Peptic Ulcer: Symptoms, Causes & Complete Treatment Guide

What Is a Peptic Ulcer?

A peptic ulcer is an open sore that forms in the lining of the stomach or duodenum when stomach acid and digestive enzymes damage the protective mucous layer. The two main types are gastric ulcers (in the stomach) and duodenal ulcers (in the small intestine). Peptic ulcer disease affects approximately 4% of the global population.

The stomach produces approximately two liters of highly acidic gastric juice every day. This gastric juice contains hydrochloric acid and the enzyme pepsin, which are essential for breaking down proteins in food. The hydrochloric acid is so strong that it can damage tissue, but the stomach protects itself by producing a thick layer of mucus that coats the inner lining. When this protective barrier is compromised, the acid can erode the stomach or duodenal wall, creating an ulcer.

The balance between protective factors (mucus, bicarbonate, blood flow) and aggressive factors (acid, pepsin, H. pylori, NSAIDs) determines whether an ulcer forms. When something disrupts this balance—such as a bacterial infection or certain medications—the aggressive factors overwhelm the protective mechanisms, and the lining becomes damaged. This damage typically develops over several weeks.

Duodenal ulcers are more common than gastric ulcers, accounting for approximately 70-80% of all peptic ulcers. They tend to occur in younger individuals and have a lower risk of malignancy. Gastric ulcers, while less common, require more careful monitoring because stomach cancer can sometimes present with similar symptoms and appearance.

Types of Peptic Ulcers

Understanding the different types of peptic ulcers helps in both diagnosis and treatment planning. Each type has distinct characteristics, risk factors, and clinical implications that guide medical decision-making.

• Gastric ulcer (K25): Forms in the stomach lining, more common in older adults, requires biopsy to rule out cancer
• Duodenal ulcer (K26): Forms in the first part of the small intestine, often associated with H. pylori, very rarely malignant
• Esophageal ulcer: Less common, usually caused by acid reflux or certain medications
• Meckel's diverticulum ulcer: Rare, occurs in a congenital pouch in the small intestine

What Are the Symptoms of a Peptic Ulcer?

The most common symptom of a peptic ulcer is a burning or gnawing pain in the upper abdomen (epigastric region), typically occurring between meals or at night. Other symptoms include nausea, bloating, feeling full quickly, heartburn, and unexplained weight loss. Symptoms may come and go in cycles lasting days to weeks.

Peptic ulcer symptoms can vary significantly between individuals. Some people with ulcers experience no symptoms at all—these are called "silent ulcers" and are often discovered incidentally during tests for other conditions. However, most people with peptic ulcers experience some degree of abdominal discomfort that affects their quality of life and eating patterns.

The characteristic pain of a peptic ulcer is typically described as a burning, gnawing, or hunger-like sensation in the upper middle portion of the abdomen, between the navel and breastbone. This area is medically known as the epigastric region. The pain often has a distinctive pattern: it may worsen when the stomach is empty and improve temporarily after eating or taking antacids, only to return later. For duodenal ulcers, pain often occurs 2-3 hours after meals and may wake patients at night, while gastric ulcer pain may be triggered or worsened by eating.

The episodic nature of peptic ulcer symptoms is another hallmark feature. Many patients report periods of symptoms lasting days to weeks, followed by symptom-free intervals that can last weeks to months. This pattern can make diagnosis challenging and may lead patients to dismiss their symptoms as "just indigestion."

Common Symptoms

The following symptoms are frequently reported by patients with peptic ulcers. While none of these symptoms alone confirms an ulcer diagnosis, their combination—particularly the characteristic pain pattern—should prompt medical evaluation.

• Burning or gnawing upper abdominal pain – the hallmark symptom, often described as "hunger pain"
• Pain between meals or at night – stomach acid without food to buffer it irritates the ulcer
• Pain relieved by eating or antacids – food and antacids temporarily neutralize acid
• Nausea and vomiting – the stomach may try to expel contents that irritate the ulcer
• Bloating and belching – gas production increases with altered digestion
• Feeling full quickly (early satiety) – especially common with gastric ulcers
• Heartburn – acid may reflux into the esophagus
• Loss of appetite – especially if eating triggers or worsens pain
• Unexplained weight loss – due to reduced food intake or impaired absorption

Bleeding and Perforated Ulcers

Peptic ulcers can develop serious complications that require immediate medical attention. A bleeding ulcer occurs when the ulcer erodes into a blood vessel in the stomach or duodenal wall. A perforated ulcer is even more dangerous—this occurs when the ulcer creates a hole completely through the wall, allowing stomach contents to leak into the abdominal cavity. Both complications can be life-threatening without prompt treatment.

Bleeding from a peptic ulcer can range from slow, chronic blood loss (causing anemia over time) to rapid, severe hemorrhage that causes shock. The blood that enters the digestive tract undergoes chemical changes as it passes through, which affects its appearance. Fresh blood in vomit appears red, while blood that has been partially digested in the stomach looks like dark coffee grounds. Blood in stool that has passed through the entire digestive tract turns black and tarry (melena).

Symptoms That May Indicate Other Conditions

Many people experience upper abdominal discomfort without having a peptic ulcer. Conditions like functional dyspepsia (sensitive stomach), irritable bowel syndrome (IBS), and gastroesophageal reflux disease (GERD) can produce similar symptoms. Additionally, a gastric ulcer can sometimes have symptoms that overlap with gastric cancer, which is why gastric ulcers always require endoscopic follow-up to ensure complete healing. Duodenal cancer is extremely rare, so duodenal ulcers carry much less concern for malignancy.

What Causes Peptic Ulcers?

The two main causes of peptic ulcers are Helicobacter pylori (H. pylori) bacterial infection, responsible for 60-90% of ulcers, and regular use of NSAIDs (non-steroidal anti-inflammatory drugs) like ibuprofen and aspirin. Contrary to popular belief, stress and spicy foods do not cause ulcers, though they may aggravate symptoms.

For decades, peptic ulcers were blamed on stress, spicy foods, and an overly anxious personality. This belief was so widespread that ulcer patients were advised to reduce stress, eat bland diets, and even undergo psychotherapy. The medical community's understanding was revolutionized in 1982 when Australian researchers Barry Marshall and Robin Warren discovered that a bacterium called Helicobacter pylori was the primary cause of most peptic ulcers. This discovery, which earned them the Nobel Prize in Medicine in 2005, transformed ulcer treatment from lifestyle modification and surgery to a simple course of antibiotics.

Understanding the underlying cause of a peptic ulcer is crucial for effective treatment. An ulcer caused by H. pylori will keep returning unless the bacteria are eradicated with antibiotics. Similarly, an NSAID-induced ulcer will not heal properly if the patient continues taking these medications. The diagnostic process therefore focuses not just on confirming the presence of an ulcer but on identifying its cause.

Helicobacter pylori Infection

H. pylori is a spiral-shaped bacterium that has evolved to survive in the harsh acidic environment of the stomach. It burrows into the mucous layer that protects the stomach lining and produces enzymes that neutralize the surrounding acid, creating a more hospitable microenvironment for itself. This bacterial colonization triggers chronic inflammation (gastritis) that can eventually lead to ulcer formation in susceptible individuals.

What makes H. pylori particularly interesting is that most infected people never develop symptoms or ulcers. Approximately half of the world's population carries H. pylori, yet only 10-20% of infected individuals will ever develop peptic ulcer disease. The reasons why some people develop ulcers while others remain asymptomatic are not fully understood but likely involve a combination of bacterial strain virulence, host genetic factors, and environmental influences.

H. pylori infection is typically acquired in childhood and persists for life unless treated. The bacteria spread through person-to-person contact, likely through oral-oral or fecal-oral routes, and transmission often occurs within families. Infection rates are higher in developing countries and in older generations who grew up before modern sanitation standards. Due to improved hygiene in developed nations, infection rates have been steadily declining, and peptic ulcer disease has become less common.

NSAIDs and Aspirin

Non-steroidal anti-inflammatory drugs (NSAIDs) are the second most common cause of peptic ulcers. These medications, which include ibuprofen (Advil, Motrin), naproxen (Aleve), diclofenac, and aspirin, work by blocking enzymes called cyclooxygenases (COX-1 and COX-2). While this mechanism effectively reduces pain and inflammation, it also has an unintended consequence: COX-1 is responsible for producing prostaglandins that protect the stomach lining. When prostaglandin production is reduced, the stomach becomes more vulnerable to acid damage.

The risk of NSAID-induced ulcers increases with higher doses, longer duration of use, and when multiple NSAIDs are taken together. Combining NSAIDs with certain other medications—particularly corticosteroids, anticoagulants, or selective serotonin reuptake inhibitors (SSRIs)—further increases the risk. Older adults are especially vulnerable to NSAID-related complications.

For people who need regular pain relief, paracetamol (acetaminophen) is a safer alternative that doesn't affect the stomach lining. If NSAIDs must be used, taking them with food or with a proton pump inhibitor (PPI) for protection can reduce ulcer risk.

Other Causes and Risk Factors

While H. pylori and NSAIDs account for the vast majority of peptic ulcers, several other factors can contribute to ulcer development or increase the risk of complications.

• Smoking: Increases ulcer risk, delays healing, and raises the chance of ulcer recurrence. Smokers should quit to promote ulcer healing.
• Alcohol: Heavy alcohol consumption irritates and erodes the stomach lining, increasing acid production and ulcer risk.
• Zollinger-Ellison syndrome: A rare condition where tumors in the pancreas or duodenum produce excessive gastrin, causing severe acid overproduction and multiple ulcers.
• Severe physiological stress: Major trauma, burns, critical illness, or major surgery can cause "stress ulcers" due to reduced blood flow to the stomach lining.
• Radiation therapy: Radiation to the abdomen can damage the stomach lining.
• Idiopathic ulcers: In approximately 5-10% of cases, no clear cause is identified despite thorough testing.

When Should You See a Doctor for Stomach Pain?

See a doctor if you have persistent upper abdominal pain, especially if you're over 50 with new symptoms, experiencing unexplained weight loss, or if symptoms don't improve with over-the-counter antacids. Seek emergency care immediately for vomiting blood, black stools, sudden severe pain, or signs of shock.

Not every episode of stomach pain or indigestion requires a doctor's visit. Occasional mild discomfort after a large meal or during periods of stress is common and usually resolves on its own. However, certain patterns and warning signs should prompt medical evaluation, as they may indicate a peptic ulcer or other serious condition that requires treatment.

The decision to see a doctor often depends on the duration, severity, and pattern of symptoms. Pain that persists for more than a couple of weeks, that consistently occurs at certain times (like at night or between meals), or that is severe enough to interfere with daily activities warrants evaluation. Similarly, if symptoms keep returning despite using over-the-counter remedies, it's time for a proper medical workup.

Schedule a Medical Appointment If:

• You have persistent upper abdominal pain lasting more than 2 weeks
• You're over 50 years old with new stomach symptoms you haven't experienced before
• You're experiencing unexplained weight loss or decreased appetite
• You have a family history of stomach cancer
• Over-the-counter antacids provide only temporary relief
• You've been diagnosed with H. pylori or ulcers in the past and symptoms are returning
• You regularly take NSAIDs or aspirin and develop stomach symptoms

How Is a Peptic Ulcer Diagnosed?

Peptic ulcers are diagnosed primarily through upper endoscopy (EGD), which allows direct visualization of the stomach and duodenum. H. pylori testing is essential and can be done via urea breath test, stool antigen test, or biopsy during endoscopy. Blood tests and imaging may also be used in certain situations.

Diagnosing a peptic ulcer involves two key steps: confirming the presence of an ulcer and identifying its underlying cause. While symptoms can suggest an ulcer, they're not specific enough for definitive diagnosis—many conditions can cause similar symptoms. Therefore, testing is necessary to confirm the diagnosis and guide appropriate treatment.

Your doctor will start by taking a detailed medical history, asking about the nature and pattern of your symptoms, your use of NSAIDs or aspirin, smoking and alcohol habits, and any family history of ulcers or stomach cancer. They'll also perform a physical examination, checking for tenderness in the upper abdomen and signs of complications like anemia or dehydration.

Upper Endoscopy (Gastroscopy/EGD)

Upper endoscopy, also called esophagogastroduodenoscopy (EGD) or gastroscopy, is the gold standard for diagnosing peptic ulcers. During this procedure, a thin, flexible tube with a camera (endoscope) is passed through the mouth and down into the esophagus, stomach, and duodenum. This allows the doctor to directly visualize the lining and identify any ulcers, inflammation, or other abnormalities.

During endoscopy, the doctor can also take tissue samples (biopsies) for several purposes: to test for H. pylori, to check for cell changes that might indicate cancer (especially in gastric ulcers), and to assess the degree of inflammation. The procedure typically takes 10-15 minutes and is usually performed under sedation for comfort.

For gastric ulcers, follow-up endoscopy is always recommended after treatment to confirm the ulcer has healed completely. This is important because gastric cancer can sometimes be mistaken for a benign ulcer. Duodenal ulcers, which very rarely become cancerous, don't typically require repeat endoscopy if symptoms resolve with treatment.

H. pylori Testing

Testing for H. pylori is a crucial part of peptic ulcer diagnosis because the treatment approach differs significantly based on whether the bacteria is present. Several testing methods are available, each with advantages and limitations.

An important consideration is that proton pump inhibitors (PPIs) can cause false-negative results on breath and stool tests. Patients should stop PPIs at least two weeks before these tests to ensure accurate results. Antibiotics should be stopped at least four weeks before testing.

How Are Peptic Ulcers Treated?

Peptic ulcer treatment depends on the cause. H. pylori-related ulcers require triple therapy (two antibiotics plus a PPI for 14 days) achieving 80-90% eradication. NSAID-induced ulcers require stopping the medication and taking acid-reducing drugs. Most ulcers heal within 4-8 weeks with proper treatment.

The goal of peptic ulcer treatment is threefold: relieve symptoms, heal the ulcer, and prevent recurrence. Modern medical treatment is highly effective, and the need for surgery has become rare. Treatment success depends largely on identifying and addressing the underlying cause—whether that's H. pylori infection, NSAID use, or another factor.

Regardless of the cause, all peptic ulcer treatment includes acid suppression to allow the damaged tissue to heal. The stomach's acidic environment constantly aggravates the ulcer, so reducing acid production creates conditions favorable for healing. Proton pump inhibitors (PPIs) are the most effective acid-suppressing medications and are the cornerstone of ulcer treatment.

Treatment for H. pylori-Related Ulcers

When H. pylori is the cause, antibiotics are essential—without eradicating the bacteria, the ulcer will almost certainly return. The standard treatment is called "triple therapy" and consists of a proton pump inhibitor plus two antibiotics taken for 14 days. This combination attacks the bacteria from multiple angles while the PPI both aids healing and enhances antibiotic effectiveness.

The most common triple therapy regimen includes:

• Proton pump inhibitor (omeprazole, esomeprazole, lansoprazole, or similar) – twice daily
• Clarithromycin 500mg – twice daily
• Amoxicillin 1000mg – twice daily (or metronidazole 500mg twice daily if penicillin-allergic)

Taking all medications exactly as prescribed is crucial for success. Missing doses or stopping early can lead to treatment failure and antibiotic resistance. After completing treatment, patients should wait at least 4 weeks before being retested to confirm eradication. This is typically done with a urea breath test or stool antigen test.

If first-line treatment fails, which occurs in 10-20% of cases, second-line "quadruple therapy" is used. This adds bismuth subsalicylate to the regimen and uses different antibiotics. Resistance testing may also be performed to guide antibiotic selection.

Treatment for NSAID-Induced Ulcers

The first step in treating NSAID-induced ulcers is stopping the offending medication. If this isn't possible due to medical necessity (such as for heart disease prevention with aspirin), the patient should take a PPI continuously to protect the stomach while using the lowest effective NSAID dose.

PPI treatment alone typically heals NSAID-induced ulcers within 4-8 weeks. H2 receptor antagonists (like famotidine) can be used as an alternative but are generally less effective than PPIs. Even if H. pylori is not the cause, testing and treating for it is recommended if the patient is positive, as the combination of H. pylori and NSAID use significantly increases ulcer risk.

Medications for Peptic Ulcer Treatment

Surgery and Hospital Treatment

Surgery for peptic ulcers has become rare thanks to effective medical therapy. However, emergency surgery may be necessary for complications that cannot be managed otherwise.

• Perforated ulcer: Requires emergency surgery to close the hole and clean the abdominal cavity. Often done laparoscopically.
• Uncontrolled bleeding: Most bleeding ulcers can be treated endoscopically (clips, cauterization, injection). Surgery is reserved for cases where endoscopic treatment fails.
• Gastric outlet obstruction: Scarring from repeated ulcers can narrow the passage between stomach and duodenum. May require endoscopic dilation or surgery.

Patients with bleeding ulcers or suspected perforation require hospitalization for monitoring, IV fluids, blood transfusion if needed, and possible intervention. Most can be managed with endoscopic treatment and medical therapy, with surgery reserved for those who don't respond to these measures.

How Can You Prevent Peptic Ulcers?

Prevent peptic ulcers by avoiding or limiting NSAID use (use paracetamol instead), not smoking, limiting alcohol, and practicing good hygiene to prevent H. pylori transmission. If you must take NSAIDs long-term, ask your doctor about taking a PPI for protection.

While not all peptic ulcers can be prevented, understanding the risk factors allows you to take steps to reduce your chances of developing one. This is especially important if you've had an ulcer before, as recurrence rates are significant without proper preventive measures.

Medication Safety

If you need pain relief, choose paracetamol (acetaminophen) over NSAIDs like ibuprofen or aspirin whenever possible. Paracetamol is effective for many types of pain and doesn't damage the stomach lining. If you must use NSAIDs:

• Use the lowest effective dose for the shortest time
• Take them with food to reduce stomach irritation
• Avoid combining multiple NSAIDs
• Ask your doctor about taking a PPI for protection if long-term NSAID use is necessary
• Tell your doctor if you've had ulcers before—they may prescribe protective medication

Lifestyle Modifications

Several lifestyle factors can influence ulcer risk and healing:

• Stop smoking: Smoking increases ulcer risk, delays healing, and promotes recurrence. Quitting is one of the most important steps you can take.
• Limit alcohol: Heavy drinking irritates the stomach lining. Moderate consumption or abstinence is advisable, especially during ulcer healing.
• Manage stress: While stress doesn't cause ulcers, it may worsen symptoms. Stress management techniques can improve quality of life.
• Dietary considerations: No specific diet prevents ulcers, but avoiding foods that personally trigger your symptoms makes sense. Eat regular meals rather than letting your stomach stay empty for long periods.

What Are the Complications of Peptic Ulcers?

Peptic ulcer complications include gastrointestinal bleeding (causing vomiting blood or black stools), perforation (creating a hole in the stomach/duodenal wall), and gastric outlet obstruction (scarring that blocks food passage). While uncommon with proper treatment, these complications can be life-threatening.

Complications from peptic ulcers are less common today thanks to effective treatment, but they remain serious when they occur. Recognizing the warning signs and seeking prompt medical attention can be lifesaving.

Bleeding (Hemorrhage)

The most common complication, affecting about 15-20% of ulcer patients at some point. The ulcer erodes into a blood vessel, causing bleeding that can range from slow and chronic to rapid and severe. Chronic slow bleeding causes anemia with symptoms like fatigue, shortness of breath, and pallor. Acute severe bleeding is a medical emergency requiring immediate treatment including endoscopy to stop the bleeding and blood transfusion if necessary.

Perforation

Occurs when the ulcer erodes completely through the stomach or duodenal wall, allowing contents to leak into the abdominal cavity. This causes sudden, severe abdominal pain and peritonitis (inflammation of the abdominal lining). Perforation requires emergency surgery. Warning signs include sudden onset of severe pain, a rigid "board-like" abdomen, and signs of shock.

Gastric Outlet Obstruction

Repeated ulceration and healing can cause scarring that narrows the pylorus (the opening between stomach and small intestine). This makes it difficult for food to pass, causing symptoms like vomiting (often of undigested food), feeling full quickly, and weight loss. Treatment may involve endoscopic balloon dilation or surgery.

Peptic Ulcers and Pregnancy

If you have a peptic ulcer during pregnancy, treatment options are more limited. Proton pump inhibitors like omeprazole are generally considered safe, but H. pylori eradication with antibiotics is usually deferred until after pregnancy and breastfeeding when possible.

Managing peptic ulcers during pregnancy requires balancing the mother's health needs with potential risks to the developing baby. Fortunately, ulcer symptoms often improve during pregnancy due to hormonal changes, but treatment may still be necessary in some cases.

PPIs, particularly omeprazole and lansoprazole, have been used extensively in pregnancy and are generally considered safe. However, the antibiotics used to treat H. pylori are typically avoided during pregnancy unless absolutely necessary, as some may pose risks to fetal development. In most cases, if the ulcer is caused by H. pylori, acid suppression alone is used during pregnancy, with H. pylori eradication deferred until after delivery and breastfeeding.

Pregnant women with known ulcer disease should inform their healthcare providers and discuss safe medication options. As with all medications during pregnancy, the benefits and risks should be weighed carefully.