Ulcers in stomach symptoms

Peptic Ulcer

A peptic ulcer is a sore in the lining of your stomach or your duodenum, the first part of your small intestine. A burning stomach pain is the most common symptom. The pain

  • Starts between meals or during the night
  • Briefly stops if you eat or take antacids
  • Lasts for minutes to hours
  • Comes and goes for several days or weeks

Peptic ulcers happen when the acids that help you digest food damage the walls of the stomach or duodenum. The most common cause is infection with a bacterium called Helicobacter pylori. Another cause is the long-term use of nonsteroidal anti-inflammatory medicines (NSAIDs) such as aspirin and ibuprofen. Stress and spicy foods do not cause ulcers, but can make them worse.

To see if you have an H. pylori infection, your doctor will test your blood, breath, or stool. Your doctor also may look inside your stomach and duodenum by doing an endoscopy or x-ray.

Peptic ulcers will get worse if not treated. Treatment may include medicines to reduce stomach acids or antibiotics to kill H. pylori. Antacids and milk can’t heal peptic ulcers. Not smoking and avoiding alcohol can help. You may need surgery if your ulcers don’t heal.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases

Symptoms & Causes of Peptic Ulcers (Stomach Ulcers)

In this section:

  • What are the symptoms of a peptic ulcer?
  • What causes a peptic ulcer?
  • How do NSAIDs cause a peptic ulcer?
  • How do H. pylori cause a peptic ulcer and peptic ulcer disease?
  • How do tumors from ZES cause peptic ulcers?
  • When should you call or see a doctor?

What are the symptoms of a peptic ulcer?

A dull or burning pain in your stomach is the most common symptom of a peptic ulcer. You may feel the pain anywhere between your belly button and breastbone. The pain most often

  • happens when your stomach is empty—such as between meals or during the night
  • stops briefly if you eat or if you take antacids
  • lasts for minutes to hours
  • comes and goes for several days, weeks, or months

Less common symptoms may include

  • bloating
  • burping
  • feeling sick to your stomach
  • poor appetite
  • vomiting
  • weight loss

Even if your symptoms are mild, you may have a peptic ulcer. You should see your doctor to talk about your symptoms. Without treatment, your peptic ulcer can get worse.

A dull or burning pain in your stomach is the most common symptom of peptic ulcers.

What causes a peptic ulcer?

Causes of peptic ulcers include

  • long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen
  • an infection with the bacteria Helicobacter pylori (H. pylori)
  • rare cancerous and noncancerous tumors in the stomach, duodenum, or pancreas—known as Zollinger-Ellison syndrome

Sometimes peptic ulcers are caused by both NSAIDs and H. pylori.

How do NSAIDs cause a peptic ulcer?

To understand how NSAIDs cause peptic ulcer disease, it is important to understand how NSAIDs work. Nonsteroidal anti-inflammatory drugs reduce pain, fever, and inflammation, or swelling.

Everyone has two enzymes that produce chemicals in your body’s cells that promote pain, inflammation, and fever. NSAIDs work by blocking or reducing the amount of these enzymes that your body makes. However, one of the enzymes also produces another type of chemical that protects the stomach lining from stomach acid and helps control bleeding. When NSAIDs block or reduce the amount of this enzyme in your body, they also increase your chance of developing a peptic ulcer.

How do H. pylori cause a peptic ulcer and peptic ulcer disease?

H. pylori are spiral-shaped bacteria that can cause peptic ulcer disease by damaging the mucous coating that protects the lining of the stomach and duodenum. Once H. pylori have damaged the mucous coating, powerful stomach acid can get through to the sensitive lining. Together, the stomach acid and H. pylori irritate the lining of the stomach or duodenum and cause a peptic ulcer.

How do tumors from ZES cause peptic ulcers?

Zollinger-Ellison syndrome is a rare disorder that happens when one or more tumors form in your pancreas and duodenum. The tumors release large amounts of gastrin, a hormone that causes your stomach to produce large amounts of acid. The extra acid causes peptic ulcers to form in your duodenum and in the upper intestine.

When should you call or see a doctor?

You should call or see your doctor right away if you

  • feel weak or faint
  • have difficulty breathing
  • have red blood in your vomit or vomit that looks like coffee grounds
  • have red blood in your stool or black stools
  • have sudden, sharp stomach pain that doesn’t go away

These symptoms could be signs that a peptic ulcer has caused a more serious problem.

Call your doctor if the pain gets worse.

What are stomach ulcers?

Dr Sarah Jarvis MBE

How common are stomach ulcers?

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.

Stomach ulcer 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).
  • Vomiting.
  • Feeling very ‘full’ 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).

Perforation
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.

Stomach blockage
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.

Stomach ulcer treatment

General advice

Lifestyle measures can improve symptoms, such as:

  • Lose weight if you are overweight.
  • Avoid any trigger foods, such as coffee, chocolate, tomatoes, fatty foods or spicy foods.
  • Eat smaller meals and eat your evening meal 3-4 hours before going to bed.
  • Stop smoking.
  • Reduce alcohol consumption to recommended limits.

Acid-suppressing medication

A 4- to 8-week course of a medicine that greatly reduces the amount of acid that your stomach makes is usually advised. See the separate leaflet called Indigestion Medication for more information.

If your ulcer was caused by Helicobacter pylori (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. For more information, see the separate leaflet called Stomach Pain (Helicobacter Pylori).

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.

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 H. pylori

Infection with H. pylori is the cause in about 8 in 10 cases of stomach ulcer. See the separate leaflet called Stomach Pain (Helicobacter Pylori) for more information.

Anti-inflammatory medicines – including aspirin

Anti-inflammatory medicines are sometimes called non-steroidal anti-inflammatory drugs (NSAIDs). Certain indigestion medications are sometimes used at the same time as an NSAID to prevent an ulcer.

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. The H. pylori bacterium can be detected in a sample of stool (faeces), or in a ‘breath test’, or from a blood test, or from a biopsy sample taken during a gastroscopy. See the separate leaflet called Stomach Pain (Helicobacter Pylori) 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.

In the past, ulcers were treated by trying to neutralize or decrease the amount of acid in the stomach. Current treatment focuses on eliminating H. pylori through antibiotics. Antibiotic treatment should be given to all ulcer patients who have been diagnosed with H. pylori, even if they have no symptoms or are being treated to reduce stomach acid. Antibiotic treatment is especially important for patients who have had complications in the past. Antibiotics to treat H. pylori are evolving, and a combination of antibiotics is usually prescribed.

The symptoms of an ulcer can be relieved by taking antacids, which can also help prevent the symptoms from coming back and help promote healing of the ulcer. Antacids must be taken five to seven times a day and can interfere with the body’s ability to absorb other drugs. The two general types of antacids are:

  • Ones that the body can absorb, such as baking soda. These are quick and effective but may have side effects when taken on a regular basis
  • Ones that interact with stomach acid to create salts that are not absorbed by the body and are excreted

While there is currently no evidence that changing the diet helps an ulcer heal faster or prevents its return, a doctor may suggest that any food that causes distress be eliminated. These may include fruit juices, spicy foods and fatty foods.

Alcohol tends to increase the acid in the stomach, and ulcer patients are usually advised to restrict their drinking of alcohol. Persons who smoke are at a higher risk of developing ulcers and complications. Smoking also slows the healing process and makes the return of ulcers more likely.

Although surgical treatment is being prescribed less often, surgery may be necessary if complications do not respond to medical therapy, symptoms are severe or there is a suspicion that the ulcer may be cancerous.

More than 60% of people have a return of their ulcers a year after traditional treatment has ended. Fewer than 10% of people have a recurrence of ulcers after anti-H. pylori therapy. The use of non-steroidal anti-inflammatory drugs might also affect recurrence of ulcers.

Complications

Certain complications can also result from peptic ulcers, including:

  • Bleeding
  • A hole in the wall of the stomach or duodenum. This causes intense, ongoing pain that may be felt in locations other than the abdomen. The pain may change with shifts in body position.
  • A hole into the peritoneal cavity, which surrounds the organs of the abdomen. This causes sudden, intense pain that spreads quickly throughout the abdomen and is worse with movement.
  • A blockage. The outlet of the stomach may become blocked as a result of scarring, muscle spasms or inflammation related to an ulcer. This causes repeated, high volume vomiting, usually at the end of the day. There may also be a feeling of bloating after eating and a loss of appetite. Dehydration and weight loss are risks if vomiting continues.

Treatment of complications varies. For example:

  • Bleeding may be stopped using a variety of minimally invasive techniques.
  • Acid-suppressing drugs may be given intravenously and continued until the condition stabilizes.
  • Emergency surgery may be necessary if the patient gets worse even with treatment and blood transfusions and if their pulse rate and blood pressure are not stable.

Persons who have H. pylori-related ulcers may be at higher risk for certain forms of cancer and lymphoma.

Stomach ulcer

If you have a stomach ulcer, your treatment will depend on what caused it.

With treatment, most ulcers heal in a month or two.

Treating Helicobacter pylori (H. pylori) infection

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

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

This is also recommended if it’s thought your stomach ulcer’s 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’ll usually be prescribed a course of 2 or 3 antibiotics.

The most commonly used antibiotics are:

  • amoxicillin
  • clarithromycin
  • metronidazole

You should take these twice a day for a week.

Side effects

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

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

Further testing

You’ll be re-tested at least 4 weeks after finishing your antibiotic course to see if there are any H. pylori bacteria left in your stomach. If there are, a further course of eradication therapy using different antibiotics may be given.

Ulcers caused by NSAIDs

If your stomach ulcer’s caused by taking NSAIDs:

  • you’ll be given a course of PPI medication
  • your use of NSAIDs will be reviewed, and you may be advised to use an alternative painkiller

Alternative painkillers

You may be advised to use an alternative painkiller not associated with stomach ulcers, such as paracetamol.

COX-2 inhibitors are sometimes recommended. These are an alternative type of NSAID that’s less likely to cause stomach ulcers.

Low-dose aspirin

If you’re taking low-dose aspirin to reduce your risk of blood clots, your GP 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.

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

Proton pump inhibitors (PPIs)

PPIs work by reducing the amount of acid your stomach produces. This prevents further damage to the ulcer as it heals naturally.

The most commonly used PPIs are:

  • omeprazole
  • pantoprazole
  • lansoprazole

They’re usually prescribed for 4 to 8 weeks.

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

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

These should pass once treatment has been completed.

H2-receptor antagonists

Sometimes a type of medication called H2-receptor antagonists are used instead of PPIs.

These also reduce the amount of acid your stomach produces.

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

Side effects are uncommon, but can include:

  • diarrhoea
  • headaches
  • dizziness
  • rashes
  • tiredness

Antacids and alginates

As these treatments can take several hours before they start to work, your GP may recommend taking additional antacid medication.

Antacids:

  • neutralise your stomach acid
  • provide immediate, but short-term, symptom relief
  • should be taken when you experience symptoms or when you expect them, such as after meals or at bedtime

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

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

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

  • diarrhoea or constipation
  • wind (flatulence)
  • stomach cramps
  • feeling and being sick

Lifestyle changes

There aren’t any special lifestyle measures you need to take during treatment.

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

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