Overview

Stomach ulcers, also known as gastric ulcers, are sores that develop on the lining of the stomach.

You can also get ulcers in part of the intestine just beyond the stomach, which are called duodenal ulcers.

Stomach ulcers and duodenal ulcers (sometimes called peptic ulcers) cause the same symptoms and treatment for both is the same.

Signs and symptoms

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

But stomach ulcers aren't always painful and some people may experience other symptoms, such as indigestion, heartburn and acid reflux and feeling sick.

When to seek medical advice

You should visit your GP if you think you may have a stomach ulcer.

Contact your GP or NHS 111 Wales immediately if:

• you are passing dark, sticky, tar-like stools
• you have a sudden, sharp pain in your tummy that gets steadily worse

Go to your nearest accident and emergency (A&E) department or call 999 if:

• you are vomiting blood – the blood can appear bright red or have a dark brown, grainy appearance, similar to coffee grounds

These could be a sign of a serious complication, such as internal bleeding.

Causes of stomach ulcers

Stomach ulcers occur when there's damage to the layer that protects the stomach lining from the acids in your stomach.

This is usually a result of:

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

It used to be thought that stress or certain foods might cause stomach ulcers, but there's little evidence to suggest this is the case.

Stomach ulcers can affect anyone but are more common in people aged 60 or over. Men are more affected than women.

How stomach ulcers are treated

Treatment will depend on what caused the ulcer.

Most people will be prescribed a medication called a proton pump inhibitor (PPI) to reduce the amount of acid in their stomach.

You’ll also need antibiotics if your ulcers were caused by a H. pylori infection.

Stomach ulcers can come back after treatment, although this is less likely to happen if the underlying cause is addressed.

Possible complications

Complications of stomach ulcers are relatively uncommon, but they 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 splitting open (perforation)
• the ulcer blocking the movement of food through the digestive system (gastric obstruction)

Symptoms

The most common symptom of a stomach ulcer is a burning or gnawing pain that develops in your abdomen (tummy).

Not all stomach ulcers are painful. Some may only be noticed if there's a complication of a stomach ulcer, such as bleeding from the ulcer.

Tummy pain

The pain caused by a stomach ulcer often feels like a burning pain in your tummy.

It can last from a few minutes to a few hours, and often starts within a few hours of eating. You may also wake up in pain during the night.

Taking antacids (indigestion medicines) may relieve the pain temporarily, but it'll keep coming back if the ulcer isn't treated.

Other symptoms

Less common symptoms of a stomach ulcer can include:

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

Some people also find they burp or become bloated after eating fatty foods.

When to seek medical advice

Visit a GP if you experience persistent symptoms of a stomach ulcer.

Contact a GP or NHS 111 Wales immediately if:

• you are passing dark, sticky, tar-like stools
• you have a sudden, sharp pain in your tummy that gets steadily worse

Go to your nearest accident and emergency (A&E) department or call 999 if:

• you are vomiting blood – the blood can appear bright red or have a dark brown, grainy appearance, similar to coffee grounds

If you're not sure that you have a stomach ulcer, see other causes of stomach ache.

Who can get it

Stomach ulcers are usually caused by an infection of Helicobacter pylori (H. pylori) bacteria, or from taking anti-inflammatory medicines (NSAIDs), such as ibuprofen and aspirin.

These can break down the stomach's defence against the acid it produces to digest food, allowing the stomach lining to become damaged and an ulcer to form.

H. pylori bacteria

It’s common to have a H. pylori infection, and it’s usually harmless for most people.

But sometimes it causes ulcers in the stomach (gastric ulcer) or in the duodenum (duodenal ulcer).

It's not clear exactly why some people are more affected than others.

Anti-inflammatory medicines (NSAIDs)

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

Commonly used NSAIDs include:

• ibuprofen
• aspriin
• naproxen
• diclofenac

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

You may be advised not to use NSAIDs if you currently have a stomach ulcer or if you have had one in the past.

Paracetamol can often be used as an alternative painkiller, as it's generally considered safer.

Lifestyle factors

There's little evidence that some lifestyle factors, like spicy foods, stress and alcohol, cause stomach ulcers. But they may make your symptoms worse.

It's thought that smoking increases your risk of developing stomach ulcers and may make treatment less effective.

Diagnosis

Treatment

Treatment for your stomach ulcer will depend on what caused it. With treatment, most ulcers heal in a few months.

If your stomach ulcer is caused by an H. pylori bacterial infection, a course of antibiotics and a medication called a proton pump inhibitor (PPI) is recommended.

This is also recommended if it's thought that your stomach ulcer is caused by a combination of an H. pylori infection and taking non-inflammatory medicines (NSAIDs).

 If your stomach ulcer is just caused by taking NSAIDs, a course of PPI medication is recommended.

An alternative type of medication, known as H2-receptor antagonists, is occasionally used instead of PPIs.

Sometimes you may be given additional medication called antacids to relieve your symptoms in the short term.

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

There aren't any special lifestyle measures you need to take during treatment, but avoiding stress, alcohol, spicy foods and smoking may reduce your symptoms while your ulcer heals.

Antibiotics

If you have an H. pylori infection, you'll usually be prescribed a course of 2 antibiotics, which each need to be taken twice a day for a week.

The antibiotics most commonly used are amoxicillin, clarithromycin and metronidazole.

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

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

You will be 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, you may need a course of different antibiotics.

Proton pump inhibitors (PPIs)

PPIs work by reducing the amount of acid your stomach produces, preventing further damage to the ulcer as it heals naturally. They're usually prescribed for 4 to 8 weeks.

Omeprazole, pantoprazole and lansoprazole are the PPIs most commonly used to treat stomach ulcers.

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

• headache
• diarrhoea or constipation
• feeling sick
• stomach ache
• dizziness
• rashes

These should pass once treatment has been completed.

H2-receptor antagonists

Like PPIs, H2-receptor antagonists work by reducing the amount of acid your stomach produces.

H2-receptor antagonists, such as famotidine, are often used to treat stomach ulcers.

Side effects are uncommon, but may include:

• diarrhoea
• headaches
• dizziness
• rashes
• tiredness

Antacids and alginates

Treatments can take several hours before they start to work, so your GP may recommend taking additional antacid medication to neutralise your stomach acid quickly and relieve symptoms in the short term.

Some antacids also contain a medicine called an alginate, which produces a protective coating on the lining of your stomach.

These medications are available to buy over the counter at pharmacies. Your pharmacist can advise on which is most suitable for you.

Antacids should be taken when you experience symptoms or when you expect them, such as after meals or at bedtime.

Antacids containing alginates are best taken after meals.

Side effects of both medications are usually minor and can include:

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

Advice on taking NSAIDs

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

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

Sometimes, an alternative type of NSAID that's less likely to cause stomach ulcers, called a COX-2 inhibitor, may be recommended.

If you are taking low-dose aspirin (an NSAID) to reduce your risk of embolism (blood clots), your GP will tell you whether you need to continue taking it.

If you do need to keep taking it, long-term treatment with a PPI or H2-receptor antagonist may be prescribed alongside the aspirin, to try 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.

Complications

Complications of stomach ulcers are relatively uncommon, but they can be very serious if they happen.

Internal bleeding

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

The bleeding can either be:

• slow, long-term bleeding, leading to anaemia – causing fatigue, shortness of breath, pale skin and heart palpitations (noticeable heartbeats)
• rapid and severe bleeding – causing you to vomit blood or pass stools that are black, sticky and tar-like

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

Contact your GP or NHS 111 Wales immediately, or go to your nearest accident and emergency (A&E) department, if you have symptoms of more severe bleeding.

Treating internal bleeding

An gastroscopy will be used to identify the cause of the bleeding and treatment can often be given during the endoscopy to stop the bleeding.

Sometimes, specialised procedures carried out under X-ray guidance are used to stop bleeding ulcers, although surgery may occasionally be required to repair the affected blood vessel.

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

Perforation

A rarer complication of stomach ulcers is the lining of the stomach splitting open, known as perforation.

This can be very serious because it enables the bacteria that live in your stomach to escape and infect the lining of your abdomen (peritoneum). This is known as 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 that gets steadily worse.

If you have this type of pain, contact your GP immediately. If this isn't possible, call NHS 111 Wales.

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

Gastric outlet obstruction

In some cases, an inflamed (swollen) or scarred stomach ulcer can stop food from going through your digestive system. This is known as gastric outlet obstruction.

Symptoms can 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
• unintentional weight loss

An gastroscopy 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 goes down.

If the obstruction is caused by scar tissue, surgery may be needed to treat it, although it can sometimes be treated by passing a small balloon through an endoscope and inflating it to widen the site of the obstruction.