threatening.

The main complications include:

• bleeding at the site of the ulcer
• the stomach lining at the site of the ulcer splits open – known as perforation
• the ulcer blocks the movement of food through the digestive system – known as gastric obstruction

More about the complications of stomach ulcers

It’s important to understand the potential risks associated with continued NSAID use.

You’re more likely to develop another stomach ulcer and could experience a serious complication, such as internal bleeding.

Read more about the complications of stomach ulcers

Stomach ulcer complications

Complications of stomach ulcers are rare, but can be very serious.

The main complications are:

• internal bleeding
• perforation – the lining of the stomach splits open
• gastric outlet obstruction – the stomach ulcer obstructs the normal passage of food through your digestive system

Internal bleeding

Internal bleeding’s the most common complication of stomach ulcers. It can occur when an ulcer develops at the site of a blood vessel.

The bleeding can either be slow and long-term, or rapid and severe.

Slow, long-term bleeding

Slow, long-term bleeding can lead to anaemia.

Symptoms of anaemia include:

• fatigue
• breathlessness
• pale skin
• heart palpitations (noticeable heartbeats)

You should visit your GP if you have persistent symptoms of anaemia. If they think you have a stomach ulcer, they may refer you to a gastroenterologist for an examination and treatment.

More about anaemia

Severe bleeding

Contact your GP or the NHS 24 111 service immediately if you have symptoms of more severe bleeding, including:

• you’re vomiting blood – the blood can appear bright red or have a dark brown, grainy appearance like coffee grounds
• you’re passing dark, sticky, tar-like stools

Stopping severe bleeding

An endoscopy will be used to identify the cause of the bleeding. Treatment can be given during the endoscopy to stop the bleeding.

Sometimes:

• specialised procedures carried out under X-ray guidance are used to stop bleeding ulcers
• surgery is needed to repair the affected blood vessel

Blood transfusions may also be needed to replace the blood you’ve lost.

Perforation

Perforations are a rarer complication of stomach ulcers. This is when the lining of the stomach splits open.

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

Peritonitis

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.

The most common symptom of peritonitis is sudden abdominal pain, which gets steadily worse. If you have this type of pain, contact your GP or the NHS 24 111 service immediately.

Peritonitis is a medical emergency that requires hospital admission. In some cases, surgery may be needed.

Gastric outlet obstruction

In some cases, an inflamed (swollen) or scarred stomach ulcer can obstruct the normal passage of food through your digestive system. This is called a gastric outlet obstruction.

Symptoms include:

• vomiting large amounts of undigested food
• a constant feeling of bloating or fullness
• feeling more full than usual after eating less food
• unexplained weight loss