Stomach (Gastric) Ulcer

Understanding your guts and digestion

Food passes down the oesophagus (gullet) into the stomach. The stomach makes acid which is not essential, but helps to digest food. After being mixed in the stomach, food passes into the duodenum (the first part of the small intestine). In the duodenum and the rest of the small intestine, food mixes with enzymes (chemicals). The enzymes come from the pancreas and from cells lining the intestine. The enzymes break down (digest) the food which is absorbed into the body.

• Peptic inflammation is inflammation caused by stomach acid. Inflammation can occur in the stomach, the duodenum (as acid flows in with food), or the lower oesophagus (if some acid splashes back up to cause 'reflux oesophagitis').
   
• A peptic ulcer is an ulcer caused by stomach acid. An ulcer is where the lining of the gut is damaged and the underlying tissue is exposed. If you could see inside your gut, an ulcer looks like a small, red crater on the inside lining of the gut.
   
• A stomach ulcer is one type of peptic ulcer. (The most common type of peptic ulcer is a duodenal ulcer.) The rest of this leaflet deals only with stomach ulcers. Separate leaflets deal with duodenal ulcers, and acid reflux which causes oesophagitis.

What causes stomach ulcers?

Many people think that a stomach ulcer is caused by too much acid in the stomach. This is not true. Most people with a stomach ulcer make normal amounts of acid. The problem is the way the lining of the stomach copes with the acid. The stomach makes chemicals and mucus which covers the surface and protects the tissues from the acid. An ulcer occurs if the acid breaks through this protection. Causes of stomach ulcer include the following.

• Infection by H. pylori is the cause in about 7 in 10 cases. This bacterium (bug) affects the lining of the stomach in some way that allows the acid to cause inflammation and ulcers.
• Anti-inflammatory medicines which many people take for arthritis, muscular pains, etc. For example: aspirin, ibuprofen, and diclofenac - but there are others. These medicines sometimes affect the lining of the stomach and allow acid to cause an ulcer.
• Other causes are rare. For example, some virus infections can cause a stomach ulcer. Crohn's disease may cause a stomach ulcer in addition to other problems of the gut.
• Stomach cancer may at first look similar to an ulcer. Stomach cancer is uncommon, but may need to be 'ruled out' if you are found to have a stomach ulcer.

What are the symptoms of a stomach ulcer?

• Pain in the upper abdomen just below the sternum (breastbone) is the common symptom. It usually comes and goes. It may be eased if you take antacid medicines. Sometimes food makes the pain worse. The pain may wake you from sleep.
• Other symptoms which may occur include: bloating, retching, and feeling sick. You may feel particularly 'full' after a meal.
• Complications develop in some cases, and can be serious. These include:
  • Bleeding from the ulcer. This can range from a 'trickle' to a life-threatening bleed.
  • Perforation. This is where the ulcer goes right through ('perforates') the wall of the stomach. Food and acid in the stomach then leak into the abdominal cavity. This usually causes severe pain and is a medical emergency.

What tests may be done?

• Endoscopy is the test that can confirm a stomach ulcer. In this test a doctor looks inside your stomach by passing a thin, flexible telescope down your oesophagus. They can see any inflammation or ulcers. (See leaflet called 'Endoscopy' for details.)
• A test to detect the H. pylori bacterium is usually done if you have a stomach ulcer. If H. pylori is found then it is likely to be the cause of the ulcer. A separate leaflet gives more details about H. pylori and how it can be diagnosed. Briefly, it can be detected in a sample of faeces, or in a 'breath test', or from a biopsy sample taken during an endoscopy.
• Biopsies (small samples) are usually taken of the tissue in and around the ulcer during endoscopy. These are sent to the 'lab' to be looked at under the microscope. This checks for cancer (which is ruled out as the cause of the ulcer in most cases).

What are the treatments for a stomach ulcer?

If H. pylori infection is the cause of the ulcer
Treatment to clear the infection will cure the ulcer. Two antibiotics are needed. In addition, a medicine to reduce the acid in the stomach is needed to allow the antibiotics to work well. You need to take this 'combination therapy' (sometimes called 'triple therapy') for a week. It is important to take the full course. One course of combination therapy clears H. pylori in up to 9 in 10 cases. (However, in a small number of cases, H. pylori infection returns at some stage in the future.)

If an anti-inflammatory medicine is the cause of the ulcer
If possible, you should stop the anti-inflammatory medicine. This allows the ulcer to heal. An acid-suppressing medicine is usually advised for several weeks to allow the ulcer to heal. However, in many cases the anti-inflammatory medicine is needed to ease symptoms of arthritis or other painful conditions. After the ulcer has healed, one option is to take an acid-suppressing medicine each day. This reduces the amount of acid made by the stomach, and greatly reduces the chance of an ulcer forming again.

Treatment for other uncommon causes
Treatment depends on the underlying cause.

After treatment
Another endoscopy may be advised to check that the ulcer has healed. Where appropriate, you may need a test to check that H. pylori has cleared. A second course of 'combination therapy' using different antibiotics is usually advised if the first did not clear the infection.

© EMIS and PIP 2005   Updated: June 2005   PRODIGY Validated