What is a peptic ulcer? 

A peptic ulcer  is a sore on the lining of the stomach or duodenum, the beginning of the small intestine. Less commonly, a peptic ulcer may develop just above the stomach in the esophagus, the tube  that connects the mouth  to the stomach. 

A peptic ulcer in the stomach  is called a gastric ulcer. One that occurs in the duodenum is called a duodenal ulcer. People can have both  gastric and duodenal ulcers at the same time. They also can develop  peptic ulcers more than once in their lifetime. 

Peptic ulcers are common. Each year in the United States, about half a million people develop a peptic ulcer.1 

What causes peptic ulcers? 

A bacterium called Helicobacter pylori (H. pylori)  is a major cause of peptic ulcers. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, are another common cause. Rarely, cancerous or noncancerous tumors  in the stomach, duodenum, or pancreas cause ulcers. 

Peptic ulcers are not caused by stress or eating spicy food, but both can make ulcer symptoms worse. Smoking and drinking alcohol also can worsen ulcers and prevent healing. 

What is H. pylori? 

H. pylori  is a type of bacteria—a germ that may cause infection. H. pylori infection is common, particularly in developing countries, and often begins in childhood. Symptoms usually don’t occur until adulthood, although most people never have any symptoms. 

H. pylori causes more than half of peptic ulcers worldwide.2 The bacterium causes peptic ulcers by damaging  the mucous coating that protects  the stomach and duodenum. Damage to  the mucous coating allows powerful stomach acid  to get through to the sensitive lining beneath. Together, the stomach acid and H. pylori irritate the lining of the stomach or duodenum and cause an ulcer. 

Yet, most people infected with H. pylori never develop ulcers. Why the bacterium causes ulcers in some people and not in others  is not known. Most likely, development of  ulcers depends on characteristics of the infected person; the type, or strain, of H. pylori present;  and factors researchers have yet to discover. 

How is H. pylori spread? 

Researchers are not certain how H. pylori is transmitted, although they think it may be spread through contaminated food or water. People may pick up  the bacterium from food that has not been washed well or cooked properly or from drinking water that has come from an unclean source. 

Other research is exploring how infection spreads from an infected person to an uninfected person. Studies suggest that having contact with  the stool  or vomit of an infected person can spread H. pylori infection. And H. pylori has been found in  the saliva  of some infected people, which means infection could be spread through direct contact with saliva. 

What are the symptoms of a peptic ulcer? 

Abdominal discomfort is the most common symptom of both duodenal and gastric ulcers. Felt anywhere between the navel and the breastbone, this discomfort usually 

• is a dull or burning pain 
• occurs when the  stomach is empty—between meals or during  the night 
• may be briefly relieved by eating food, in the case of duodenal ulcers, or by taking antacids, in both types of peptic ulcers 
• lasts for minutes  to hours 
• comes and goes for several days or weeks 

• weight loss 
• poor appetite 
• bloating 
• burping 
• nausea 
• vomiting 

• sharp, sudden, persistent,  and severe stomach pain 
• bloody or black stools 
• bloody vomit or vomit that looks like coffee grounds 

• bleeding—when acid or  the peptic ulcer breaks a blood vessel 
• perforation—when  the peptic ulcer burrows completely through  the stomach or duodenal wall 
• obstruction—when the peptic  ulcer blocks  the path of food trying to leave the stomach 

How is an H. pylori-induced  ulcer diagnosed? 

Noninvasive Techniques 

If a patient has peptic ulcer symptoms, the doctor first asks about use  of over-the-counter and prescription NSAIDs. Patients who are taking an NSAID are asked to stop, reduce  the dose, or switch to another medication. 

Then the doctor tests to see if H. pylori is present. Testing is important because H. pylori-induced ulcers are treated differently than ulcers caused by NSAIDs. 

Doctors use one  of three simple, noninvasive tests to detect H. pylori in  a patient’s blood, breath,  or stool. Because  the breath test and stool test more accurately detect H. pylori than the blood test, some doctors prefer to use one of these two tests. Each test described below  is easily performed, often  in an outpatient setting such as  a doctor’s office or lab. 

Blood test.  A blood sample is taken from the patient’s vein  and tested for H. pylori antibodies. Antibodies are substances  the body produces  to fight invading harmful substances—called antigens—such as the H. pylori bacterium. 

Urea breath test.  The patient swallows a capsule, liquid,  or pudding that contains urea “labeled” with a special carbon atom. After a few minutes,  the patient breathes into a container, exhaling carbon dioxide.  If the carbon atom  is found in  the exhaled breath, H. pylori  is present, as this bacterium contains large amounts of urease,  a chemical that breaks urea down into carbon dioxide  and ammonia. 

Stool antigen test. The patient provides  a stool sample, which is tested for H. pylori antigens. 

Invasive Techniques 

If a patient has any alarm symptoms, the doctor orders an endoscopy or upper gastrointestinal (GI) series. Many doctors also recommend these tests for patients who first experience peptic ulcer symptoms around age 50. Often performed as outpatient procedures in a hospital, both procedures are painless and allow the doctor to look inside the patient’s stomach and duodenum. 

For an endoscopy,  the patient is lightly sedated. The doctor passes an endoscope—a thin, lighted tube with a tiny camera on the end—into the patient’s mouth and down the throat  to the stomach and duodenum. With this tool, the doctor can closely examine the lining of the esophagus, stomach, and duodenum. 

The doctor can use  the endoscope to take photos  of ulcers or remove  a tiny piece of tissue—no bigger than a match head—to view with a microscope. This procedure is called a biopsy. The biopsied tissue is examined to see if H. pylori is present. 

If an  ulcer is bleeding,  the doctor can use the endoscope to inject medicines that help the blood clot  or to guide a heat probe  that burns tissue to stop bleeding—a process called cauterization. 

For an upper GI series, the patient drinks a white, chalky liquid called barium. The barium makes the esophagus, stomach, and duodenum and any ulcers show up on an x ray. Sedation is not necessary for this procedure. 

How is an H. pylori-induced ulcer treated? 

Peptic ulcers caused  by H. pylori are treated with drugs that kill  the bacteria, reduce stomach acid, and protect the stomach and duodenal lining. 

Antibiotics are used to treat H. pylori. Antibiotic regimens may differ throughout the world because some strains  of H. pylori have become resistant to certain antibiotics—meaning that an antibiotic that once destroyed  the bacterium is no longer effective. Doctors closely follow research on antibiotic treatments for H. pylori infection to know which treatment strategy will destroy which strain. 

• Medicines that reduce stomach acid include proton pump inhibitors (PPIs) and histamine receptor blockers (H2 blockers). Both acid-reducing medicines help relieve peptic ulcer pain after a few weeks and promote ulcer healing. PPIs and H2 blockers work in different ways: 
• PPIs suppress acid production by halting  the mechanism that pumps acid into the stomach. 

H2 blockers work by blocking histamine, which stimulates acid secretion.
While PPIs cannot kill H. pylori, research shows they do help fight the H.  pylori infection. Research also shows that after 4 weeks of treatment, patients taking PPIs had earlier pain relief and better healing rates than those taking H2 blockers. 

Bismuth subsalicylate (Pepto-Bismol) coats ulcers, protecting them from stomach acid. Although bismuth subsalicylate may kill H. pylori, it is used with—not in place of—antibiotics in some treatment regimens. 

In the United States, clarithromycin-based triple therapy—triple therapy, for short—is the standard treatment for an  ulcer caused by H. pylori. The doctor prescribes the antibiotic clarithromycin, a PPI, and the antibiotics amoxicillin or metronidazole for 10 to 14 days. Because research shows higher cure rates with 14 days of treatment, some doctors now prescribe triple therapy for this longer period. 

Bismuth quadruple therapy  is another treatment strategy used in the United States. The patient takes a PPI, bismuth subsalicylate, and the antibiotics tetracycline and metronidazole for 10 to 14 days. Bismuth quadruple therapy  is used to treat patients in one of several situations, including if  the patient 

• cannot take amoxicillin—a penicillin-like antibiotic—because  of a penicillin allergy 
• has been treated before with a macrolide antibiotic, such as clarithromycin 
• is still infected with H. pylori because  triple therapy failed to kill the bacteria 

Triple therapy and bismuth quadruple therapy may cause nausea and other side effects, including 

• stomach upset 
• diarrhea 
• headache 
• a metallic taste 
• a darkened tongue or stools 
• flushing when drinking alcohol 
• sensitivity to the sun 

Patients should discuss any bothersome side effects with their doctor, who may prescribe other medicines to kill the bacteria and cure the ulcer. 

Although antibiotics can cure 80 to 90 percent  of ulcers caused by H. pylori, eliminating  the bacteria can be difficult. Patients must take all medicines exactly as prescribed, even when the peptic ulcer pain is gone. 

At least 4 weeks after treatment, doctors test patients using a breath or stool test to be sure the H. pylori infection has been cured. Blood tests are not useful after treatment because a patient’s blood can test positive for H. pylori even after the bacteria have been eliminated. 

If infection is still present, ulcers could recur or, less commonly, stomach cancer could develop. Thus, some patients need to take more than one round of medicines to kill the H. pylori bacteria. Bismuth quadruple therapy is one of several treatments used after initial treatment has failed—a strategy called “rescue” or “salvage” therapy. In the second round of treatment, the doctor prescribes different antibiotics than those used in the first round. Amoxicillin, however, can be used again to treat H. pylori infection because H. pylori  resistance to this antibiotic is rare. 

Can antacids or milk help  a peptic ulcer heal? 

An antacid may make the ulcer pain go away temporarily, but it will not kill H. pylori. People being  treated for an H. pylori ulcer should check with their doctor before taking antacids. Some  of the antibiotics used to kill H. pylori may not work as well if combined with an antacid. 

People used to believe drinking milk helped peptic  ulcers heal. But doctors know now that while milk may make an ulcer feel better briefly, it  also increases stomach acid, which can  make ulcers worse. Patients should talk with their doctor about drinking milk while an ulcer is healing. 

Can H. pylori infection be prevented? 

No one knows for sure how H. pylori spreads, so prevention is difficult. Researchers are trying to develop a vaccine to prevent—and even cure—H. pylori infection. To help prevent infection, doctors advise people to
wash their hands with soap and water after using the bathroom and before eating
eat food that has been washed well and cooked properly
drink water from a clean, safe source