how a peptic ulcer develops

Your stomach produces acid to help you digest food. The lining of your stomach and first part of your small bowel (duodenum) have a layer of mucus that protects them from the acid. If this protection mechanism doesn't work properly, the acid can eat into your stomach lining and cause an ulcer.

Stomach (gastric) ulcers and small bowel (duodenal) ulcers are collectively known as peptic ulcers.
Stomach ulcers can affect people of any age, but they are more common as you get older. They affect men and women equally.
The size of peptic ulcers can vary from millimetres (mm) to several centimetres (cm) across.

Symptoms of peptic ulcers

If you have a peptic ulcer, you may not have any symptoms at all. However, you may have pain in your abdomen (tummy), just below your breastbone (sternum). This pain is often described as burning or gnawing and may extend to your back. It usually comes on after eating – often one to two hours after a meal – and may come and go for several days or weeks. The pain may wake you at night.
Other symptoms may include:

• heartburn
• a poor appetite
• feeling bloated
• feeling sick or vomiting
• burping

It's important to see your GP if you have:

• difficulty swallowing food (similar to having indigestion)
• lost weight without dieting
• seen blood in your vomit or bowel movements
• sudden, severe abdominal pain

However, these symptoms may be caused by problems other than a peptic ulcer.

Complications of peptic ulcers

Possible complications of a peptic ulcer include the following.

• Bleeding. Occasionally ulcers can cause the lining of your stomach or small bowel to bleed. If this happens suddenly, you may vomit blood, which may be bright red or look like coffee grains (dark brown bits of clotted blood). You might also have dark faeces that look like tar and have a strong odour.
• Anaemia. If the bleeding from the ulcer is slow, you may develop anaemia – where you have too few red blood cells or not enough haemoglobin in your blood.
• Perforation. Rarely, the ulcer may develop deep in your stomach wall or small bowel and make a hole into your abdomen. This is called perforation – it causes severe pain and you will need emergency surgery.
• Pyloric stenosis. This can result if you have a peptic ulcer that causes long-term inflammation in the lining of your stomach or small bowel. It causes the small passage called the pylorus, which links your stomach and the first part of your small bowel, to narrow. The main symptom of pyloric stenosis is vomiting.

Causes of peptic ulcers

Helicobacter pylori (H. pylori) infection

The most common cause of peptic ulcers is a stomach infection caused by a bacterium called Helicobacter pylori (H. pylori). This infection is quite common – it’s estimated that about half of the world's population is infected, but it doesn't always cause illness.

H. pylori can cause inflammation in the lining of your stomach. Inflammation is when part of your body reacts to an infection or injury, which causes it to become swollen, hot, red and/or painful. The inflammation reduces the layer of mucus that protects your stomach and small bowel from stomach acid, and causes an ulcer. If the H. pylori infection is in the upper part of your stomach, it can cause more acid to be produced. This can overload the protective layer of mucus and cause an ulcer.

Non-steroidal anti-inflammatory drugs

The second most common cause of peptic ulcers is a type of medicine called non-steroidal anti-inflammatory drugs (NSAIDs). Examples of these medicines include aspirin, ibuprofen, naproxen and diclofenac. Most people can take these safely, but sometimes if you take NSAIDs over a long period of time, they can damage the mucus lining in your stomach and cause a peptic ulcer.

Other causes

If you smoke, any peptic ulcers you have may get worse and heal more slowly. You may also be more at risk if other people in your family have had ulcers. However, this is probably due to H. pylori passing from one family member to another rather than an inherited risk.
It was previously thought that stress could cause a peptic ulcer. However, stress is now only considered to be important if it's the result of a major operation or trauma.

Diagnosis of peptic ulcers

Your GP will ask about your symptoms and examine you. He or she may also ask you about your medical history. If your doctor thinks you may have a peptic ulcer, he or she may recommend some of the following tests.

H. pylori test

As H. pylori is the most common cause of a peptic ulcer, your GP may test you for the bacterium and, if necessary, prescribe medicines to treat the infection.
The most common test for H. pylori is to have a blood test. Alternatively a sample of your faeces will be sent to a laboratory to test for H. pylori.

H. pylori can also be detected in a urea breath test. You will be asked to swallow a liquid containing a substance called urea that is broken down by H. pylori to produce water and carbon dioxide. Your breath will then be tested using a machine to see how much carbon dioxide is in it. If the carbon dioxide is over a certain level, H. pylori is present.

Endoscopy

If you have a suspected peptic ulcer, your GP may arrange for you to have a gastrointestinal endoscopy (also called a gastroscopy). An endoscopy is a test that allows a doctor to look at the inside of your body. The test is done using a narrow, flexible, tube-like telescopic camera called an endoscope that is passed through your mouth and into your stomach and duodenum.
Your doctor will be able to see the lining of your stomach and can take a sample of your stomach lining at the same time. This sample will either be sent to a laboratory and examined under a microscope, or directly tested for H. pylori.
Not everyone who has abdominal pain needs an endoscopy, so your doctor may use one of the other tests first. However, endoscopy is the only way to be certain whether or not you have a peptic ulcer.

Treatment of peptic ulcers

Self-help

There are lifestyle changes that you can make to help your ulcers heal and prevent them coming back. These include:

• not having food and drink that gives you more severe symptoms, such as spicy foods and alcohol
• stopping smoking
• not taking painkillers that are likely to cause ulcers in the future – your GP or pharmacist can give you advice on other medicines you can take instead

Medicines

Your GP may advise you to take over-the-counter medicines called antacids, which can help to ease some of the discomfort of having a peptic ulcer.
There are two main groups of medicines used to treat peptic ulcers. These are:

• proton pump inhibitors, such as omeprazole and lansoprazole
• H2-blockers – examples include ranitidine and cimetidine

Both types of medicine will reduce acid production in your stomach, allowing your ulcer to heal. They can both be used long-term to prevent your ulcer coming back.
These medicines will relieve your symptoms and within four to eight weeks your ulcer will heal. However, once you stop taking the medicine, your ulcer may come back unless the H. pylori infection is treated.
If your peptic ulcer is caused by taking NSAIDs, it’s important to follow your GP’s advice and continue taking your medicine until told otherwise.

Treating H. pylori infection

If tests confirm that you have H. pylori, you will be prescribed medicines to treat it. This is usually a combination of a proton pump inhibitor and two antibiotics that you take for seven days. Treating the H. pylori infection should allow your ulcer to heal and prevent it from coming back. Your GP will test you again about four weeks later to make sure the infection has gone.
Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your pharmacist or GP for advice.

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