Version August 2024
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PEPTIC ULCER DEFINITION — Peptic ulcers are open sores in the upper part of the digestive tract (figure 1) that can cause stomach pain or stomach upset and lead to internal bleeding. There are two types of peptic ulcers:
●Gastric ulcers, which form on the lining of the stomach
●Duodenal ulcers, which form on the lining of the upper part of the small intestine (called the "duodenum")
In some cases, peptic ulcers heal without treatment. However, most people with ulcers (sometimes called "peptic ulcer disease") need treatment to relieve symptoms and prevent complications. It is also important to identify the cause of the ulcer so that it is optimally treated and does not recur.
PEPTIC ULCER CAUSES — Peptic ulcers form when stomach acid erodes the lining of the digestive tract. This can happen when there is excess acid produced, or when the protective layer of mucus on the lining is broken down (making it more susceptible to damage).
There are two major causes of peptic ulcers, bacterial infection and the use of pain relievers called nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs include aspirin, ibuprofen (sample brand names: Advil, Motrin), and naproxen (sample brand name: Aleve).
H. pylori infection — Helicobacter pylori is a type of infectious bacteria that lives in the stomach. H. pylori is very common; some data suggest that it is present in approximately 50 percent of the world population. (See "Patient education: H. pylori infection (The Basics)".)
Most people who have H. pylori do not develop ulcers, but some do. This is because the bacteria can cause the following, all of which can contribute to peptic ulcer formation:
●An increase in the amount of acid in the stomach and small intestine
●Inflammation of the lining of those organs
●A breakdown of the protective mucus layer
NSAIDs — The use of nonsteroidal anti-inflammatory drugs (NSAIDs) can also cause peptic ulcers in some people. They are commonly used to relieve pain and reduce inflammation. Many people also take low-dose aspirin daily to prevent heart attack or stroke.
NSAIDs can cause injury to the lining of the stomach or intestine and make it more vulnerable to damage from stomach acid. In some people, this damage can cause ulcers. The risk of ulcer formation depends on multiple factors, including the NSAID type, dose, and duration of use.
Other risk factors — Neither the presence of H. pylori nor the use of NSAIDs causes ulcers in every case; there are other factors as well:
●Genetics likely play a role, as studies have shown that having a family member with peptic ulcers makes a person more likely to develop ulcers as well.
●People who smoke cigarettes are more likely than nonsmokers to develop peptic ulcers.
●Although certain foods and beverages can cause stomach upset, there is no good evidence that they cause or worsen ulcers. Still, eating a healthy diet with plenty of fruits, vegetables, and fiber may decrease the risk of ulcers.
●The role of psychologic stress in the formation of ulcers is controversial. There is some evidence that psychologic factors (such as stress, anxiety, and depression) may contribute to the development of ulcers as well as impaired healing and increased recurrence. However, this relationship is not fully understood, as there are many other variables involved (eg, the presence or absence of H. pylori; use of NSAIDS; other individual characteristics) and "stress" can be difficult to measure and study.
●Other (non-NSAID) medications and health conditions can also cause ulcers, but this is fairly uncommon.
PEPTIC ULCER SYMPTOMS — Some people with peptic ulcers do not have any symptoms. (Ulcers that cause no symptoms are sometimes called "silent ulcers.") People who do have symptoms may experience any of the following:
●Stomach or upper abdominal pain or discomfort (often a burning or hunger-like feeling)
●Feeling full quickly when eating
●Nausea
●Vomiting (in severe cases, there may be blood in the vomit)
●Stools that are black or look like tar
Duodenal ulcers tend to cause abdominal pain that comes on several hours after eating (often during the night). Eating or taking an antacid or an acid-reducing medication may relieve the abdominal pain.
PEPTIC ULCER DIAGNOSIS — Many of the symptoms of peptic ulcers can also be caused by other conditions, including acid reflux or gallstones. Your health care provider will review your history and symptoms and can run tests to determine if you have an ulcer.
Upper endoscopy — An upper endoscopy is a procedure in which a thin, flexible tube is inserted into the mouth and down the throat. The tube has a light and a tiny camera on the end that projects images from within the digestive tract onto a monitor. (See "Patient education: Upper endoscopy (The Basics)".)
Ulcers can often be diagnosed through upper endoscopy. A small sample of tissue, called a biopsy, can also be taken to check for abnormal cells, cancer, or an infection with H. pylori.
H. pylori testing — Anyone with a confirmed peptic ulcer should be tested for H. pylori so that the infection, if present, can be treated (see 'Treatment of H. pylori' below). In people who have had a biopsy, the sample can be tested for infection. People who have not had a biopsy can instead have a breath or a stool sample test to check for H. pylori.
PEPTIC ULCER TREATMENT — The exact course of treatment for peptic ulcers depends on the underlying cause. Most ulcers can be healed with medications.
Identifying the cause — Your health care provider will first try to determine what has caused your ulcer, since some causes (eg, H. pylori infection) need to be treated directly for the ulcer to heal and not recur.
Acid suppression — All ulcers are treated with medicines to suppress acid production called proton pump inhibitors. These include esomeprazole (sample brand name: Nexium), lansoprazole (sample brand name: Prevacid), and omeprazole (sample brand name: Prilosec) (table 1). The duration of treatment with a proton pump inhibitor depends on the type and severity of the ulcer and whether infection with H. pylori is present.
Treatment of H. pylori — H. pylori is treated with several medications, usually including at least two antibiotics (to kill the bacteria) and a proton pump inhibitor for acid suppression. Treatment for H. pylori usually takes two weeks. It is important to take all of the medicines for the entire course of treatment.
Treatment of ulcers not due to H. pylori — If you have an ulcer but tested negative for H. pylori, your health care provider will still prescribe an acid-suppressing medication in order to help the ulcer heal. This will usually be a proton pump inhibitor. (See 'Acid suppression' above.)
You should take your ulcer medication as directed, even if your ulcer doesn't cause bothersome symptoms. Some people can stop the medication after four to six weeks; others may need to keep taking it for longer if their ulcers are large or at risk of recurring, or if they have had complications due to ulcers in the past. (See 'Peptic ulcer complications' below.)
Stopping NSAIDs — If you are taking any nonsteroidal anti-inflammatory drugs (NSAIDs), your provider may advise you to stop them or recommend that you switch to a different NSAID that is safer for your stomach and intestine. They may recommend alternative medications to NSAIDs to treat your pain, such as acetaminophen (sample brand name: Tylenol). If it is not possible for you to stop taking NSAIDs, you will likely need to keep taking a proton pump inhibitor medication as long as you are taking the NSAIDs. This will help protect the lining of the digestive tract and reduce the risk of bleeding. (See 'Bleeding' below.)
Other methods of symptom relief — In addition to taking prescribed medications and avoiding NSAIDs, there are other things you can do to relieve symptoms and help ulcers to heal:
●Quit smoking, if you smoke
●Limit the amount of alcohol you drink
●Take antacids if they relieve your upset stomach
PEPTIC ULCER COMPLICATIONS — Although most peptic ulcers heal completely with treatment, they can sometimes lead to complications. The risk of serious complications depends on the cause of the ulcer, the size and location of the ulcer, and the person's age and health.
Bleeding — Bleeding ulcers most often affect older people. Symptoms may include blood in the vomit or in the stool (this can give stools a black, tar-like appearance). People with bleeding ulcers usually need to take a proton pump inhibitor (see 'Peptic ulcer treatment' above). Those with heavy or rapid bleeding may require IV fluids and blood transfusions in the hospital.
Ulcers that are actively bleeding, or are at risk of bleeding again, can be treated during an upper endoscopy (see 'Upper endoscopy' above). Treatment may involve cauterizing the ulcer, applying tiny clips to close off the blood vessels, injecting a medication called epinephrine, or using a special type of powder to form a barrier. The goal is to stop the bleeding and prevent future bleeding.
In rare cases, a person with a bleeding ulcer may need surgery or embolization. Embolization involves identifying the specific blood vessels that are the source of the bleeding and blocking off the flow of blood through them.
Perforation — Perforation is when an ulcer causes a hole through the wall of the stomach or duodenum. Symptoms include sudden, severe abdominal pain and a rapid heartbeat. Pain may radiate to one or both shoulders, and the abdomen may become rigid.
A perforated stomach or duodenal ulcer is a medical emergency and needs treatment immediately. Treatment usually involves a surgical procedure to close the perforation, insertion of a nasogastric tube (a tube that goes through the nose into the stomach), IV fluids, and medications to help the ulcer heal.
Obstruction — Gastric outlet obstruction is a less common complication of peptic ulcers. It refers to an obstruction or blockage of the outlet of the stomach (the part that leads to the small intestine). Vomiting is the most common symptom; other symptoms include feeling full quickly after eating, bloating, abdominal pain, loss of appetite, and nausea.
Gastric outlet obstruction is treated by inserting a nasogastric tube to remove food and fluid that has been unable to pass from the stomach into the small intestine and giving medications to reduce production of stomach acid and secretions. Many people also need IV fluids to stay hydrated. If the obstruction is related to an ulcer that was caused by H. pylori or nonsteroidal anti-inflammatory drug (NSAID) use, addressing those causes (treating the H. pylori infection and/or stopping NSAIDs, along with treating the ulcer with acid-suppressing medication) often resolves the obstruction.
For people who don't respond to medication, obstruction can be treated during an endoscopy (see 'Upper endoscopy' above). This is done by inserting a tiny balloon to dilate (open) the gastric outlet. A biopsy may be performed to rule out other, more serious causes of obstruction, such as stomach cancer.
If balloon dilation is not possible (or doesn't work), surgery to remove or bypass the obstruction may be an option.
FOLLOW-UP — Whether or not you need follow-up monitoring for your ulcer depends on:
●The size, location, and cause of the ulcer
●How the ulcer has responded to treatment
●Whether there were any complications
Duodenal ulcers — If you have been treated for a duodenal ulcer without complications, you most likely will not need any follow-up monitoring of the ulcer itself. If your symptoms persist or recur, your health care provider may recommend a repeat endoscopy to make sure the ulcer is healing.
Gastric ulcers — Some health care providers recommend a follow-up endoscopy for anyone with a gastric ulcer to confirm that the ulcer has healed and does not contain any cancerous cells. If you had a stomach biopsy to exclude cancer when your gastric ulcer was initially diagnosed, and the ulcer has responded well to treatment, you may not need follow-up endoscopy to confirm healing. Your health care provider will decide whether a repeat endoscopy is necessary based on your individual situation.
Ulcers caused by H. pylori — If your ulcer was due to H. pylori, your health care provider will order a test to confirm that the infection is gone (see 'H. pylori testing' above). A stool or breath test is performed four to eight weeks after the initial course of treatment is completed. This is because some medications (including antibiotics and proton pump inhibitors) can cause a "false-negative" test result even if H. pylori is still present. If the H. pylori has not been eradicated, then another course of treatment will be prescribed.
WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Peptic ulcers (The Basics)
Patient education: H. pylori infection (The Basics)
Patient education: GI bleed (The Basics)
Patient education: Gastritis (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Helicobacter pylori infection and treatment (Beyond the Basics)
Patient education: Upper endoscopy (Beyond the Basics)
Patient education: Upset stomach (functional dyspepsia) in adults (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Association between Helicobacter pylori infection and duodenal ulcer
Peptic ulcer disease: Clinical manifestations and diagnosis
Overview of complications of peptic ulcer disease
Peptic ulcer disease: Treatment and secondary prevention
Approach to refractory peptic ulcer disease
Surgical management of peptic ulcer disease
Overview of the treatment of bleeding peptic ulcers
Unusual causes of peptic ulcer disease
Peptic ulcer disease: Epidemiology, etiology, and pathogenesis
The following organizations also provide reliable health information.
●National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
●Centers for Disease Control and Prevention (CDC)
Phone: (404) 639-3534
Toll-free: (800) 311-3435
●National Institute of Diabetes and Digestive and Kidney Diseases
Phone: (301) 654-3810
●The American Gastroenterological Association
●The American College of Gastroenterology (ACG)
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ACKNOWLEDGMENTS — We are saddened by the death of Mark Feldman, MD, who passed away in March 2024. UpToDate gratefully acknowledges Dr. Feldman's role as a Section Editor on this topic and his dedicated and longstanding involvement with the UpToDate program.
The editorial staff at UpToDate would also like to acknowledge Sheila E Crowe, MD, FRCPC, FACP, FACG, AGAF, who contributed to an earlier version of this topic review.
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