Stomach ulcer

A stomach ulcer, also called a gastric ulcer, is an open sore that develops on the lining of the stomach. Ulcers can also form in the part of the intestine just beyond the stomach. These are called duodenal ulcers.

Doctors sometimes use the term peptic ulcers for both stomach and duodenal ulcers, and what you read here applies to both.

The most common symptom of a stomach ulcer is a burning or gnawing pain in the centre of the abdomen (tummy). But not all stomach ulcers are painful.

Some people have:

• indigestion
• heartburn
• nausea (feeling sick)

If you think you have a stomach ulcer, speak to your doctor.

See a doctor straight away, or call the 16263 health line, if any of these happen with a stomach ulcer:

• your symptoms don't go away
• you're vomiting blood, which can look bright red or dark brown and grainy, like coffee grounds
• you're passing dark, sticky stools that look like tar
• you feel a sudden, sharp pain in your tummy that keeps getting worse

These could be a sign of a serious complication.

A stomach ulcer happens when the layer that protects the stomach lining from stomach acid breaks down. Once that layer is gone, the lining can become damaged.

Most stomach ulcers are caused by one of two things:

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

There's little evidence that stress or certain foods cause stomach ulcers.

If your stomach ulcer was caused by an H. pylori infection, you'll be given antibiotics. These kill the bacteria and should stop the ulcer coming back.

If NSAIDs caused your stomach ulcer, you'll be given a proton pump inhibitor (PPI). Your doctor will prescribe it and talk with you about whether you should keep using NSAIDs. A different medicine, such as paracetamol, may be recommended instead of NSAIDs.

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

Complications from a stomach ulcer are rare, but they can be very serious and may even threaten your life. The main ones are:

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

The most common sign of a stomach ulcer is a burning or gnawing pain in your abdomen (tummy). But not every stomach ulcer hurts. Some cause no pain at all and only come to light when a complication develops, such as bleeding from the ulcer.

The pain from a stomach ulcer can travel in different directions. It can move:

• out from the middle of your tummy up to your neck
• down to your belly button
• through to your back

The pain also tends to follow a pattern. It:

• can last from a few minutes to a few hours
• often starts within a few hours of eating
• can cause you to wake up during the night

Antacids (indigestion medicine) may ease the pain for a while, but it will keep coming back if the ulcer isn't treated.

Some people with a stomach ulcer have other symptoms, though these are less common. They include:

• indigestion
• heartburn
• loss of appetite
• feeling and being sick
• weight loss

You may also burp or feel bloated after eating fatty foods.

A stomach ulcer is usually caused by Helicobacter pylori (H. pylori) bacteria or by non-steroidal anti-inflammatory drugs (NSAIDs). Either of these can break down the stomach's defence against the acid it makes to digest food. The stomach lining then becomes damaged, and an ulcer forms.

H. pylori bacteria live in the lining of your stomach. They can irritate that lining and leave it more open to damage from stomach acid.

The infection is common, and you can have it without knowing, because it doesn't usually cause symptoms.

People of all ages can be infected. Doctors don't know exactly why some people are more affected by H. pylori than others.

NSAIDs are medicines that many people use to treat pain, a high temperature (fever) and inflammation (swelling).

Commonly used NSAIDs include:

• ibuprofen
• aspirin
• naproxen
• diclofenac

Many people take NSAIDs without any side effects. But there's always a risk the medicine could cause problems, such as stomach ulcers, particularly if you take it for a long time or at high doses.

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

There's little evidence that stomach ulcers are caused by:

• spicy foods
• stress
• alcohol

But these can make the symptoms worse.

Smoking is different. It can:

• increase your risk of developing stomach ulcers
• make treatment less effective

• will want to know if you're taking non-steroidal anti-inflammatory drugs (NSAIDs)
• might test you for a Helicobacter pylori (H. pylori) infection

In some cases, you may be referred for a gastroscopy to look for an ulcer inside your stomach.

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

• urea breath test
• stool antigen test (a small stool sample is tested for the bacteria)
• blood test

You'll be given a special drink that contains a chemical which H. pylori breaks down. Your breath is then tested to see whether you have an H. pylori infection or not.

In the blood test for a stomach ulcer, a sample of your blood is tested for antibodies to the H. pylori bacteria. Antibodies are proteins your body makes naturally in the blood to help fight infection.

This test has now largely been replaced by the stool antigen test.

A gastroscopy means passing a thin, flexible tube (an endoscope) with a camera at one end through your mouth and down into your stomach and the first section 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 it more comfortable to pass the endoscope

The camera images will usually confirm or rule out a stomach ulcer. The doctor may also take a small tissue sample from your stomach or duodenum to test for the H. pylori bacteria.

You'll have this done as an outpatient in hospital, so you won't have to spend the night there.

You may have a repeat gastroscopy after 4 to 6 weeks to check that the ulcer's healed.

What treatment you get for a stomach ulcer depends on what caused it. Once treatment starts, most ulcers heal within a month or two.

When a Helicobacter pylori (H. pylori) bacterial infection is behind your stomach ulcer, your doctor will give you two things:

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

The same treatment is recommended if your stomach ulcer is thought to come from both an H. pylori infection and non-steroidal anti-inflammatory drugs (NSAIDs).

If you have a stomach ulcer caused by an H. pylori infection, your doctor will usually prescribe a course of 2 or 3 antibiotics. The ones most commonly used are:

• amoxicillin
• clarithromycin
• metronidazole

You take these twice a day for a week.

These medicines usually cause only mild side effects, but they can include:

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

You'll be tested again at least 4 weeks after you finish your antibiotic course, to check whether any H. pylori bacteria are still left in your stomach. If they are, you may be given another course of eradication therapy, this time with different antibiotics.

If NSAIDs have caused your stomach ulcer:

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

Your doctor may advise a different painkiller, one that isn't linked with stomach ulcers, such as paracetamol.

Sometimes COX-2 inhibitors are recommended. They're another type of NSAID, but they're less likely to cause stomach ulcers.

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

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

If you keep taking NSAIDs, you run real risks. You're more likely to get another stomach ulcer, and you could have a serious complication such as internal bleeding.

PPIs work by cutting down the amount of acid your stomach makes. With less acid, the ulcer isn't damaged any further while it heals naturally.

The most commonly used PPIs are:

• omeprazole
• pantoprazole
• lansoprazole

Doctors usually prescribe them for 4 to 8 weeks.

Side effects from these medicines are usually mild, but they can include:

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

These should pass once you have finished the treatment.

Sometimes doctors use a type of medicine called H2-receptor antagonists instead of PPIs. These also lower the amount of acid your stomach makes. For treating a stomach ulcer, ranitidine is the one most widely used.

Side effects are uncommon, but they can include:

• diarrhoea
• headaches
• dizziness
• rashes
• tiredness

These treatments can take several hours before they start to work, so your doctor may suggest you also take an antacid medicine in the meantime.

Antacids:

• neutralise your stomach acid
• give immediate, but short-term, relief from symptoms
• 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 on the lining of your stomach. Antacids with alginates are best taken after meals.

You can buy these medicines at a pharmacy, and your pharmacist can tell you which one suits you best.

Both medicines usually cause only mild side effects, but these can happen:

• diarrhoea or constipation
• farting
• stomach cramps
• feeling sick or being sick

You don't need to follow any special lifestyle rules while you're being treated for a stomach ulcer. Still, cutting out stress, alcohol, spicy foods and smoking may ease your symptoms while the ulcer heals.

Complications from a stomach ulcer are rare, but when they happen they can be very serious. There are three main ones:

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

Internal bleeding is the most common complication of a stomach ulcer. It can happen when an ulcer develops at the site of a blood vessel.

The bleeding may be slow and go on for a long time, or it may be rapid and severe.

Slow, long-term bleeding from a stomach ulcer can lead to anaemia. The symptoms of anaemia include:

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

If these symptoms don't go away, see your doctor. If the doctor thinks you have a stomach ulcer, you may be referred to a gastroenterologist for an examination and treatment.

• you're vomiting blood, which can look bright red or dark brown and grainy, like coffee grounds
• you're passing dark, sticky stools that look like tar

Doctors will use an endoscopy to find out what is causing the bleeding from a stomach ulcer, and they can give treatment during the same endoscopy to stop it.

Sometimes other steps are needed:

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

You may also need a blood transfusion to replace the blood you've lost.

A perforation is a rarer complication of a stomach ulcer. It happens when the lining of the stomach splits open.

This can be very serious. The bacteria that live in your stomach can escape through the split and infect the lining of your abdomen (the peritoneum). That infection is called peritonitis.

With peritonitis, the infection can spread very quickly into the blood (this is called sepsis) and then on to other organs. That puts you at risk of several organs failing together, and it can be fatal if it isn't treated.

The most common symptom of peritonitis is sudden pain in the abdomen that keeps getting worse.

Peritonitis is a medical emergency, and you need to be admitted to hospital. Sometimes surgery may be needed.

Sometimes a stomach ulcer becomes inflamed (swollen) or scarred, and this can block the normal passage of food through your digestive system. Doctors call this a gastric outlet obstruction.

The 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

An endoscopy can confirm a gastric outlet obstruction.

If inflammation is causing the obstruction, proton pump inhibitors (PPIs) or H2-receptor antagonists can be used to bring down stomach acid levels until the swelling goes down.

If scar tissue is the cause, you may need surgery. This can involve passing a small balloon through an endoscope and inflating it to widen the site of the obstruction.