Stomach Ulcer (Peptic): Symptoms, causes, treatment

Stomach Ulcer (Peptic): Symptoms, causes, treatment

Brief overview

  • What is a stomach ulcer? deep wound in the stomach lining; men and women are affected about equally often.
  • Causes: Infection with the stomach germ Helicobacter pylori, disturbed gastric emptying, disturbed stomach acid production, certain drugs, genetic predisposition, unfavourable lifestyle (stress, alcohol etc.)
  • Symptoms: pain in the upper abdomen, nausea, feeling of fullness, loss of appetite, possibly tarry stools, anaemia
  • Complications: Bleeding from the ulcer, perforation of the stomach with peritonitis
  • Examination: doctor-patient consultation (anamnesis), physical examination, blood test, ultrasound, gastroscopy, breath test
  • Therapy: drug treatment; surgical intervention in case of complications
  • Prognosis: good with early treatment and stomach-friendly lifestyle

Peptic ulcer: Symptoms

Stomach ulcers are one of the most common gastrointestinal diseases. Even more frequently, only the duodenal ulcer (medical term: duodenal ulcer) occurs.

Both stomach and duodenal ulcers typically cause pressing or burning pain in the upper abdomen (epigastrium = between the costal arch and the navel). The complaints often occur in connection with eating or drinking. However, people with duodenal ulcers often have pain on an empty stomach (sobriety pain) and at night. In contrast, an increase in pain shortly after eating is a typical sign of a stomach ulcer.

In addition, loss of appetite, feeling of fullness, nausea and vomiting, and weight loss may indicate a stomach ulcer. Some patients also develop signs of anaemia as a result of a bleeding stomach ulcer.

Some stomach ulcers do not cause any discomfort at all. They are then often only discovered by chance during an examination or only become noticeable when complications arise.

In rare cases, stomach cancer can also cause symptoms similar to those of a stomach ulcer. A gastroscopy, during which a tissue sample is taken (biopsy) and histological examination is performed, will provide clarity.

Peptic ulcer: Complications

Certain painkillers and anti-inflammatory drugs such as acetylsalicylic acid (ASA), ibuprofen or diclofenac can cause stomach ulcers on the one hand. On the other hand, if taken regularly, they can suppress the pain stimulus so that those affected do not notice the typical symptoms of a stomach ulcer. As a result, (severe) complications can develop unnoticed.

The most common complication of stomach ulcers (and duodenal ulcers) is bleeding from the ulcer. A possible sign of this is a pitch-black discolored stool (tarry stool). The black coloration occurs when the blood from the ulcer is decomposed by the acidic gastric juice.

Sometimes the bleeding from the stomach ulcer is so small that the stool does not change colour. However, the continuing blood loss is reflected in a lowered hemoglobin level in the blood.

If a stomach ulcer bleeds very heavily, the person affected may even vomit the blood (vomiting blood or haematemesis). This is life-threatening and must be treated immediately by a doctor!

Rarely does a stomach ulcer break through the stomach wall into the abdominal cavity. Through this hole, digested food and acid can enter the peritoneal cavity and cause peritonitis. Those affected then feel massive pain throughout the entire abdominal cavity (peritonism) and develop a fever.

The rupture of a stomach ulcer is an emergency that must be treated as soon as possible!

Peptic ulcer: Causes and risk factors

Psychological factors: “With so much stress you will get an ulcer sooner or later” – such warnings are heard more often. In fact, stress at work or at home seems to increase the risk of getting a stomach ulcer. This is probably due to the fact that the body produces excessive amounts of gastric acid when under constant stress, while at the same time producing less protective mucus.

Acute stress or shock situations as well as depression also seem to favour the development of stomach ulcers. However, they are unlikely to be the sole triggers. Rather, they only trigger ulcers in combination with other risk factors.

Too much gastric acid: A stomach ulcer develops when the aggressive gastric acid and the protective factors of the stomach lining (e.g. mucus and acid-neutralising salts) are out of balance. If the acid is too strong or the protective factors are too weak, the mucous membrane is damaged and a stomach ulcer can develop. Such an imbalance first causes the stomach lining to become inflamed (gastritis). If the inflammation lasts for a long time or recurs again and again, a stomach ulcer may develop over time.

Disturbed processes in the stomach: Disturbed stomach movements are also suspected of being able to cause a stomach ulcer. If there is a delay in emptying the stomach and at the same time more bile acid flows back into the stomach, this can promote the development of a stomach ulcer. An increased tendency to ulcers is also observed in people who only produce reduced amounts of the protein that repairs the stomach lining.

The stomach is a hollow muscle and lined inside with a mucous membrane. It protects the stomach from gastric acid. For digestion, food and gastric acid are mixed together in the stomach and transported further towards the intestines by muscle work.

Colonization with Helicobacter plyori: This bacterium, which does not mind the aggressive stomach acid, is the main trigger for a stomach ulcer. The bacterium can be detected in 75 percent of all patients with a stomach ulcer and in up to 99 percent of all patients with a duodenal ulcer. However, the stomach germ alone is not responsible for an ulcer. Only in combination with other risk factors can ulcer formation occur. These risk factors include, for example, the use of certain drugs and unfavourable living and eating habits (see the following points).

Gastritis caused by bacteria
In the case of gastritis caused by bacteria, the protective mucous layer is destroyed by the germs. The stomach acid now attacks the mucous membrane directly and a stomach ulcer can develop.

Taking certain drugs: People who regularly take pain- and anti-inflammatory drugs from the group of non-steroidal anti-inflammatory drugs (NSAIDs or NSAIDs) are particularly susceptible to stomach ulcers. These include active ingredients such as acetylsalicylic acid (ASS), ibuprofen and diclofenac. The combination of cortisone (glucocorticoids) and non-steroidal anti-inflammatory drugs is considered particularly problematic.

Unfavourable eating and living habits: Smoking, alcohol and coffee increase the production of gastric acid and thus increase the risk of stomach ulcers. Certain foods (e.g. spicy foods) can also irritate the stomach lining. What is tolerated is individually very different.

Genetic predisposition: In some families stomach ulcers are more common. This suggests that genetic factors are involved in ulcer formation.

Other causes: Very rarely, stomach ulcers can also be caused by metabolic disorders such as hyperparathyroidism or tumor disease (gastrinoma, Zollinger-Ellison syndrome). Even after major operations, accidents or burns, stomach ulcers can occur. Since various “stress reactions” take place in the body in these situations, such a stomach ulcer is also called a stress ulcer. In addition, people over the age of 65 and those with blood group 0 are more susceptible to stomach ulcers. In addition, people who have already had such an ulcer once can easily develop a new one.

Peptic ulcer: Treatment and prevention

How doctors treat a stomach ulcer depends mainly on the cause. A particularly important role is played by whether the stomach germ Helicobacter pylori has been detected in the stomach of the patient. If this is the case, the doctor will primarily use antibiotics to treat the stomach ulcer in order to eliminate the infection. For this purpose, the affected person takes two different antibiotics (clarithromycin and amoxicillin or metronidazole) daily for seven days. In addition, the doctor will prescribe an acid-reducing medication (for example, a so-called “proton pump inhibitor“). As “stomach protection” they inhibit the production of gastric acid, so that the affected mucous membrane can recover.

Helicobacter treatment with antibiotics is called “Helicobacter pylori eradication therapy”. It is successful in more than 90 percent of patients with a gastric or duodenal ulcer. In rare cases, however, the pathogens causing the stomach ulcer are resistant to one of the antibiotics. Then an effective gastric ulcer therapy is more difficult.

If the bacterium Helicobacter pylori cannot be detected, no antibiotics are used, but only acid-reducing drugs, especially “proton pump inhibitors”. The therapy is symptomatic. This means that it only alleviates the symptoms. Without the damaging effect of gastric acid, the stomach ulcer usually heals itself. In addition, however, it must be ensured that the affected person avoids stomach-irritating substances and foods (alcohol, coffee, nicotine) completely until the stomach ulcer has healed.

In addition to proton pump inhibitors, H2 antihistamines and antacids also have an acid-reducing effect. Here you can read more about the effect and use of these groups of active ingredients in the treatment of stomach ulcers:

Proton pump inhibitors (“stomach protection”)
Proton pump inhibitors block a certain enzyme in the stomach mucosa (H+/K+-ATPase = “proton pump”). This enzyme is very important for the production of gastric acid. By inhibiting the enzyme, the production of gastric acid is completely stopped for a period of about 24 hours. Since an excess of gastric acid is a major cause of peptic ulcer, proton pump inhibitors are an important part of therapies. They are usually taken in the morning because the enzyme to be blocked is mainly formed in the morning. Typical representatives of proton pump inhibitors are the active ingredients omeprazole and pantoprazole.

H2 antihistamine
H2 antihistamines such as cimetidine or ranitidine occupy the sites of attack of histamine, an important messenger substance for the formation and release of gastric acid. Since the formation of gastric acid mainly takes place at night, antihistamines should be taken at night. In some cases an additional dose per day is necessary. As part of the treatment of stomach ulcers, an H2 antihistamine can also be combined with a proton pump inhibitor if necessary.

So-called antacids are rarely used in stomach ulcer therapy due to the good effectiveness of proton pump inhibitors and H2 antihistamines. They bind and neutralize the gastric acid, but do not inhibit gastric acid production per se. A typical antacid is the active ingredient sucralfate.

Gastric ulcer treatment: gastroscopy

After completion of the drug treatment of stomach ulcers, a gastroscopy is performed within six to eight weeks. During this process, it is checked whether the ulcer has really healed completely.

In addition, a gastroscopy can be performed to treat complications: If the ulcer is bleeding, the doctor can inject a special protein adhesive (fibrin glue) into the wound during the gastroscopy to stop the bleeding.

Gastric ulcer treatment: Operation

Stomach ulcers are rarely operated on nowadays. For example, in the case of a very persistent ulcer, it may be useful to remove part of the stomach. As a rule, the vagus nerve is also cut (vagotomy) to reduce the production of gastric acid.

If complications of a stomach ulcer occur, surgery may also be necessary. A perforation of the stomach, for example, must always be treated surgically.

Peptic ulcer: Examinations and diagnosis

The right person to contact if you suspect a stomach or duodenal ulcer is a specialist in internal medicine and gastroenterology. However, affected persons can also go to their family doctor first. He may then arrange for further investigations if necessary.

Medical history

At first, the doctor will have a detailed conversation with the patient in order to establish his or her medical history. Possible questions here are:

  • Where exactly do you have stomach pains?
  • Does eating and drinking make the pain stronger or weaker?
  • Do you drink alcohol? If so, how much?
  • You smoke? If so, how much?
  • Do you drink coffee? If so, how much?
  • Are you under a lot of stress right now?
  • Do you take over-the-counter painkillers such as acetylsalicylic acid (ASS), ibuprofen or diclofenac?
  • Are you taking any other medications?
  • Have you or a family member ever had a stomach or duodenal ulcer?
  • Have you ever had a gastroscopy before? If so, when?
  • Do you have any pre-existing conditions or underlying diseases?

Physical examination

After the interview, the doctor will briefly examine the patient if necessary. He carefully palpates the stomach. That way he gets an idea of how much pain is involved. In addition, the palpation may reveal a defensive tension: this means that the abdominal muscles are involuntarily tense due to the pain. For the doctor, this is a sign that he must immediately initiate further examinations and appropriate treatment.

Blood tests

If a stomach ulcer is suspected, the blood of the patient is also examined. If a bleeding stomach ulcer is present, the continuous blood loss may be reflected in anaemia. Typically, the haemoglobin value (Hb) is then lowered.

Various blood values can also indicate whether an inflammation is taking place in the body (number of white blood cells, CRP etc.). This is possible, for example, in the case of a stomach ulcer that has penetrated the stomach wall.


An ultrasound examination of the abdomen can help to rule out other possible causes for the abdominal pain. Thus, the pain can also originate from other abdominal organs such as the liver or gall bladder. However, in order to be able to assess the condition of the stomach and duodenum more accurately, a gastroscopy is necessary.


The gastroscopy (gastroscopy) serves to confirm the diagnosis of “stomach ulcer”. A flexible hose with a light source and small optics installed at the front end helps here. This endoscope is carefully advanced via the mouth and oesophagus into the stomach and up to the duodenum. In this way, the doctor can directly examine possible changes in the mucous membrane.

Tissue removal

During gastroscopy, the doctor can take tissue samples (biopsies) from suspicious mucous membrane areas using the endoscope. They are examined microscopically in the laboratory. In this way it can be determined whether the mucous membrane changes are actually a stomach ulcer and not stomach cancer. In addition, the tissue samples can be used to detect colonisation with the stomach germ Helicobacter pylori.

13C-breath test

Another method to detect an infection with Helicobacter pylori is a special breath test. The patient drinks a special solution with marked 13C-urea. If Helicobacter bacteria live in the stomach, they break down the urea. As a result, carbon dioxide labelled with 13C can be detected in the exhaled air.

Peptic ulcer: Course of disease and prognosis

If a stomach ulcer is consistently treated with medication at an early stage and a stomach-friendly lifestyle is maintained, the ulcer usually heals without any problems or complications. A stomach-friendly lifestyle includes avoiding alcohol, nicotine and caffeine as far as possible, not eating any foods that irritate the stomach (because they are very hot or spicy) and avoiding stress as far as possible.

If complications such as bleeding or a perforation of the stomach wall occur, healing usually takes much longer.

Peptic ulcer: Prevention

You can do a lot yourself to prevent an ulcer. This is especially important if you have had a stomach ulcer before.

Pay attention to your diet, for example: Avoid very hot as well as spicy foods, because they irritate the stomach lining. For the same reason, you should be careful with alcohol and coffee – some people’s stomachs react irritably to even small amounts of these stimulants, in which case a complete abstention is advisable. Other people tolerate at least an occasional glass of wine or a cup of coffee quite well.

To prevent stomach ulcers, you should also avoid stress if possible. Ensure regular periods of relaxation in everyday life, for example in the form of walks, gardening, meditation or yoga. Try out what will give you the best rest.

Some people need to take medication regularly, which can damage the stomach and cause a stomach ulcer. Then you should talk to the doctor treating you to see if it is possible to reduce the dose or switch to a better tolerated preparation.


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