Gastric ulcer (stomach ulcer): symptoms, causes and treatment

The stomach makes acid to digest food, and protects itself with a layer of mucus. NHS inform explains that an ulcer develops when that protective layer breaks down, allowing the lining underneath to be damaged by acid. The result is a raw patch, a little like a sore inside the mouth but in a place where acid is constantly present.

Doctors group ulcers of the stomach and of the duodenum, the first section of the small intestine, as peptic ulcers, and most of the information on this page applies to both. Ulcers of the stomach are the ones normally described as gastric ulcers, and the gastroscopy used to diagnose them can include a small tissue sample taken from the stomach or duodenum.

Gastric ulcers are not the same thing as functional dyspepsia, where there is indigestion but no ulcer or other visible cause. Guts UK points out that people can have H. pylori and indigestion for unrelated reasons, which is part of why testing and sometimes endoscopy are used rather than guessing.

According to the NHS, the pain of a stomach ulcer is usually in the upper part of the tummy, may feel like burning and is often worse at night. NHS inform adds that it can spread towards the neck, the belly button or through to the back, often starts within a few hours of eating, may last from minutes to hours and can wake you from sleep. Antacids may ease it for a while, but it tends to return if the ulcer is not treated.

Other symptoms include indigestion, heartburn, bloating and feeling or being sick. NHS inform lists loss of appetite and weight loss as less common features, and says some people burp or feel bloated after fatty food. Some ulcers cause no pain at all and are discovered only when a complication such as bleeding occurs.

• Ask for an urgent GP appointment or call NHS 111 if pain is getting worse or not going away, if you have lost your appetite, feel full after very little food, are losing weight without trying, have a lump in your tummy, find swallowing painful or difficult, keep vomiting or feel tired all the time.

• Call 999 or go to A&E if you vomit bright red blood or something that looks like ground coffee, your poo is black, sticky and very smelly or has blood in it, you have severe tummy pain or a tummy that hurts to touch, or you have sudden chest pain.

Helicobacter pylori lives in the stomach lining and can make it more vulnerable to damage from acid. Guts UK says up to 2 in 5 people in the UK carry it and that 8 to 9 out of 10 never have a problem, with about 3 in 20 of those infected developing an ulcer. It is thought to spread mainly within families in childhood.

Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, diclofenac and aspirin, are the other main cause, particularly when taken for a long time or at high doses. Many people take them without trouble, but the risk is always there. A smaller number of ulcers have no identifiable cause.

NHS inform says there is little evidence that spicy food, stress or alcohol cause ulcers, although they can make symptoms worse. Smoking, by contrast, increases the chance of developing an ulcer and makes treatment less effective.

A GP will ask about your symptoms and about any anti-inflammatory painkillers, including over-the-counter ones, and may weigh you and feel your tummy. The NHS says tests can include a breath test, a stool sample or a blood test to look for H. pylori. NHS inform notes that the blood test has largely been replaced by the stool antigen test.

Guts UK explains that tests for H. pylori can be inaccurate if you have taken antibiotics in the previous month or a proton pump inhibitor (acid-lowering medicine) in the last 2 weeks, so tell the person arranging the test what you have taken. NICE Clinical Knowledge Summaries make the same point about breath and stool tests.

You may be referred for a gastroscopy, where a thin camera is passed through the mouth into the stomach. This can confirm or rule out an ulcer and allows a small tissue sample to be taken. NHS inform says a repeat gastroscopy after 4 to 6 weeks may be used to check that the ulcer has healed.

Treatment depends on the cause. If H. pylori is responsible, NHS inform says you will be given a course of two or three antibiotics, most commonly amoxicillin, clarithromycin or metronidazole, taken twice a day for a week, together with a proton pump inhibitor. Side effects are usually mild, such as feeling or being sick, diarrhoea or a metallic taste. Guts UK stresses that finishing the full course exactly as prescribed makes treatment more likely to succeed, and that people taking metronidazole should avoid alcohol.

If an NSAID is the cause, you will be given a proton pump inhibitor and your use of anti-inflammatory painkillers will be reviewed. Paracetamol may be suggested as an alternative, and NHS inform says COX-2 inhibitors, a different type of NSAID that is less likely to cause ulcers, are sometimes recommended. Do not stop any prescribed medicine, such as low-dose aspirin for blood clots, without asking your doctor.

The NHS adds that a doctor may advise stopping smoking, changing medicines that make symptoms worse and getting help with stress, anxiety and depression. If symptoms come back after treatment you should speak to a GP, as you may need a different medicine or a longer course.

The NHS suggests eating smaller meals, finishing your evening meal 3 to 4 hours before bed, keeping to a healthy weight and finding ways to manage stress. It advises not taking anti-inflammatory painkillers without speaking to a doctor, avoiding foods and drinks that trigger your symptoms, which for some people include fatty or spicy food, coffee and chocolate, not smoking and not drinking too much alcohol.

These steps do not replace treatment of the underlying cause but may help symptoms settle and reduce the chance of a recurrence.

With the right treatment most ulcers heal and, once the cause is dealt with, are unlikely to return. Guts UK explains that before H. pylori was understood, ulcers healed with acid-reducing medicines but came back when treatment stopped, whereas clearing the bacteria greatly reduces the risk of recurrence.

Complications are uncommon but important. NHS inform names bleeding at the site of the ulcer, perforation where the stomach wall splits and obstruction of food passing through the digestive system. The NHS also lists iron deficiency anaemia from slow bleeding and, from untreated H. pylori, an increased risk of stomach cancer. This is why seeking review when pain is persistent matters.

Most stomach ulcers are diagnosed and treated through the GP, using a H. pylori breath or stool test and a course of tablets, with a gastroscopy arranged by a hospital team when it is needed. That route is free and usually sufficient.

People who have repeated symptoms, a bleed, or who want a faster endoscopy sometimes see a private gastroenterologist. The tests and medicines involved are the same, so the difference is mainly timing and appointment choice rather than a different kind of treatment. Whichever route you use, it is worth asking for the result of the H. pylori test and, if you were treated, when and how clearance will be checked.