Overview
Peptic ulcers are sores on the inner lining of the stomach (gastric ulcers) or the first part of the small intestine (duodenal ulcers). They develop when the mucous layer protecting the gut from stomach acid breaks down. The most common causes are Helicobacter pylori infection and NSAID use. Most peptic ulcers heal completely with treatment.
How common is it?
Peptic ulcer disease affects approximately 4 million people in the UK at some point. Duodenal ulcers are 4 times more common than gastric ulcers. Prevalence has declined significantly since H. pylori eradication therapy became standard.
Causes and risk factors
The protective mucous barrier of the stomach and duodenum is disrupted by H. pylori bacteria or NSAIDs, allowing acid to erode the lining.
Common risk factors
- Helicobacter pylori infection (most common cause globally — present in 80 to 90% of duodenal ulcers)
- Regular NSAID use (aspirin, ibuprofen, naproxen, diclofenac)
- Smoking
- Excess alcohol
- Zollinger-Ellison syndrome (gastrin-secreting tumour causing extreme acid production)
- Severe physiological stress (critical illness, burns, head injury — stress ulcers)
- Family history
Symptoms
- Burning or gnawing pain in the upper abdomen
- Duodenal ulcer pain: relieved by eating, returns 2 to 3 hours later, wakes patient at night
- Gastric ulcer pain: may worsen with eating
- Nausea
- Bloating and belching
- Loss of appetite
- Complications: haematemesis (vomiting blood), melaena (black tarry stools), sudden severe abdominal pain (perforation — emergency)
When to see a doctor
Go to A&E immediately for vomiting blood, passing black tarry stools, or sudden severe abdominal pain. These indicate haemorrhage or perforation — life-threatening emergencies. See a GP for persistent upper abdominal pain or dyspepsia not responding to antacids.
Diagnosis
Urea breath test or stool antigen test for H. pylori. Upper GI endoscopy (OGD) directly visualises ulcers and allows biopsy. Biopsy essential for gastric ulcers to exclude malignancy. Repeat endoscopy after 6 to 8 weeks to confirm healing of gastric ulcers.
Treatments
H. pylori eradication (triple therapy)
Standard first-line: 7-day course of omeprazole + clarithromycin + amoxicillin (or metronidazole if penicillin allergic). Eradication rates 70 to 85%. Confirm eradication with urea breath test 4 weeks after completing treatment.
Proton pump inhibitors (PPIs)
Omeprazole, lansoprazole, or pantoprazole taken 30 to 60 minutes before meals heal the ulcer by suppressing acid. Used for 4 to 8 weeks. Continued in NSAID users at high risk.
Stopping NSAIDs and aspirin
Stopping NSAIDs is the most important step for NSAID-induced ulcers. Where NSAIDs must continue, add PPI protection. Use COX-2-selective NSAIDs where possible.
Endoscopic treatment of bleeding ulcers
Endoscopic haemostasis using injection, thermal coagulation, or clips stops active bleeding in most cases. Transfusion and IV PPI infusion are concurrent treatments.
Surgery
Reserved for perforation, pyloric obstruction, or uncontrolled haemorrhage. Much rarer than in the pre-H. pylori eradication era.
Self-care and lifestyle
- Avoid NSAIDs if possible — switch to paracetamol for pain relief
- Stop smoking (delays healing and increases recurrence risk)
- Limit alcohol
- Eat regular meals — an empty stomach allows acid to cause more damage
Prevention
H. pylori eradication prevents ulcer recurrence and also reduces gastric cancer risk. Always co-prescribe PPI protection when prescribing NSAIDs to high-risk patients (over 65, previous ulcer, on anticoagulants).