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Peptic Ulcer Disease


Nimish Vakil

, MD, University of Wisconsin School of Medicine and Public Health

Topic Resources



  • Discomfort caused by ulcers comes and goes and tends to occur after meals because stomach acid is produced in response to eating.



Ulcers penetrate into the lining of the stomach or duodenum (the first part of the small intestine). Ulcers may range in size from several millimeters to several centimeters. Ulcers can occur at any age, including infancy and childhood, but are most common among middle-aged adults. Gastritis Gastritis Gastritis is inflammation of the stomach lining. The inflammation can be caused by many factors, including infection, stress resulting from severe illness, injury, certain drugs, and disorders... read more Gastritis (stomach inflammation) may develop into ulcer disease.



Gastric ulcers (stomach ulcers) are less common and usually occur in the lower part of the stomach.





By far, the two most common causes of peptic ulcers are



People who smoke are more likely to develop a peptic ulcer than people who do not smoke, and their ulcers heal more slowly and are likely to return. Although alcohol increases stomach acid production, drinking moderate amounts of alcohol does not seem to cause ulcers or delay their healing. Psychologic stress may cause ulcers. Doctors found a higher incidence of ulcer disease in Japan after an earthquake and in New York after the terrorist attacks of 9/11.

A rare cause of peptic ulcers is a type of cancer that releases a hormone called gastrin that causes excess acid production (see Zollinger-Ellison Syndrome Gastrinoma A gastrinoma is a tumor usually in the pancreas or duodenum (the first segment of the small intestine) that produces excessive levels of the hormone gastrin, which stimulates the stomach to... read more ). The symptoms of cancerous ulcers are very similar to those of noncancerous ulcers. However, cancerous ulcers usually do not respond well to the treatments used for noncancerous ulcers.

About 50 to 60% of children who have duodenal ulcers have a family history of peptic ulcer disease. Recent data suggest that this is because H. pylori infection is transmitted among family members. Doctors doubt that people inherit an increased risk of infection.


Symptoms of peptic ulcer disease can vary with the location of the ulcer and the person's age. For example, children, older people, and people whose ulcers were caused by NSAIDs may not have the usual symptoms or may have no symptoms at all. In these instances, ulcers are discovered only when complications Complications A peptic ulcer is a round or oval sore where the lining of the stomach or duodenum has been eaten away by stomach acid and digestive juices. Peptic ulcers can result from Helicobacter pylori... read more Complications develop.

The most common symptom of a peptic ulcer is

  • Mild to moderately severe pain in the upper abdomen

The pain is typically described as gnawing, burning, aching, or soreness or sometimes as a sensation of hunger and is usually located in the upper abdomen just below the breastbone. It is usually relieved by food or antacids. The typical ulcer tends to heal and return. Thus, pain may occur for days or weeks, then wane or disappear, and then return again when the ulcer returns. Only about half of people have typical symptoms.

Duodenal ulcer symptoms tend to follow a pattern. People usually do not have pain when they awaken, but pain appears by mid-morning. Drinking milk or eating (which buffers stomach acid) or taking antacids generally relieves the pain, but it usually returns 2 or 3 hours later. Pain that awakens the person during the night is common. Frequently, the pain erupts once or more a day over a period of one to several weeks and then may disappear without treatment. However, pain usually returns, often within the first 2 years and occasionally after several years. People generally develop patterns and often learn by experience when a recurrence is likely (commonly in spring and fall and during periods of stress).




  • Bleeding (hemorrhage)

  • Penetration

  • Perforation

  • Obstruction (blockage)

  • Cancer


Bleeding (hemorrhage) is the most common complication of ulcers even when they are not painful (see Gastrointestinal Bleeding Gastrointestinal Bleeding Bleeding may occur anywhere along the digestive (gastrointestinal [GI]) tract, from the mouth to the anus. Blood may be easily seen by the naked eye (overt), or blood may be present in amounts... read more Gastrointestinal Bleeding ). Vomiting bright red blood or reddish brown clumps of partially digested blood that look like coffee grounds (hematemesis) and passing black tarry stools (melena) or obviously bloody stools (hematochezia) can be symptoms of a bleeding ulcer. Blood loss may also cause weakness, a decrease in blood pressure when a person stands up, sweating, thirst, and fainting. However, small amounts of blood in the stool may not be noticeable but, if persistent, can still lead to anemia Overview of Anemia Anemia is a condition in which the number of red blood cells is low. Red blood cells contain hemoglobin, a protein that enables them to carry oxygen from the lungs and deliver it to all parts... read more .

Bleeding may result from other digestive conditions as well, but doctors begin their investigation by looking for the source of bleeding in the stomach and duodenum. Unless bleeding is massive, a doctor uses a flexible viewing tube (endoscope) to do an upper endoscopy Diagnosis A peptic ulcer is a round or oval sore where the lining of the stomach or duodenum has been eaten away by stomach acid and digestive juices. Peptic ulcers can result from Helicobacter pylori... read more Diagnosis . If a bleeding ulcer is seen, the endoscope can be used to cauterize it (that is, stop the bleeding with heat). A doctor may also use the endoscope to inject a material that causes a bleeding ulcer to clot.








Doctors do x-rays or CT to aid the diagnosis.



Swelling of inflamed tissues around an ulcer or scarring from previous ulcer flare-ups can narrow the outlet from the stomach or narrow the duodenum. A person with this type of obstruction Intestinal Obstruction An obstruction of the intestine is a blockage that completely stops or seriously impairs the passage of food, fluid, digestive secretions, and gas through the intestines. The most common causes... read more may vomit repeatedly—often regurgitating large volumes of food eaten hours earlier. A feeling of being unusually full after eating, bloating, and a lack of appetite are symptoms of obstruction. Over time, vomiting can cause weight loss, dehydration, and an imbalance in body chemicals (electrolytes Overview of Electrolytes Well over half of the body's weight is made up of water. Doctors think about the body's water as being restricted to various spaces, called fluid compartments. The three main compartments are... read more ).

Doctors base the diagnosis of obstruction on the results of x-rays.

Treating the ulcers and swelling relieves the obstruction in most cases, but severe obstructions caused by scarring may require endoscopic dilation or surgery.



  • Upper endoscopy



During endoscopy, a doctor can do a biopsy (removal of a tissue sample for examination under a microscope) to determine if a gastric ulcer is cancerous and to help identify the presence of Helicobacter pylori bacteria. An endoscope also can be used to stop active bleeding and decrease the likelihood of recurring bleeding from an ulcer.


If Helicobacter pylori infection is successfully treated, peptic ulcer disease comes back in only 10% of people. However, peptic ulcer disease comes back in 70% of infected people who are treated only with drugs that suppress the production of acid.


  • Antibiotics

  • Acid-reducing drugs

  • Antacids

  • Sometimes surgery

Because infection with H. pylori bacteria is a major cause of ulcers, treatment of H. pylori infection with two antibiotics together with bismuth subsalicylate and a proton pump inhibitor (called quadruple therapy) is given when infection is diagnosed. Several different antibiotics may be used, including amoxicillin, clarithromycin, metronidazole, and tetracycline. Some treatments include two antibiotics and a proton pump inhibitor without bismuth subsalicylate (called triple therapy).


Surgery for ulcers is now rarely needed because drugs so effectively heal peptic ulcers and endoscopy so effectively stops active bleeding. Surgery is used primarily to deal with complications of a peptic ulcer, such as

  • A perforation


  • Two or more major episodes of bleeding ulcers

  • A gastric ulcer suspected of being cancerous

  • Severe and frequent recurrences of peptic ulcers


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