Peptic ulcer

Page last reviewed: 13/07/2011

A peptic ulcer is an open sore that develops on the inside lining of the stomach (a gastric ulcer), or the small intestine (a duodenal ulcer). Both types of ulcers are also referred to as peptic ulcer disease.

The most common symptom of a peptic ulcer is a burning or gnawing pain in the centre of the abdomen (stomach).

How common are peptic ulcers?

It is hard to accurately estimate exactly how common peptic ulcers are because in many people they do not cause any symptoms. However, a Swedish study that tested 1,000 adults at random found that four per cent of them had a peptic ulcer.

Peptic ulcers can affect people of any age, including children, but the condition is most common in people who are 60 years of age, or over. Both sexes are equally affected by peptic ulcers.

In the past, it was mistakenly thought that the main causes of peptic ulcers were lifestyle factors, such as diet, smoking, alcohol, and stress. While these factors may play a limited role, it is now known that the leading cause of peptic ulcers is a type of bacteria called H. pylori.

H. pylori can infect the stomach and small intestines and, in some people, the bacteria can irritate the inner layer of the stomach and small intestine, leading to the formation of an ulcer.

A group of painkillers known as non-steroidal anti-inflammatory drugs (NSAIDs), which include aspirin and ibuprofen, are the second most common cause of peptic ulcers. These types of painkillers can irritate the lining of the stomach and small intestine in some people, particularly if they are taken on a long-term basis.

Outlook

Since the link between peptic ulcers, H. pylori bacteria, and NSAIDs was discovered, treatment for peptic ulcers has become much more effective and the outlook is generally good.

Treatment for H. pylori associated peptic ulcers usually involves taking antibiotics to kill the bacteria. Following this treatment, only five per cent of people will experience another ulcer.

Treatment for NSAID associated peptic ulcers usually involves stopping using the NSAID before using medication to heal the ulcer. If withdrawing NSAID treatment is not possible, additional medication can be used to compensate for the effects of the NSAID.

Complications of peptic ulcers are serious but uncommon and include internal bleeding, which may require emergency surgery.

Tissue

Body tissue is made up of groups of cells that perform a specific job, such as protecting the body against infection, producing movement or storing fat.

Ulcer

An ulcer is a sore break in the skin, or on the inside lining of the body.

Stomach

The stomach is the sac-like organ of the digestive system. It helps digest food by churning it and mixing it with acids to break it down into smaller pieces.

Page last reviewed: 13/07/2011

The most common symptom of a peptic ulcer is a burning pain that develops in the centre of your abdomen (stomach). However, the pain can also travel up to your neck and down to your navel (belly-button).

The pain is caused by two factors:

  • the ulcer itself, and
  • stomach acid that comes into contact with the ulcer and irritates it.

The pain can last from a few minutes to a few hours. It often develops between 2-5 hours after eating food, so many people find that they wake up during the night due to the pain.

The pain is often worse when you have an empty stomach and you will probably find that eating something can help to reduce the pain.

Less common symptoms of a peptic ulcer include:

  • indigestion and heartburn,
  • vomiting, and
  • loss of appetite.

Some people also find that they can no longer tolerate eating fatty foods.

When to seek medical advice

You should always visit your GP if you suspect that you have a peptic ulcer. While there are over-the-counter (OTC) remedies that can provide temporary relief from your symptoms, they will not treat the underlying causes.

When to seek urgent medical advice

A number of symptoms can develop if a peptic ulcer suddenly causes serious complications, such as internal bleeding. These include:

  • vomiting blood - the blood can appear bright red, or have a darker, grainy appearance similar to coffee granules,
  • passing stools (faeces) - which are very dark in colour or 'tar-like', and
  • a sudden, sharp pain in your abdomen (stomach) that gets steadily worse.

If you experience any of the symptoms that are listed above, you should contact your GP immediately.

Glossary

Nausea
Nausea is when you feel like you are going to be sick.
Indigestion
Heartburn, also known as indigestion, is a painful, burning discomfort felt in the chest, usually after eating.
Ulcer
An ulcer is a sore break in the skin, or on the inside lining of the body.
Pain
Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.
Blood vessel
Blood vessels are the tubes in which blood travels to and from parts of the body. The three main types of blood vessels are veins, arteries and capillaries.
Loss of appetite
Loss of appetite is when you do not feel hungry or want to eat.
Vomit
Vomiting is when you bring up the contents of your stomach through your mouth.
Stomach
The sac-like organ of the digestive system. It helps digest food by churning it and mixing it with acids to break it down into smaller pieces.
Blood
Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.
Stools
Stool (also known as faeces) is the solid waste matter that is passed from the body as a bowel movement.

Page last reviewed: 13/07/2011

Peptic ulcers are usually caused in one of two ways:

  • H. pylori bacteria - which are responsible for 95 per cent of duodenal ulcers and 80 per cent of gastric ulcers, and
  • non-steroidal anti-inflammatory drugs (NSAIDs) - which are responsible for 20 per cent of gastric ulcers, and the remaining five per cent of duodenal ulcers.

Both causes disrupt the protective effects of the mucus that lines the stomach. This disruption causes the ulcer to form which, due to the high levels of acid found in the stomach and intestines, is unable to heal naturally. This is why reducing stomach acid levels are often an important part of treatment.

H. pylori

H. pylori infections are very common, and it is often possible to be infected without realising it because the infection does not usually cause any symptoms.

However, in some cases, an H. pylori infection can cause the protective mucus that lines your stomach to become inflamed and swollen. As the sensitive wall of your stomach is no longer protected by the stomach lining, stomach acid can damage it, causing an ulcer to develop. 

Duodenal ulcers (that develop in the upper part of the small intestine) can occur if an H. pylori infection is limited to the upper part of your stomach. An infection in this part of your stomach will result in an excess amount of stomach acid being produced, which flows into the duodenal area, increasing the risk of a duodenal ulcer developing.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs (NSAIDs) are medicines that are commonly used to treat:

  • pain - such as toothache, headache, joint pain, and period pain,
  • high temperature (fever), and
  • inflammatory conditions - conditions that cause painful inflammation of the joints, such as rheumatoid arthritis.

Some people with cardiovascular disease (conditions that affect the heart and the blood) also take the NSAID aspirin on a regular basis because it can reduce the risk of blood clots.

NSAIDs usually come in tablet form, although they are also available as liquids, creams, sprays, and suppositories, which is a capsule that you insert into your rectum (back passage)..

Examples of over-the-counter (OTC) NSAIDs include:

  • ibuprofen,
  • aspirin, and
  • naproxen.

Examples of prescription NSAIDs include:

  • diclofenac,
  • etodolac, and
  • fenoprofen

Most of the time, NSAIDs are safe to use and do not cause any side effects. However, if NSAIDs are taken over long periods of time, they can damage the protective mucus lining in your stomach, resulting in a peptic ulcer

Due to the risk of getting peptic ulcers, it is usually recommended that you do not use NSAIDs if you currently have a peptic ulcer, or if you have had one in the past.

Other medications

Other medications (as well as NSAIDs) have been known to cause peptic ulcers in a small number of people. These include:

  • corticosteroids - which are often used to treat inflammation and auto-immune conditions (conditions where the immune system attacks healthy tissue),
  • bisphosphonates - used to treat osteoporosis (a condition that causes thinning and weakening of the bones),
  • potassium chloride - used to treat low levels of potassium in the blood (hypokalaemia), and
  • some chemotherapy medications.

 

Glossary

Aches
An ache is a constant dull pain in a part of the body.
Ulcer
An ulcer is a sore break in the skin, or on the inside lining of the body.
Pain
Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.
Enzyme
Enzymes are proteins that speed-up and control chemical reactions, such as digestion, in the body.
Blood
Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.
Bacteria
Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and some others are good for you.
Stomach
The sac-like organ of the digestive system. It helps digest food by churning it and mixing it with acids to break it down into smaller pieces.
Inflammation
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
Anti-Inflammatory
Anti-inflammatory medicines reduce swelling and inflammation.
Genetic
Genetic is a term that refers to genes- the characteristics inherited from a family member.

Does H pylori cause cancer?

H pylori is associated with a very slightly increased risk of stomach cancer. However, treating H pylori for this reason alone is not recommended. The risk of any of us getting stomach cancer is small and no one knows whether treating H pylori will actually reduce your risk of developing stomach cancer.

Page last reviewed: 13/07/2011

Although your doctor may suspect an ulcer based on what you tell them about your symptoms, you'll need a test to confirm the diagnosis.

Endoscopy

The most accurate way of confirming a peptic ulcer is by endoscopy. This hospital procedure involves passing a flexible, thin tube (endoscope) through the mouth, down the gullet and into the stomach and duodenum. The views obtained by endoscopy are so good that your doctor will be able to confirm or exclude an ulcer without further tests.

While carrying out an endoscopy, the specialist may take a tissue sample from your stomach or duodenum. The sample can be tested for Helicobacter pylori (H pylori) at the same time that the procedure is carried out.

Diagnosing H pylori infection

If your GP thinks that your symptoms may be due to an H pylori infection, you may need to have several tests:

  • A urea breath test - you are given a special drink that contains a chemical that is digested by H pylori. The amount of carbon dioxide on your breath indicates whether or not you have H pylori infection. 
  • A stool antigen test - a pea-sized stool sample (faeces) is tested for H pylori bacteria.
  • A blood test - where a sample of your blood is tested for antibodies to the H pylori bacteria. Antibodies are proteins that help fight infection and are produced naturally in your blood.

If you test positive for H pylori, you will need to have treatment to clear the infection and to allow your peptic ulcer to heal (see the 'treatment' section).

Glossary

Ulcer
An ulcer is a sore break in the skin, or on the inside lining of the body.
Blood test
During a blood test, a sample of blood is taken from a vein using a needle, so it can be examined in a laboratory.
Antibodies
Antibodies and immunoglobins are proteins in the blood. They are produced by the immune system to fight against bacteria, viruses and disease.
Biopsy
A biopsy is a test that involves taking a small sample of tissue from the body so it can be examined.
Blood
Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.
Stomach
The sac-like organ of the digestive system. It helps digest food by churning it and mixing it with acids to break it down into smaller pieces.
Faeces
Stool (also known as faeces) is the solid waste matter that is passed from the body as a bowel movement.

Page last reviewed: 13/07/2011

Your treatment plan

Your treatment plan will be determined by whether your peptic ulcer is due to a H. pylori infection or the use of non-steroidal anti-inflammatory drugs (NSAIDs) or, in some cases, by a combination of H. pylori infection and NSAIDs.

If your peptic ulcer is caused by a H. pylori infection, the recommended treatment plan is a course of antibiotics to kill the bacteria. This is known as eradication therapy.

If your peptic ulcer is caused by NSAIDs, and you do not have a H. pylori infection, your recommended treatment plan is a 1-2 month course of proton pump inhibitors (PPIs). Your use of NSAIDs will also need to be reviewed. For example, an alternative painkiller, such as paracetamol, may be recommended.

If it is thought that your peptic ulcer is caused by a combination of NSAID use and H. pylori infection, you will been given a two month dose of PPIs, followed by a course of eradication therapy.

An alternative medication called H2-receptor antagonists can be used in people who fail to respond to treatment with PPIs.

Eradication therapy

Eradication therapy involves taking a combination of three different antibiotics. A combination is used just in case the bacteria have evolved a resistance to one or more of the antibiotics.

You will usually be asked to take each antibiotic twice a day for seven days. The antibiotics that are normally used in eradication therapy are:

  • amoxicillin,
  • clarithromycin, and
  • metronidazole.

The side effects of these antibiotic are usually mild and include:

  • nausea,
  • vomiting,
  • diarrhoea, and
  • a metallic taste in the mouth.

All three antibiotics can make oral contraception ('the pill') work less effectively so you should use an alternative method of contraception during treatment and for seven days after treatment.

Some people who are taking metronidazole find that they experience unpleasant reactions if they drink alcohol such as:

  • hot and flushed skin, and
  • increased breathing and/or heart rate.

It is therefore usually recommended that you avoid drinking alcohol while taking metronidazole.

You will be re-tested at least four weeks after eradication therapy has been completed to see whether there is any H. pylori bacteria left in your stomach and intestines. If there is, you will be given a further course of eradication therapy using a different mixture of antibiotics in combination with PPIs.

Proton pump inhibitors (PPIs)

Proton pump inhibitors (PPIs) work by blocking the actions of proteins called proton pumps, which are partially responsible for producing stomach acid. Reducing the amount of stomach acid prevents any further damage to your peptic ulcer, allowing it to heal naturally.

The two most commonly used PPIs in the treatment of peptic ulcers are lansoprazole and omeprazole.

Side effects of PPIs are generally mild and include:

  • headache,
  • diarrhoea,
  • nausea,
  • abdominal pain,
  • constipation,
  • dizziness, and
  • skin rashes.

The side effects should pass once treatment has been completed.

H2-receptor antagonists

H2-receptor antagonists work by blocking the actions of a protein called histamine which is also responsible for stimulating the production of acid.

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

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

  • diarrhoea,
  • headaches,
  • dizziness,
  • skin rashes, and
  • tiredness.

Antacids and alginates

All of the treatments discussed above can take several weeks to become effective, so it is likely that your GP will recommend some additional medication to help provide short-term relief from your symptoms.

Two types of medication that can be used are:

  • antacids - to neutralise stomach acid on a short-term basis, and
  • alginates - which produce a protective coating on the lining of your stomach.

Both antacids and alginates are over-the-counter (OTC) medications that are available from pharmacists. The pharmacist will be able to advise you about which particular types of antacid and alginate are most suitable for you.

Antacids are best taken when you experience symptoms, or when symptoms are expected, such as after meals, or at bedtime.

Alginates are best taken after meals.

Side effects for both medications are uncommon but include:

  • diarrhoea,
  • vomiting, and
  • flatulence (wind).

Reviewing NSAID use

If your peptic ulcer has been caused by taking NSAIDs, your GP will want to review your use of NSAIDs.

You will usually be advised to use an alternative painkiller that is not linked to peptic ulcers, such as paracetamol, or a low-dose opiate-based painkiller.

If you are taking aspirin to reduce your risk of blood clots, you have a number of possible options:

  • stop taking aspirin to allow the ulcer to heal, and then combine aspirin with a PPI, which will help counteract the negative effects of aspirin, or
  • switch to an alternative anti-clotting medication called clopodogrel.

If you (or your GP) feel that the continued used of NSAIDs is absolutely necessary, you will be prescribed a long-term dose of a PPI, or H2-receptor antagonist.

It is important to understand the potential drawbacks and risks that are associated with continued NSAID use. You are more likely to develop another peptic ulcer and the risks of experiencing serious complications, such as internal bleeding, are higher.

 

 

 

Glossary

Antibiotics
Antibiotics are medicines that can be used to treat infections caused by micro-organisms, usually bacteria or fungi. For example amoxicillin, streptomycin and erythromycin.
Brain
The brain controls thought, memory and emotion. It sends messages to the body controlling movement, speech and senses.
Ulcer
An ulcer is a sore break in the skin, or on the inside lining of the body.
Blood vessels
Blood vessels are the tubes in which blood travels to and from parts of the body. The three main types of blood vessels are veins, arteries and capillaries.
Blood
Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.
Dose
Dose is a measured quantity of a medicine to be taken at any one time, such as a specified amount of medication.
Bacterium
Bacteria are tiny, single-celled organisms that live in the body. Some can cause illness and disease and some others are good for you.
Stomach
The sac-like organ of the digestive system. It helps digest food by churning it and mixing it with acids to break it down into smaller pieces.
Anti-Inflammatory
Anti-inflammatory medicines reduce swelling and inflammation.
Allergic
An allergen is a substance that reacts with the body's immune system and causes an allergic reaction.
Blood transfusion
A blood transfusion involves transferring blood into a person using a tube that goes directly into a vein in the arm.

Page last reviewed: 13/07/2011

Internal bleeding

If a peptic ulcer develops near the site of a blood vessel, it can damage the vessel and cause bleeding. Internal is one of the most common complications of a peptic ulcer occurring in between 15-20% of cases.

Risk factors for bleeding include:

  • continued use of non-steroidal anti-inflammatory drugs (NSAIDs), and
  • being 60 years of age, or over.

Depending on the site and type of the blood vessel, this could cause moderate but long-term bleeding which can lead to anaemia (a condition where the body does not have enough oxygen-carrying red blood cells).

Symptoms of anaemia include:

  • fatigue,
  • breathlessness (dyspnoea),
  • pale skin, and
  • irregular heart beats.

Alternatively, the bleeding can be rapid and massive, causing you to:

  • vomit blood, and/or
  • pass stools that are very dark or tar-like.

If the bleeding is moderate, it can usually be treated by giving you injections of proton pump inhibitors (PPIs). Research has found that lowering the amount of acid around the site of the bleeding makes the blood more likely to clot so that the bleeding will stop.

Massive bleeding can be treated using blood transfusions to replace any blood loss. Surgery can be used to repair the blood vessels.

Once you are in a stable condition, an endoscopy will be carried out to determine whether there is a high risk of the bleeding recurring. If your risk is thought to be high, you will be given a further course of eradication therapy and PPIs.

Perforation

Perforation means that the ulcer has eaten through all of your stomach lining. It occurs in an estimated 2-10% of all cases.

Perforation is potentially very serious because bacteria that live in your stomach can move out of your stomach and infect the lining of your abdomen (peritoneum). This is known as peritonitis.

Peritonitis is a medical emergency because tissue of the peritoneum is usually sterile (germ-free) so unlike other parts of the body, such as the skin, it does not have an inbuilt defence mechanism for fighting off infection.

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, if left untreated, death.

The most common symptom of peritonitis is the sudden onset of abdominal pain that then gets steadily worse.

Peritonitis requires admission to hospital where you will be treated with injections of antibiotics to get rid of the infection. Surgery is then used to seal the hole in the stomach wall.

Gastric obstruction

In some cases, a peptic ulcer can produce inflammation (swelling) and /or scar tissue that can obstruct the normal passage of food through your digestive system. This is known as gastric obstruction. Gastric obstruction occurs in an estimated 5-8% of cases of peptic ulcers.

Symptoms of gastric obstruction include:

  • repeated episodes of vomiting, with large amounts of vomit that contain undigested food,
  • a persistent feeling of bloating, or fullness,
  • feeling very full after eating less food than usual, and
  • unexplained weight loss.

If a diagnosis of gastric obstruction is suspected, an endoscopy will be used to determine the type and site of the obstruction.

If the obstruction is due to inflammation, PPIs or H2-receptor antagonists can be used to reduce the inflammation.

If the obstruction is due to scar tissue, surgery will be required to treat it. One option is to pass a small balloon through an endoscope and then inflate it in order to widen the site of the obstruction.

In more severe cases of scarring, it may be necessary to surgically remove the affected section of stomach, before and reattaching the remainder of the stomach.

Page last reviewed: 13/07/2011

You can reduce your risk of developing an ulcer or relieve the severity of your symptoms by making some changes to your lifestyle:

  • Cut down on the amount of coffee and tea you drink. This can increase the amount of acid your stomach produces. Try herbal teas instead.
  • Drink milk and eat milk-based foods, such as yoghurt and cheese. Milk is thought to coat the stomach and neutralise the effects of stomach acid.
  • Lose any extra weight you are carrying.
  • Eat little and often. This could help reduce the build-up of stomach acid between meals.
  • Ask your GP for advice about other medicines if you're very sensitive to aspirin and other NSAIDs.
  • Limit your intake of alcohol. Too much alcohol can irritate the areas of inflammation in your stomach. 
  • Avoid spicy or excessively rich foods if they make your symptoms worse.
  • Quit smoking. It can put you at greater risk of developing an ulcer and impede your recovery.


Stress can cause your stomach to produce more acid. This won't necessarily cause an ulcer, but it can make your symptoms worse. Try these tips for de-stressing:

  • If you find yourself becoming angry or upset, take time out, even if only for five minutes. Relax your muscles and calm yourself by slow, deep breathing. 
  • Identify the underlying causes of your stress. Are you taking on too much? Are there things you're doing that could be handed over to someone else? 
  • Make time to relax. Saying 'I just can't take the time off' is no use if you're forced to take time off later through ill health. 
  • Sleeping problems are common when you're suffering from stress, but try not to take sleeping pills for longer than a night or two. 
  • Enjoy yourself. Have some fun and reward yourself for positive actions, attitudes and thoughts.

 

Page last reviewed: 13/07/2011

Indigestion is a common symptom of peptic ulcers. If you have a peptic ulcer, you may often experience pain in your upper abdomen or lower chest, which may even wake you up at night. It's also possible to have frequent bouts of indigestion after your peptic ulcer has been treated and has healed.

The following advice may help to ease your indigestion:

Stop smoking

If you have a peptic ulcer, smoking can impair the healing process.

The chemicals that you inhale when smoking may also contribute to your indigestion. These chemicals can cause the muscles that separate your oesophagus (gullet) from your stomach to relax, allowing stomach acid to leak back up into your gullet more easily (acid reflux).

As well as helping to cause indigestion, smoking increases your risk of developing lung cancer, chronic obstructive pulmonary disease (COPD), chronic bronchitis (infection of the main airways of the lungs), emphysema (damage of the small airways of the lungs), heart disease and stroke.

Diet and alcohol

You should avoid any food and drink that makes your indigestion symptoms worse. For example, this may mean eating less rich, spicy and fatty foods, and cutting down on drinks that contain caffeine, such as tea, coffee and cola. You should also avoid drinking alcohol if it is aggravating your indigestion symptoms and making them worse.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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