An ulcer is the term used to describe a break in the lining of any part of the body. This can occur most visibly in the skin, but many people will suffer from mouth ulcers affecting their tongue or gums.
What are peptic ulcers?
Ulcers in the lining of the stomach are called gastric ulcers. In the lining of the duodenum, which is part of the intestine immediately below the stomach, they are called duodenal ulcers. The term peptic ulcer includes both gastric and duodenal ulcers.
What causes a peptic ulcer?
One of the important functions of the stomach is to produce acid and a chemical called pepsin, which are important in starting the digestion of food. Acid and pepsin are also capable of digesting the lining of the stomach and duodenum. In a healthy stomach or duodenum the lining defends itself by producing a protective layer of mucus and secreting bicarbonate, which neutralises acid to protect the lining. An ulcer occurs when the acid and pepsin overcome these natural defences and cause a break in the lining.
The two most important factors that upset the balance between attack and defence are infection with a bacterium called Helicobacter pylori (also known as H pylori) and taking non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin.
What is Helicobacter pylori and how does it cause ulcers?
Helicobacter pylori is a bacterium, which is the main cause of peptic ulcers throughout the world. It produces ulceration by:
- Infecting the lining of the stomach and duodenum and causing inflammation, which tips the balance towards ulceration caused by acid peptic attack.
- Resetting acid production to a higher level.
Do all of those infected with Helicobacter pylori get ulcers?
No – most people infected with Helicobacter pylori have no ulceration or symptoms. Why some people get ulcers and others do not is still the subject of research.
How are NSAIDs and aspirin involved?
These drugs are very commonly prescribed. NSAIDs such as ibuprofen (Nurofen®, Brufen®), diclofenac (Voltarol®) or naproxen (Naprosyn®) are used for treating painful conditions whilst aspirin is widely prescribed to prevent heart attacks and strokes. Unfortunately, both interfere with the gastric and duodenal defences, increasing the risk of ulceration.
In most developed countries the numbers of people infected with H pylori have steadily decreased and in some parts of the world NSAIDs are the main cause of peptic ulcers.
Are there any other causes of peptic ulcers?
Knowing that H. pylori NSAIDs and aspirin cause most ulcers has helped us to recognise other rarer causes more reliably. These rarer causes include Crohn’s disease and hormonal changes that switch on excess acid secretion.
In addition, there are other factors which make ulcers caused by H. pylori or NSAIDs more likely to occur.
- Smoking increases the chances of developing an ulcer and makes treatment less effective.
- Steroid drugs, such as prednisolone, are not thought to cause ulcers when taken alone, but seem to increase the risk of ulceration if taken in conjunction with NSAIDs and may be associated with ulceration caused by the condition for which the steroids themselves are prescribed.
- Diet: specific foods and beverages do not cause ulcers although some may give rise to indigestion in some people.
- Stress was at one time blamed for peptic ulcer, but it is no longer thought to be important, apart from the stress caused by major surgical operations or trauma.
- Inheritance of an ulcer tendency may exist in some families, but is probably more often due to H pylori passing from one family member to another than an inherited risk.
How do I know if I've got an ulcer?
The most common symptom is pain in the upper abdomen (tummy). Most typically it may come for several weeks at a time when it is felt every day, often several hours after meals or waking the patient at night. If antacids, milk or acid reducing drugs like cimetidine (Tagamet®), ranitidine (Zantac®) or famotidine clearly relieve the pain it is likely to be due to an ulcer, reflux (see other leaflet) or simple acid indigestion.
Management of patients taking NSAIDs is difficult because nevertheless many ulcers are silent and do not cause symptoms, whilst the drugs often cause indigestion without an ulcer. However, if a patient taking aspirin or NSAIDs gets new indigestion pain, especially after taking the drugs, ulcer development should be considered.
Although your doctor may suspect an ulcer on the basis of what you tell them about your symptoms, the diagnosis cannot be confirmed without tests.
If uncomplicated ulcers are not treated some will bleed or perforate. For people with silent ulcers this may be the first sign. Ulcer bleeding results in vomiting of blood (haematemosis) or the passage of black sticky stools (maleana). The main symptom of perforation is sudden onset of very severe abdominal pain. Ulcer bleeding and perforation require urgent admission to hospital.
What tests are needed?
The most accurate way of confirming a peptic ulcer is by endoscopy. This involves passing a flexible, thin tube through the mouth, down the gullet and into the stomach and duodenum.
The views obtained are so good that an ulcer can be confirmed or excluded without the need for further tests. A sample of the lining of the stomach will also be taken for microscopic examination and to check for H pylori infection.
Is there an alternative to endoscopy?
There is now good evidence that testing for H pylori, and treating it if the test is positive, is an effective alternative to an endoscopy because it is less trouble for patients and may reduce costs of treatment. An accurate way of testing for H pylori infection is by means of a breath test, in which you will be asked to swallow a small amount of fluid containing a trace of radioactive urea. Because H pylori splits urea in the stomach into water and carbon dioxide, a measurement of the amount of carbon dioxide in your breath is an indication of whether or not you have Helicobacter pylori infection.
Stool antigen tests, in which a small portion of a bowel motion is analysed, are now widely used as tests for H pylori infection. Doing a blood test is a less accurate alternative to a urea breath test or stool antigen test.
Barium meals, which are x-ray procedures involving swallowing a white tasteless liquid which outlines the wall of the duodenum and stomach, are now rarely used , although sometimes, depending on your symptoms, a barium meal may be performed instead of an endoscopy.
What is the best way of treating an H pylori ulcer?
If the ulcer is the result of H pylori infection you will be recommended to take an acid-reducing drug together with two for 7-14 days. Many doctors now advise this treatment not only for newly diagnosed ulcers but for patients who continue to have symptoms thought to be due to an ulcer which has been diagnosed in the past.
CORE also publishes a leaflet on Helicobacter pylori, containing further information.
What if my ulcer is due to NSAID treatment?
A strong acid suppressing drug such as omeprazole is effective in healing ulcers due to NSAIDs or aspirin can be healed using a proto pump inhibitor (PPI).
PPIs are strong acid suppressing drugs, and include omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole. These drugs are more effective if the NSAID is stopped, but are quite effective at keeping the ulcer healed even if the NSAID cannot be stopped. Another approach is to swap the NSAID for a more selective drug called a COX-2 inhibitor (eg celecoxib), which has a greatly reduced effect on ulceration. In some patients at high risk a COX-2 inhibitor and acid suppression will be used together.
Will I need another test to prove the ulcer has healed?
For all gastric ulcers and for duodenal ulcers that have bled or perforated it is routine to repeat the endoscopy to confirm healing. In other patients with duodenal ulcers a further endoscopy is usually not necessary.
What about checking that H pylori has been eliminated?
Because eradication treatment is effective in approximately 90% of patients the odds are very much on your side. However, if symptoms persist you may need a further test such as a urea breath test to test for success.
Will the ulcer come back?
H pylori related ulcers very rarely recur after the bacterium has been eradicated and NSAID ulcers will not return unless the drugs are taken again.
Do recurrent symptoms always mean the ulcer has come back?
No – in the great majority of patients if H pylori is treated and NSAIDs are avoided, a return of indigestion is usually due to some other problem, most often reflux disease.
Core also publishes a leaflet on Gastrooesophageal Reflux, containing further information.
Will acid reducing drugs be needed long term?
Ulcers due to H pylori symptoms usually resolve when the bacterium is eradicated. If NSAIDs can be stopped the risk of recurrence falls substantially. If they are continued, most patients should take a PPI (see above). For most patients continuing to take aspirin gives important benefits in the prevention of heart attacks and strokes, and should be taken under the protection of a PPI (see above).
What are the main side effects of ulcer treatment drugs?
Acid suppressing drugs have been used for over 30 years and are amongst the safest of all prescribed drugs. Diarrhoea, rash and headache are the main side effects. They can increase the risk of enteric infections and use should be reviewed with your doctor if you have had an infection with Clostridium difficile (often known as C. Diff). There is current concern that PPIs might increase the risk of osteoporosis but this is not proven and is an area of current research.
The antibiotics used to eradicate H pylori quite commonly cause diarrhoea, bloating and sickness but most people are able to complete the treatment course without problems.
Some patients on aspirin will also take the drug clopidogrel. Some PPIs such as omeprazole, may interfere with the action of this drug. This should be discussed with your doctor. This is an area of current research but taking the PPI in the morning and clopidogrel at night is likely to avoid problems.
Will an operation be needed?
Because medical treatment is so effective surgery is not needed except in a rare emergency when ulcers bleed or perforate.
What can I do to help myself?
- Do not smoke.
- Avoid NSAIDs if you can and ask your doctor to prescribe a PPI if you cannot.
- If you have established heart or vascular disease continue to take aspirin but ask your doctor for a protective PPI as well.
- Make sure you complete the prescribed course of H pylori eradication treatment.
Do peptic ulcers turn into cancer?
What can I eat?
Diet does not influence whether you get a peptic ulcer. You can eat normally, and do not need to follow a special diet. A healthy diet including a wide variety of foods and plenty of fruit and vegetables is good for your general health. Aim to eat five portions of fruit and vegetables each day and to drink at least two litres (8-10 cups) of fluid every day. Further information on healthy eating is available from the Food Standards Agency (www.food.gov.uk).
What further research is needed?
We still don’t fully understand why only a small proportion of people with H pylori infection get ulcers, although because the level of H pylori infection in the population is gradually falling, this is becoming less of a problem. More research is needed into safe alternatives to aspirin and NSAIDs, and into better ways of detecting ulceration without endoscopy.
Fact sheet produced by Core and provided by MIMS
Last reviewed: July 2013
Core is the charity for research and information on gut and liver disease