Stomach and Duodenal Ulcer: Symptoms, Causes, Diagnosis and Treatment

The commonest symptom is pain or burning in the epigastrium, the upper abdomen below the breastbone. Classically, the pain of a duodenal ulcer appears when fasting or at night and eases after eating, whereas the pain of a gastric ulcer more often worsens after a meal. These patterns are only a guide, however: in many people the symptoms cannot be told apart from functional dyspepsia (which we cover in a separate article), and some ulcers, especially in older people taking NSAIDs, cause no pain at all.

Other symptoms are fullness and early satiety, nausea, bloating, belching and heartburn. Note that the symptoms typical of an ulcer are not specific: they do not allow a certain diagnosis without endoscopy, which is one reason why gastroscopy is recommended for people with alarm features or of older age. Sometimes the first sign is only a complication — gastrointestinal bleeding.

The first cause is infection with Helicobacter pylori. The bacterium colonises the gastric lining, causes chronic inflammation and disturbs defence mechanisms, which favours the formation of an ulcer, especially in the duodenum. The infection is now formally recognised as an infectious disease, and the Maastricht VI/Florence consensus (2022) recommends in principle treating all infected people, stressing the problem of rising antibiotic resistance and the need to choose effective regimens.

The second cause is non-steroidal anti-inflammatory drugs such as ibuprofen, diclofenac, naproxen or ketoprofen, and aspirin, including the low doses used in cardiology. They inhibit the synthesis of prostaglandins that protect the lining. The risk is especially significant in older people, those with a history of ulcer and those taking anticoagulant or antiplatelet drugs at the same time. Importantly, the two main causes act together: H. pylori in people taking low-dose aspirin increases the risk of upper gastrointestinal bleeding.

Other causes are rarer: tobacco smoking (promotes ulcers and delays healing), severe general illness, certain infections, conditions with excessive acid secretion (for example Zollinger-Ellison syndrome) and Crohn’s disease. The Lancet review notes that ulcers unrelated to H. pylori or NSAIDs need special diagnostic attention. Neither coffee, nor spicy food, nor stress on its own is considered a main cause of ulcers, although they may worsen the symptoms felt; we write about coffee on an empty stomach separately.

Diagnosis of an ulcer rests on endoscopic examination of the upper gastrointestinal tract (gastroscopy), during which the doctor assesses the lining and can take biopsies. In a gastric ulcer, biopsies are especially important because they make it possible to exclude a malignant lesion that looks like an ulcer. After treatment of a gastric ulcer, doctors often order a follow-up examination to confirm healing — the decision is individual. We describe the procedure, its preparation and risks in the knowledge base entry on gastroscopy.

Independently of gastroscopy, a test for H. pylori is done: a urea breath test, a stool antigen test or examination of a biopsy. In practice it is stressed that certain drugs can falsify results — this applies especially to proton pump inhibitors and to antibiotics taken shortly before the test, so whether they should be stopped beforehand is for the doctor, not the patient, to decide. A positive result is an indication for eradication therapy, and its success is usually confirmed with another test after the course ends.

When is gastroscopy necessary? It depends on age and symptoms. Dyspepsia guidelines propose gastroscopy for people from age 60 with new symptoms, and in younger people an H. pylori test as the first step. Regardless of age, the examination is indicated with bleeding, anaemia, weight loss, difficulty swallowing and persistent vomiting. If trouble swallowing is the main problem, we recommend our article on dysphagia.

Treatment rests on three pillars: removing the cause, suppressing acid secretion and avoiding harmful factors. The cause is most often H. pylori — in which case an eradication regimen of several drugs is used (a proton pump inhibitor and antibiotics, usually for 10–14 days, chosen according to local resistance), and with NSAIDs, stopping or changing the painkiller if possible. The best-documented effect of eradication is reduced ulcer relapse.

Proton pump inhibitors (PPIs) speed ulcer healing. In a large meta-analysis of randomised trials (849 trials, more than 142,000 participants), gastroprotectant drugs increased healing of endoscopic ulcers (odds ratio 3.49), with PPIs more effective (5.22) than prostaglandin analogues and H2 blockers. In prevention, these drugs reduced the development of endoscopic ulcers (OR 0.27) and upper gastrointestinal bleeding (OR 0.40), with the largest reduction in bleeding given by PPIs (OR 0.21). The authors caution that the results may have overestimated the benefit because of small-study bias.

How long should a PPI be taken? The duration depends on the ulcer’s location, cause and complications; in practice it is usually weeks (often 4–8), and the decision on length of therapy and dose rests with the doctor. After treatment ends there is usually no need to take a PPI indefinitely, provided the cause has been removed and the patient is not taking drugs risky for the stomach. Long-term PPI use without a clear indication carries possible adverse effects — we write about lowered magnesium and vitamin B12 in a separate article and in the knowledge base entry on PPIs.

Many patients take NSAIDs or aspirin out of necessity — for rheumatic disease, chronic pain, after a heart attack or stroke. Stopping aspirin yourself after a heart attack or stroke can be dangerous, so the decision to change treatment belongs to the doctor. In such situations the protective strategy is to add a proton pump inhibitor and, in infected people, to treat H. pylori.

Bleeding is the commonest dangerous complication of an ulcer. It shows as black, tarry stools, vomiting blood or matter resembling coffee grounds, weakness, pallor, palpitations and dizziness. This is a life-threatening condition needing immediate medical help, not home treatment.

The 2021 American College of Gastroenterology (ACG) guideline suggests endoscopy within 24 hours of presentation and endoscopic therapy for ulcers with active bleeding or a non-bleeding visible vessel. After successful haemostasis it recommends high-dose PPI therapy — continuously or intermittently — for three days, followed by an oral PPI twice daily for the first two weeks after endoscopy. It also suggests a red-cell transfusion threshold of 7 g/dL haemoglobin in hospitalised patients and the possibility of outpatient care for very-low-risk people (Glasgow-Blatchford score 0–1). These are recommendations for doctors and hospitals, not a self-treatment manual.

In the gastroprotectant meta-analysis, among patients with acute upper gastrointestinal bleeding these drugs reduced the risk of further bleeding (OR 0.68), blood transfusion (0.75) and surgery (0.72), without significantly reducing mortality. This shows that drug therapy helps limit complications but does not replace prompt medical help.

A second common myth is the belief that once the pain goes away with a protective drug, the ulcer is cured. Pain relief does not mean healing or removal of the cause, and relapse is highly likely if the bacterium is not eliminated. That is why, after eradication therapy, its success is usually confirmed with a follow-up test.

A stomach or duodenal ulcer is a disease in which establishing the cause matters as much as healing the defect. An H. pylori test and a review of painkillers and anticoagulants are the two most worthwhile steps. Eradication therapy and proton pump inhibitors are well documented, and the key to avoiding complications is a quick response to signs of bleeding.