8 Things to Know About Peptic Ulcers

Many people experience indigestion after a meal. For some, it’s accompanied by a burning or gnawing pain in their stomach. But is that just discomfort or a sign of something more serious, such as a peptic ulcer?

A peptic ulcer, an umbrella term describing an open sore on the lining of your stomach or duodenum (the initial segment of the small intestine), is fairly common. Almost 6% of Americans—or 14.8 million people—are diagnosed with peptic ulcers each year, according to a 2018 National Health Interview Survey conducted by the Centers for Disease Control and Prevention (CDC).

For years, doctors and patients attributed peptic ulcers to stress or spicy foods. However, it’s now known that there are two likelier causes: infection with bacteria called Helicobacter pylori (H. pylori) and/or the long-term, high-dose use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, and naproxen, for pain.

That knowledge—and the fact that you can treat an H. pylori infection and stop taking an NSAID—has contributed to a steady decline in the incidence of peptic ulcers in the United States. However, untreated peptic ulcers can lead to serious complications that require urgent medical attention (more on that below).

“The good news is that most peptic ulcers can be fully cured,” says Kenneth Hung, MD, a Yale Medicine gastroenterologist.

Below, Dr. Hung shares eight things to know about peptic ulcers, including how to identify and best treat them.

A peptic ulcer, or peptic ulcer disease, is an open sore on the lining of the stomach or duodenum. The term "peptic" originates from "pepsin," a primary enzyme in the stomach that combines with stomach acid to form the digestive juices responsible for breaking down food in your stomach and duodenum.

In a healthy digestive system, the entire gastrointestinal (GI) tract is safeguarded from these acidic juices by a layer of mucus, secretions, and compounds that act as a shield. However, in someone with a peptic ulcer, this protective layer is damaged, allowing the digestive juices to erode the lining.

There are different types of peptic ulcers, named for their location in the body. The two most common are stomach (or gastric) ulcers and duodenal ulcers, which occur on the duodenum. However, ulcers can occasionally develop in other parts of the GI tract as well, such as the esophagus (as a result of chronic acid reflux).

The two culprits known to cause the vast majority of ulcers—alone or in combination—weaken and injure the GI tract lining over time, making it vulnerable to damage. They are:

• H. pylori infection: Half of all people worldwide are estimated to have this bacterial infection in their stomach and/or duodenum. Over time, H. pylori can overgrow and disrupt the gut’s microbiota, causing the immune system to release inflammatory cells that injure the stomach lining, leading to an ulcer. The bacteria, which usually does not cause symptoms, is passed from one person to another—usually in childhood—through saliva, vomit, or stool. Although only a minority of people with H. pylori will develop an ulcer, it is thought to be responsible for most peptic ulcers.

• NSAIDs: These over-the-counter medicines reduce pain, fever, and inflammation. But these drugs can also irritate and erode the lining of the stomach and duodenum, making it easier for an ulcer to develop, especially if they are taken in high doses or over an extended period of time.

There are other factors that may cause or exacerbate a peptic ulcer and/or raise the risk of complications (more on that below). They include a variety of other medications, including anticoagulants (blood-thinning medications) and selective serotonin reuptake inhibitors (SSRIs), used for clinical depression.

"There are also rare conditions, such as Zollinger-Ellison syndrome, where people have hormone abnormalities that cause them to secrete too much stomach acid, which leads to ulcers,” Dr. Hung says. “But that's very uncommon.”

This is a difficult question to answer, since about 70% of people with peptic ulcers don't have symptoms, Dr. Hung says.

However, for those with symptoms, the most common ones include upper abdominal pain, with a burning or gnawing sensation, and indigestion; these symptoms typically come and go persistently and may worsen after a meal.

Other symptoms may include bloating, feeling full too quickly during a meal, a loss of appetite, and nausea or vomiting.

When an ulcer is left untreated, complications, such as GI bleeding, a GI perforation (or hole), or a blockage, can develop, and symptoms may be more serious, making medical attention critical.

For instance, if an ulcer erodes into a blood vessel and starts to bleed, it can lead to anemia, or a low red blood cell count, which causes such symptoms as pale skin, lack of energy, and fatigue.

In some cases, an ulcer will bleed rapidly, causing black and sticky or tarry stool, dark red blood mixed with stool, and/or vomit that contains red blood or what looks like coffee grounds. There may be sudden pain, dizziness, and even fainting.

An untreated ulcer can also perforate the wall of the duodenum or stomach, leading to a life-threatening infection (peritonitis) in the abdominal lining, which causes such symptoms as fever, nausea, and vomiting, as well as abdominal pain and tenderness.

And while it’s uncommon, a peptic ulcer can cause swelling and/or scarring that can block the path of food as it moves through the digestive system, which can also cause nausea and vomiting.

Anyone with any of the above-mentioned symptoms should seek urgent medical care by calling 911 or going to a hospital emergency room immediately.

These complications may require surgery. “But these cases are extraordinarily rare, because most people have symptoms before this point, when the ulcer is easier to treat,” Dr. Hung says.

Peptic ulcers are more common with age. “As people get older, the risk for ulcers rises as the number of mucous cells in the body declines, and the stomach secretes less bicarbonate [a chemical compound in the body], which helps to neutralize stomach acid,” Dr. Hung says.

“Cigarette smoking is also associated with a higher risk of peptic ulcers, because it affects the vascular system,” Dr. Hung says. “That can affect how much blood flows to your stomach and small intestine, and that blood flow is necessary to ensure a healthy GI tract.”

Other risk factors include alcohol consumption in high concentrations, which has been found to stimulate acid secretion.

None of these factors alone can cause a peptic ulcer; however, the risk increases if they are combined with H. Pylori infection and/or chronic, high-dose use of NSAIDs.

The good news is that, with treatment, most peptic ulcers that are diagnosed early get better over time. Treatment will often include proton pump inhibitors (PPIs), which are sold over the counter and include omeprazole (Prilosec®), esomeprazole (Nexium®), lansoprazole (Prevacid®), pantoprazole (Protonix®), rabeprazole (AcipHex®), dexlansoprazole (Dexilant®), and omeprazole with sodium bicarbonate (Zegerid®).

“These medications work by lowering the amount of stomach acid,” Dr. Hung says. “Because acid in the stomach will irritate an ulcer, we have to lower the acid level to allow the ulcer to heal naturally.” But even though the medications are available over the counter, it’s important to talk to a doctor before taking them to treat a suspected ulcer, since a variety of factors, including what caused the ulcer, shape treatment decisions.

Although Dr. Hung notes that the length of time someone needs to be on a PPI varies depending on their circumstance, “if it’s a small, superficial ulcer, a two-week PPI course may be sufficient,” he says. “However, if there is a large ulcer causing an obstruction, then longer courses, such as eight to twelve weeks, may be necessary.”

It’s also important to treat H. pylori if it’s detected. A full course of antibiotics can eradicate the infection and keep it from returning, and is prescribed with acid-reducing medicine. (A follow-up H. pylori test will make sure it is fully eradicated.)

The treatment for ulcers associated with NSAID use is to take a PPI and stop taking the NSAIDs.

If a PPI doesn’t work—or a patient has a severe ulcer—new medications called potassium competitive acid blockers (PCABs) may lower the acid levels even more than the PPIs, says Dr. Hung.

An upper endoscopy can be used to stop bleeding from an ulcer, in some cases by injecting the ulcer with medicine or applying heat therapy or clips during the procedure. But some severe ulcers with complications may require more intensive and invasive treatment, such as blood transfusions to replace lost blood or surgery.

Despite some people’s perceptions, there is no solid data to support the idea of chronic emotional or psychological stress as a cause of ulcers. The same is true of spicy foods. “There is some very weak evidence that suggests spicy food may potentially affect the production of stomach acid, but it's not strong enough to say that foods will cause you to have an ulcer,” Dr. Hung says.

Dietary changes usually aren’t necessary—in fact, there is no good research to show that diet plays an important role in either preventing or treating a peptic ulcer—but it does help to avoid smoking and drinking alcoholic beverages, since those things can exacerbate an ulcer, Dr. Hung says.

“Time and medication will heal most ulcers,” he says, adding that most people will recover within a month or two.