Ulcers - Stomach

We have selected the following expert medical opinion based on its clarity, reliability and accuracy. Credits: Sourced from the website Patient UK, authored by Dr Colin Tidy (see below). Please refer to your own medical practitioner for a final perspective, assessment or evaluation.

Overview

Stomach ulcers are open sores that develop when the lining of the stomach has become damaged. Stomach ulcers are also called gastric ulcers.

Causes

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 defense 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 Helicobacter pylori

Infection with Helicobacter pylori (also referred to as H. pylori) is the cause in about 8 in 10 cases of stomach ulcer. More than a quarter of people in the UK become infected with H. pylori at some stage in their lives. Once you are infected, unless treated, the infection usually stays for the rest of your life. 

Anti-inflammatory medicines - including aspirin

Anti-inflammatory medicines are sometimes called non-steroidal anti-inflammatory drugs (NSAIDs). There are various types and brands. For example, aspirin, ibuprofen, diclofenac, etc. These medicines sometimes affect the mucous barrier of the stomach and allow acid to cause an ulcer. About 2 in 10 stomach ulcers are caused by anti-inflammatory medicines. 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.

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: 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.

Complications

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.

Diagnosis

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. 
• 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.

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. 

If your ulcer was caused by 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. 

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. In most cases, the test is 'negative' meaning that the infection has gone. If it has not gone then a repeat course of combination therapy with a different set of antibiotics may be advised.

Prognosis

What is the outlook?

For most people with a stomach ulcer, the outlook (prognosis) is excellent. Depending on the cause of the stomach ulcer, treatment of H. pylori infection or avoiding non-steroidal anti-inflammatory medicines greatly reduces the risk of having any more stomach ulcers in the future.

About the author

Dr Colin Tidy

MBBS, MRCGP, MRCP, DCH

Dr Colin Tidy qualified as a doctor in 1983 and he has been writing for Patient since 2004. Dr Tidy has 25 years’ experience as a General Practitioner. He now works as a GP in Oxfordshire, with a special interest in teaching doctors and nurses, as well as medical students.  In addition to writing many leaflets and articles for Patient, Dr Tidy has also contributed to medical journals and written a number of educational articles for General Practitioner magazines.

Recommended websites

For further reading go to:

• Duodenal Ulcers
• Non-ulcer Dyspepsia
• Indigestion / Dyspepsia

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