The stomach produces a strong peptic acid to help digest food and protect against microbes — a thick layer of mucus lines the gastrointestinal tract to protect from the acid. If the stomach acid etches away the protective layer of mucus, the acid can damage the stomach tissue, causing stomach ulcer.

A stomach ulcer is one of three types of peptic ulcer – the other types are a duodenal ulcer and esophageal ulcer. Duodenal ulcers refer to ulcers that develop in the uppermost region of the small intestine (duodenum), whereas esophageal ulcer refers to ulcers that develop in the esophagus. The peptic ulcers share similar characteristics but are differentiated by their location in the gastrointestinal tract.

Stomach ulcers – also known as gastric ulcers – are a current problem. Even healed ulcers can recur unless proper treatment is directed at preventing their recurrence. While relatively easy to cure, they can cause significant problems if left untreated.

Stomach ulcers occur when stomach acid eats away at the inner lining of the stomach. It may result in a painful open sore that may bleed.

 

Common Symptoms

Burning Stomach Pain

Burning or gnawing pain in the stomach is the most common symptom of stomach ulcer. The pain may last between 30 minutes to 3 hours. It can be felt anywhere from the navel up to the sternum.

A stomach ulcer would cause epigastric pain during the meal, with accompanying nausea or vomiting. On the other hand, if your pain is aggravated by hunger and is commonly felt at night, it might be due to duodenal ulcers instead.

Indigestion (Dyspepsia)

Another classic symptom is indigestion, whereby you feel pain behind the breastbone (heartburn) or in the upper abdomen. Indigestion and heartburn may occur together or on their own. You may also feel full and bloated.

It’s worth noting that not all stomach ulcers present with indigestion.

Fatty Food Intolerance

When the peptic acid escapes from your stomach, you may have insufficient acid in the stomach for the breaking down of food. The food remains undigested and becomes a free meal for the gut bacteria. As a result, you may suffer from bloating, stomach cramps, wind, and diarrhea.

In particular, people with stomach ulcers may be unable to tolerate fatty food.

Heartburn

Heartburn is a painful burning feeling in the chest and throat, just behind the breastbone. It happens when stomach acid backs up into your esophagus.

The pain often worsens after eating, when lying down or bending over.

 

Causes

Two of the common causes of stomach ulcers are H. pylori infection and the chronic use of pain killers.

Helicobacter pylori (H. Pylori)

The H. pylori may reside in the mucosal layer of the stomach, where it may cause the inflammation of the stomach lining, producing a stomach ulcer [1]. Many people infected with H. pylori do not get ulcers.

Helicobacter pylori (H. pylori) bacteria may spread via person-to-person contact (e.g., handshake) or food transmission. You can protect yourself from H. pylori infections by washing your hands thoroughly with soap and by eating foods that have been properly cooked.

Smoking may increase your risk of stomach ulcers in people who are infected with H. pylori [4]. It also reduces the efficacy of treatments and increases the risk of serious complications, such as obstruction, perforation, and bleeding.

It’s possible to be infected with H. pylori without realizing it – because there usually aren’t any apparent symptoms.

Antibiotics that specifically target the H. pylori bacteria can help heal the stomach ulcers and prevent future recurrence.

Long-term use of Pain Killers

Taking aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) for the long term can irritate the stomach lining. Commonly used NSAIDs include ibuprofen, naproxen, and diclofenac.

The risk of stomach ulcers increases if the pain killers are taken in high doses, or regularly for a long time. This is especially true for older adults due to their relatively thin stomach lining. Cooperate with your doctor to determine the optimal dose of pain killers that can provide relief.

You may be advised not to use aspirin or NSAIDs if you have a history of stomach ulcer. A safer alternative painkiller would be a COX-2 inhibitor, which is a type of NSAID that doesn’t cause stomach ulcers [2]. Likewise, if you’re taking aspirin, your doctor may prescribe proton-pump inhibitors or H2-receptor antagonists to prevent stomach ulcers [3].

 

Diagnosis

Diagnostic tests are typically ordered if the symptoms do not resolve after a few weeks of treatment. If the ulcers are resistant to treatment or are in atypical locations, a comprehensive diagnostic test is required to identify the underlying problem.

Esophagogastroduodenoscopy (gastroscopy)

An esophagogastroduodenoscopy (EGD), also known as gastroscopy, is a form of endoscopy that is performed on people in whom a stomach ulcer is suspected. By looking inside your stomach with a camera, your doctor can confirm or rule out an ulcer. It can also determine the location and severity of the ulcer. If there is an ulcer in your stomach, a follow-up endoscopy should also be performed after treatment to confirm that it has healed.

If your doctor detects a stomach ulcer, small tissue samples (biopsy) may be extracted for lab examination. The biopsy can identify whether H. pylori is in your stomach lining or whether you have a cancerous ulcer.

Laboratory Tests for H. Pylori

Your doctor may recommend laboratory tests to determine whether H. pylori is present in your stomach. There are three standard tests for H. pylori – blood, stool, and breath test.

Breath test. The breath test is the most accurate. You’ll be given a drink containing a chemical that’s broken down by H. pylori. Your breath is then analyzed to see whether or not you have an H. pylori infection.

Stool antigen test. A small stool sample would be tested for H. pylori.

Blood test. Blood tests are not routinely used due to inaccuracy. It’s now replaced mainly by the stool antigen test.

If you are taking an antacid, make sure to let your doctor know before being tested for H. pylori. This is because antacids may lead to false-negative results.

Barium Contrast X-Rays

Barium contrast X-rays are also known as “upper gastrointestinal series” or a “barium swallow.” It is a series of X-rays of your esophagus, stomach, and small intestine.

During the X-ray, you would be requested to swallow a chalky liquid containing barium. The liquid coats your digestive tract, making an ulcer more visible on X-Rays.

Nevertheless, barium contrast X-rays are inaccurate and may miss ulcers up to 20% of the time.

 

Treatment

Treatment for stomach ulcers depends on the underlying cause. The goal of stomach ulcer treatment is to reduce pain, heal the ulcer, and prevent complications. Symptoms often subside within a month or two following treatment.

You may need another gastroscopy after 4 to 6 weeks of treatment to check that the ulcer has healed.

H.Pylori Eradication Therapy

If H. pylori bacterial infection is responsible for the stomach ulcers, your doctor may recommend a combination of antibiotics to kill the bacteria. The most commonly used antibiotics may include amoxicillin (Amoxil), clarithromycin (Biaxin), and metronidazole (Flagyl). You’ll likely need to take the antibiotics for up to two weeks. Treatment with antibiotics carries the risk of diarrhea, allergic reactions, and colitis (inflammation of the colon).

Treatment may require additional medications to reduce stomach acid. Types of medication that can neutralize the acid include proton pump inhibitors (PPIs), H2 antagonists, and bismuth subsalicylate (Pepto-Bismol).

Eradication of H. pylori prevents recurrence of ulcers and reduce the risk of developing gastric cancer in the future.

You’ll be retested at least four weeks after completing your antibiotic course. The test will determine whether there are any H. pylori bacteria remaining in your stomach. If the bacteria is still present, you may be prescribed with a further course of eradication therapy using a different combination of antibiotics.

Acid-blocking Medications

While acid blockers are effective in healing ulcers, they have a limited role in eradicating H. pylori when given alone without antibiotics. Therefore, ulcers frequently when acid blockers are stopped.

Proton pump inhibitors (PPIs) reduce stomach acid by blocking its production and promote natural healing. Examples include omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium). PPIs are generally well-tolerated, and side effects are uncommon. It’s safe for long-term use.

Histamine-2 (H2) antagonists reduce the amount of stomach acid released into the digestive tract. Examples of H2 antagonists are cimetidine (Tagamet), ranitidine (Zantac), nizatidine (Axid), and famotidine (Pepcid). Generally, H2 antagonists are well-tolerated and have few side effects associated with long-term use.

Antacids that neutralize stomach acid

Your doctor may introduce an antacid into your drug regimen. Antacid medication can provide immediate, short-term relief by neutralizing your stomach. Some antacids also contain alginate, which confers additional protective coating of the stomach lining. The ulcers may return when antacids are discontinued.

 

Lifestyle and Home Remedies

Adopt a healthy diet

Dietary polyphenols are shown to aid in the treatment of stomach ulcer [4]. It’s found abundantly in natural plant food sources that are rich in antioxidant properties. Examples of dietary phenols include fruits, vegetables, tea, chocolates, and extra virgin olive oil. These foods may also inhibit acid secretion and contain anti-inflammatory properties.

Cabbage juice is highly rich in vitamin C, which may help prevent and treat H. pylori infections. Doctors reportedly used cabbage juice to treat stomach ulcers decades before antibiotics were available[5].

Probiotics can help to reduce an H. pylori infection and achieve optimal gut health. It can also help enhance the efficacy of treatment and reduce the side effects of antibiotics. Foods that are rich in probiotics include yogurt, fermented food, miso, and sauerkraut. Alternatively, you may also want to consider probiotics supplements.

Foods to Avoid

Certain foods and drinks may increase the likelihood of developing stomach ulcers, exacerbate symptoms, and impede healing. This include:

Spicy and fatty foods take longer to digest, which can lead to abdominal pain and bloating – bad news if you have an ulcer.

Caffeine and alcohol may exacerbate symptoms if consumed in excess. They can erode and irritate the mucous lining in your stomach, causing inflammation and bleeding.

Don’t Smoke

Smoking may increase stomach acid, which can interfere with the protective lining of your stomach. As a result, the stomach becomes more susceptible to ulcer formation.

Control Stress

Stress may worsen the symptoms of a stomach ulcer. Consider the sources of your stress and address it accordingly.

 

Stomach Ulcers that Don’t Heal

Refractory ulcers refer to stomach ulcers that fail to heal with treatment. There are many reasons why a stomach ulcer may become refractory, including:

  • Not taking medications accordingly
  • Resistant to antibiotics
  • Regular use of tobacco
  • Daily use of pain relievers – aspirin and NSAIDs

Less often, refractory ulcers may be due to:

  • Extreme overproduction of stomach acid
  • An infection other than pylori
  • Stomach cancer

Conditions that may cause sore-like ulcers:

  • Gastritis
  • Stomach cancer
  • Gastroesophageal reflux disease
  • Pancreatitis
  • Hepatic congestion
  • Cholecystitis
  • Biliary colic
  • Inferior myocardial infarction
  • Referred pain (pleurisy, pericarditis)
  • Superior mesenteric artery syndrome

 

Complications

Some stomach ulcers remain unnoticed until after serious complications emerge. Common complications include bleeding, perforation, and obstruction of the food passage.

Gastrointestinal Bleeding

The most common complication of stomach ulcers is internal bleeding. It can occur when an ulcer develops at the site of a blood vessel.

The bleeding can either be:

    • Slow blood loss, leading to anemia – causes fatigue, breathlessness, heart palpitations, and pale skin; OR
  • Sudden and severe bleeding – vomit blood or pass bloody stools.

Initial treatment of gastrointestinal bleeding may involve intravenous fluid replacement. If you have persistent or severe blood loss, you may need a blood transfusion.

Perforation

A rarer complication of stomach ulcer is a perforation. It occurs when stomach acid eats a hole through (perforate) the wall of your stomach.

The first sign of perforation is sudden intense abdominal pain that gets steadily worse. Abdominal muscles may become rigid and worsen by any movement.

The gut bacteria and stomach content may also spill into the abdominal cavity, causing a severe infection (peritonitis). In peritonitis, an infection can spread into the blood (sepsis), which can spread to other organs. This carries the risk of multiple organ failure and can be life-threatening if left untreated.

Obstruction

Stomach ulcers can block the passage of food through the digestive tract. It may cause you to bloat, vomit, and lose weight.

Obstruction can be due to either through swelling or scarring. In some cases, it can obstruct the passage of food (gastric outlet obstruction).

Symptoms may include:

  • Severe vomiting
  • A persistent feeling of bloating or fullness
  • Unexplained weight loss

If inflammation is the cause of the obstruction, PPIs, or H2 antagonists can be used to reduce the stomach acid levels until the swelling goes down. However, surgery may be needed if the obstruction is caused by scar tissue.

 

When to See a Doctor

Seek urgent medical care if you experience severe symptoms such as:

  • Vomiting blood (bright red or dark brown vomit)
  • Dark, tarry, sticky stools
  • Sudden, sharp pain in the tummy that gradually worsens
  • Breathing difficulty
  • Nausea or vomiting
  • Unexplained weight loss
  • Appetite changes

A hole in the stomach (perforation) is also a medical emergency. Without prompt treatment, the wall of the stomach can become infected by gut bacteria.

 

The Bottom Line

Stomach ulcers are a relatively common cause of abdominal. Some stomach ulcers heal on their own but may recur. Proper treatment can confer you a relatively healthy life without recurrence in the future.