Stomach ulcer

What is a stomach ulcer?

A stomach ulcer is a sore or shallow hole in the lining of the stomach.

The main symptom of a stomach ulcer is having upper abdominal pain.

Other common symptoms may include:

• Bloating. This is swelling of the abdomen because the stomach is full of gas.

• Retching. Also known as 'heaving'. This means appearing about to be sick (vomit) but not actually vomiting.

• Feeling sick (nausea).

• Vomiting.

• Feeling very 'full' after a meal.

• The stomach acid often also causes heartburn. The is caused by acid reflux.

The stomach contains high levels of acid which helps to break down foods. A stomach ulcer occurs when there is damage to the layer that protects the stomach lining from these acids in the stomach. This damage is usually initially an area of redness and inflammation (gastritis). Over time, this inflammation can erode further and a stomach ulcer develops. Causes of this damage include:

Infection with H. pylori

Infection with the bacteria Helicobacter pylori (usually called H. pylori) is the cause in about 8 in 10 cases of stomach ulcer. See the separate leaflet called Helicobacter pylori for more information.

Anti-inflammatory medicines

Anti-inflammatory medicines are sometimes called non-steroidal anti-inflammatory drugs (NSAIDs). Common examples include: ibuprofen, naproxen and aspirin.

These drugs are more likely to cause a stomach ulcer if taken at high doses for a long time. Certain indigestion medications are sometimes used at the same time as an NSAID to prevent an ulcer, for example: omeprazole or lansoprazole

Other causes and factors

• Smoking.

• Some viral infections.

• Crohn's disease.

• Zollinger-Ellison syndrome.

Stomach cancer may at first look similar to an ulcer. Stomach cancer is uncommon but people with stomach ulcers will usually have a sample taken (a biopsy) to ensure that there is no cancer present.

Stomach ulcers occur in between 1 in 10 and 1 in 20 people over a lifetime. They have become much less common since the 1980s because of much more effective treatments. Stomach ulcers are less common than duodenal ulcers.

Stomach ulcers can cause various complications and side-effects but these are much less common now because of more effective treatments.

However, complications can be very serious and include:

Bleeding ulcers

• This can range from a small amount of blood to a life-threatening bleed.

• If there is sudden heavy bleeding then this often causes vomiting of blood (this is called a haematemesis) and may make people feel faint.

• Less sudden bleeding may cause you vomiting where the vomit looks dark brown because the stomach acid has partly broken down the blood. Doctors call this "coffee grounds" vomit because it looks like the dregs remaining after brewing coffee.

• A more gradual trickle of blood will pass through the gut (bowel) and cause the stools (faeces) to look black and sticky (this is called melaena).

• Urgent medical advice should be sought for symptoms of a bleeding stomach ulcer.

Perforation

This is the term used to describe the ulcer having made a hole all the way through (perforated) the wall of the stomach. Food and acid in the stomach then leak out of the stomach into the abdominal cavity. This usually causes severe pain and makes people very unwell.

Stomach ulcer perforation is a medical emergency and needs hospital treatment as soon as possible.

Stomach blockage

This is a very rare complication. 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.

The main tests that are used to diagnose a stomach ulcer are as follows:

A test to detect the H. pylori bacteria

H. pylori bacteria can be detected in a sample of stool (faeces) or from a biopsy sample taken during a gastroscopy.

Blood tests

Blood tests can look for anaemia because of any bleeding from the ulcer. They may also check that the liver, kidneys and pancreas are working properly.

Gastroscopy (endoscopy)

A gastroscopy is the definitive test for a stomach ulcer. During a gastroscopy a clinician looks inside the stomach by passing a thin, flexible telescope down the oesophagus. They will then be able to see any inflammation or ulcers in the stomach.

Biopsies

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. Most stomach ulcers are not caused by cancer and can be completely treated with medication.

Acid-suppressing medication

It is usual to be prescribed a 6-8 week course of a medicine designed to reduce the amount of acid produced by the stomach. The most commonly used medications to suppress acid are proton pump inhibitors and H2 blockers. They are usually very well tolerated and side-effects are uncommon.

See the separate leaflet called Indigestion medicine for more information.

Antibiotics

Most stomach ulcers are caused by infection with H. pylori. If this is confirmed by tests then part of the treatment is to clear this infection. The treatment given is a combination of antibiotics and acid-suppressing medication.

If the infection is not cleared, the ulcer is likely to return once the acid-suppressing medication is stopped.

Stopping anti-inflammatory medicine

Anti-inflammatory medicines should be stopped if a stomach ulcer is diagnosed (or if symptoms of stomach inflammation - gastritis - develop. Gastritis often occurs before an ulcer develops). This will allow the ulcer to heal although acid-suppressing medication will also be needed at the same time.

As far as possible, anti-inflammatory medication should be avoided following a stomach ulcer. However, they can be important in managing arthritis symptoms. Aspirin (a type of anti-inflammatory medication) is often essential to protect against heart disease. In these situations, it is usual nowadays to prescribe an acid-suppressing medication daily alongside the anti-inflammatory medication in people over the age of 40.

Surgery

Surgery is usually only needed if a complication of a stomach ulcer develops, such as severe bleeding or a perforation.

General advice

Lifestyle measures can reduce the risks of inflammation and therefore a stomach ulcer developing. These include:

• Losing weight if overweight.

• Avoiding any trigger foods that cause acid reflux, such as coffee, chocolate, tomatoes, fatty foods or spicy foods (these vary from person to person and not everyone has trigger foods).

• Eating smaller meals and eating the evening meal 3-4 hours before going to bed.

• Stopping smoking.

• Reducing alcohol consumption to recommended limits.

A repeat gastroscopy (endoscopy) is usually advised 6-8 weeks after treatment has finished. This is to ensure that the ulcer has healed. It is also to be doubly certain that the stomach ulcer was not due to stomach cancer.