Peptic ulcer disease

Peptic ulcer disease refers to open sores that develop on the inside lining of the stomach (gastric ulcers) or the upper portion of the small intestine (duodenal ulcers). The most common causes are Helicobacter pylori infection and long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin.

Contrary to older beliefs, stress and spicy food do not cause ulcers, though they can aggravate symptoms. Most peptic ulcers heal with medicines that reduce acid and, when present, eradicate H. pylori. Untreated ulcers can bleed, perforate, or obstruct the digestive tract.

Common symptoms include:

• Burning stomach pain, often between meals or at night
• Pain that may improve briefly with eating or with antacids (especially duodenal ulcers) or worsen with eating (some gastric ulcers)
• Feeling of fullness, bloating, or belching
• Intolerance to fatty foods
• Heartburn
• Nausea

Many people have no symptoms until a complication occurs. Warning symptoms of complications include vomiting blood, black or tarry stools, severe sudden abdominal pain, and unexplained weight loss or anemia.

Peptic ulcers develop when the protective mucus layer of the stomach or duodenum is disrupted and acid damages the tissue. Main causes:

• Helicobacter pylori infection — a common bacterium that inflames the mucosa
• NSAIDs and aspirin — inhibit prostaglandins that protect the stomach lining
• Less commonly: Zollinger-Ellison syndrome (excess acid from a gastrinoma), other medicines, severe physiologic stress (ICU ulcers), and rare causes

Smoking and heavy alcohol use impair healing and increase risk of complications.

Risk factors include:

• H. pylori infection
• Regular NSAID or aspirin use (risk rises with dose, duration, age, prior ulcer, and concurrent corticosteroids or anticoagulants)
• Smoking
• Heavy alcohol consumption
• Older age
• Prior peptic ulcer
• Family history in some studies
• Serious medical illness requiring intensive care

Serious complications include:

• Bleeding — can be slow (leading to anemia) or acute and life-threatening
• Perforation — ulcer erodes through the wall, causing peritonitis (surgical emergency)
• Gastric outlet obstruction — swelling or scarring blocks emptying of the stomach
• Penetration into adjacent organs
• Increased risk of gastric cancer with chronic H. pylori infection (especially when associated with certain types of gastritis)

To reduce ulcer risk:

• Use NSAIDs at the lowest effective dose for the shortest time; consider protective co-therapy (PPI) if long-term NSAIDs are required
• Test for and treat H. pylori when indicated (prior ulcer, before long-term NSAID use in some guidelines, or other accepted indications)
• Do not smoke
• Limit alcohol
• Take medicines with food when advised

Evaluation may include:

• History of NSAID use and prior ulcers
• Testing for H. pylori — urea breath test, stool antigen, or gastric biopsy; blood serology is less useful for confirming active infection
• Upper endoscopy (EGD) — gold standard to visualize ulcers, obtain biopsies (including for H. pylori and to exclude malignancy in gastric ulcers), and treat bleeding
• Complete blood count for anemia
• Cross-sectional imaging if perforation or other complications are suspected

See a clinician for persistent stomach pain, unexplained anemia, or black stools. Seek emergency care for severe acute abdominal pain, vomiting blood, or bloody/black stools with dizziness or fainting.

Treatment addresses acid, H. pylori when present, and NSAID use:

• Proton-pump inhibitors (PPIs) — mainstay for healing (omeprazole, esomeprazole, pantoprazole, etc.)
• H. pylori eradication — multi-drug regimens (e.g., bismuth quadruple therapy or clarithromycin-based triple therapy where resistance is low) for 10–14 days; confirm eradication with breath or stool test when appropriate
• Stop or reduce NSAIDs when possible; if continued, use PPI protection and the lowest effective NSAID dose
• H2 blockers, antacids, and sucralfate in selected situations
• Endoscopic therapy for bleeding ulcers; interventional radiology or surgery for refractory bleeding or perforation
• Follow-up endoscopy for gastric ulcers to confirm healing and exclude cancer when indicated

While healing:

• Take prescribed acid-reducing and antibiotic medicines exactly as directed
• Avoid NSAIDs and aspirin unless your clinician says otherwise
• Do not smoke; limit alcohol
• Eat regular meals; avoid personal trigger foods if they worsen symptoms
• Report black stools, vomiting blood, or severe pain immediately
• Complete follow-up testing for H. pylori eradication when requested

Bring:

• Description of pain pattern and relation to meals
• Complete list of medicines including over-the-counter NSAIDs and aspirin
• Prior ulcer history or endoscopy results
• Questions about H. pylori testing, NSAID alternatives, and warning signs of bleeding