Peptic ulcer disease

Overview

A peptic ulcer is a sore that forms when the inner lining of the gut is worn away by stomach acid and digestive juices. An ulcer in the stomach is called a gastric ulcer. An ulcer in the duodenum (the first part of the small intestine, just after the stomach) is called a duodenal ulcer. Duodenal ulcers are more common than stomach ulcers.

Normally the lining protects itself from acid. Ulcers form when this protection breaks down. The two main reasons are infection with Helicobacter pylori (H. pylori, a germ that lives in the stomach) and regular use of anti-inflammatory painkillers called NSAIDs, which include aspirin and ibuprofen. Many people carry H. pylori and never get an ulcer, so other things such as smoking and alcohol also play a part. Somewhere between 5 and 10 out of every 100 people will have a peptic ulcer at some time in their life.

The main symptom is a burning or gnawing pain in the upper tummy, but some people have no pain at all. The good news is that most ulcers heal with treatment. Clearing H. pylori and stopping or changing NSAIDs greatly lowers the chance of the ulcer coming back. Without treatment, ulcers tend to return and can cause serious problems such as bleeding or a hole in the stomach wall.

Symptoms

• Burning or gnawing pain in the upper tummy, between the belly button and the breastbone
• Pain that is often worse at night or when the stomach is empty, one to three hours after a meal
• With a duodenal ulcer, pain that often eases for a while after eating; with a stomach ulcer, pain that may start soon after eating
• Indigestion or heartburn that keeps coming back
• Bloating or feeling full quickly
• Feeling sick (nausea) or vomiting
• Loss of appetite and weight loss
• Tiredness, which can be a sign of slow blood loss from the ulcer
• Some people, especially those taking NSAIDs, have no pain until a complication such as bleeding happens

Causes and risk factors

Causes

• Infection with H. pylori, a germ that damages the stomach lining; it is behind most duodenal ulcers and many stomach ulcers
• Regular use of NSAID painkillers, including aspirin, ibuprofen and naproxen, which weaken the lining's natural protection
• Some other medicines, such as steroid tablets (corticosteroids), bisphosphonates for weak bones and potassium chloride tablets, especially when combined with NSAIDs
• Very serious illness or injury, such as major burns, head injury or needing a breathing machine (stress ulcers)
• Rare conditions that make the stomach produce too much acid, such as Zollinger-Ellison syndrome

What makes it more likely

• H. pylori infection, which is more common in crowded living conditions and is often picked up in childhood
• Taking NSAIDs or aspirin regularly, especially at older ages or together with steroids or blood thinners
• Smoking or chewing tobacco
• Drinking a lot of alcohol
• Older age
• A close family member (parent, brother or sister) who has had a peptic ulcer
• A past peptic ulcer
• Serious illness, radiation treatment to the belly, or long-term stress

Complications

Most ulcers heal without problems, but some cause serious harm if they are not treated. An ulcer can bleed. Slow bleeding leads to iron deficiency anaemia (low blood), while fast bleeding causes vomiting of blood or black stools and is an emergency. An ulcer can wear right through the wall of the stomach or duodenum (perforation), letting gut contents leak into the belly and causing peritonitis (a serious infection of the belly lining). Swelling and scarring near the stomach exit can block food from leaving the stomach (gastric outlet obstruction), causing repeated vomiting. An ulcer can also burrow into a nearby organ. Long-term untreated H. pylori infection raises the risk of stomach cancer. Ulcers often come back if their cause is not removed.

Diagnosis

The doctor will ask about your symptoms and about every medicine you take, especially painkillers. A blood test may be done to look for anaemia. If there are no warning signs, the usual first step is to check for H. pylori with a breath test or a stool (poo) test. Acid-lowering medicines should be stopped for two weeks before these tests, and antibiotics or bismuth for four weeks, because they can make the result falsely negative. Quick blood antibody tests done in the clinic are not reliable and are not recommended.

An upper endoscopy (gastroscopy: a thin, flexible camera passed through the mouth into the stomach and duodenum) is the most accurate test. It is used for people with warning signs such as bleeding, weight loss, anaemia, swallowing problems or repeated vomiting, and for older people with new symptoms. Small tissue samples (biopsies) can be taken to test for H. pylori and to rule out cancer. People with a stomach ulcer usually have a repeat endoscopy six to eight weeks after starting treatment to make sure it has healed. A CT scan may be used in an emergency to look for a perforation.

Treatment

1. Find the cause: you will be tested for H. pylori, and the doctor or pharmacist will review all your medicines, especially NSAIDs and aspirin. Do not stop any prescribed medicine, such as aspirin for the heart, without asking your doctor.
2. If you have H. pylori, you will be given a short combination treatment, usually lasting one to two weeks: an acid-lowering medicine together with two or more antibiotics, sometimes with bismuth. Your doctor chooses the combination and the dose based on any allergies, antibiotics you have taken before and local resistance patterns. Take every dose until the course is finished.
3. To heal the ulcer, the doctor usually prescribes a proton pump inhibitor (PPI) for several weeks, often four to eight. An H2 blocker is an alternative when a PPI is not suitable or does not work well enough.
4. If NSAIDs caused the ulcer, they are stopped whenever possible. If you really need them, your doctor may switch you to a gentler type of anti-inflammatory and add a stomach-protecting medicine, and will review the need regularly.
5. Check that treatment worked: a breath or stool test is repeated at least four weeks after the H. pylori treatment ends, and stomach ulcers are usually checked again with endoscopy.
6. If H. pylori is still present, a second course with different antibiotics is given. If that also fails, or symptoms do not settle, you will be referred to a stomach specialist (gastroenterologist).
7. Complications are treated in hospital: a bleeding ulcer is usually treated during endoscopy with an injection, clips or heat, and surgery is needed if bleeding cannot be stopped or the ulcer has made a hole in the gut wall.

Medicines in Pakistan

Medicines a doctor may use, by group. Each link opens our page for that medicine, with every brand and its official DRAP price. Your doctor decides which medicine and dose are right for you.

Also used (not yet in our price list): Bismuth preparations (added to some H. pylori treatment combinations), Vonoprazan (a potassium-competitive acid blocker used in some newer H. pylori combinations), Rifabutin (an antibiotic used in some H. pylori combinations), Pantoprazole, lansoprazole and rabeprazole (other proton pump inhibitors), Famotidine (H2 blocker), Sucralfate (a medicine that coats and protects the ulcer)

Self-care and prevention

Self-care

• Do not take NSAIDs such as aspirin, ibuprofen or naproxen unless a doctor has advised it; ask your pharmacist about a safer painkiller such as paracetamol
• Finish the whole H. pylori treatment, even if you feel better after a few days, and go for the follow-up test
• Stop smoking and do not chew tobacco
• Avoid alcohol or keep it to a minimum
• Eat smaller meals and have your evening meal three to four hours before bed
• Cut back on foods and drinks that make your symptoms worse, such as spicy or fatty food, coffee and chocolate
• Keep to a healthy weight and find ways to manage stress
• Tell every doctor, dentist and pharmacist that you have had an ulcer before you are given any new medicine

Prevention

• Use NSAID painkillers only when truly needed and on medical advice; if you must take them long term, ask whether you need stomach protection
• Do not smoke or use any tobacco
• Avoid heavy drinking
• If you have had an ulcer, make sure you were tested for H. pylori and that a follow-up test showed it was cleared
• Adults who live with someone who has H. pylori can ask their doctor about being tested
• Good hygiene and clean drinking water are thought to have helped reduce H. pylori and ulcers worldwide

Common questions

Does spicy food cause stomach ulcers?

The main causes of peptic ulcers are H. pylori infection and NSAID painkillers, not food. However, spicy or fatty food, coffee and chocolate can make the pain worse in some people. It makes sense to cut back on any foods that bother you while the ulcer heals.

Can a peptic ulcer be cured completely?

Yes, in most people. Clearing H. pylori and stopping or changing NSAIDs allows the ulcer to heal and greatly lowers the chance of it coming back. A follow-up breath or stool test is important to confirm the germ has gone.

Why do I need to stop my acid medicine before an H. pylori test?

Acid-lowering medicines, antibiotics and bismuth can hide the germ and give a falsely negative result. Doctors usually ask you to stop acid-lowering medicine for two weeks, and antibiotics or bismuth for four weeks, before a breath or stool test. Ask your doctor what to take for symptoms in the meantime.

Is it safe to take painkillers if I have had an ulcer?

NSAIDs such as aspirin, ibuprofen and naproxen can cause ulcers to come back or bleed. Paracetamol is usually a safer choice for pain, but ask your pharmacist or doctor first. If you need an NSAID or daily aspirin for another condition, your doctor can add a stomach-protecting medicine.

Does stress cause ulcers?

Stress alone is not a main cause, but it is listed as a risk factor and can make symptoms worse. Very severe physical stress, such as major burns, head injury or intensive-care illness, can cause stress ulcers. Managing everyday stress is part of the self-care advice for people with ulcers.

Sources

1. NICE. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management (CG184) - Recommendations (2019).
2. American College of Gastroenterology. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection - Guideline Highlights (2024).
3. NHS. Stomach ulcer - NHS (2025).
4. StatPearls. Peptic Ulcer Disease (2023).
5. MedlinePlus. Peptic ulcer: MedlinePlus Medical Encyclopedia (2025).
6. Journal of the Pakistan Medical Association. Emerging trends of antimicrobial resistance in Helicobacter pylori isolates obtained from Pakistani patients: The need for consideration of amoxicillin and clarithromycin (2016).
7. Tropical Medicine and Infectious Disease (via DOAJ). Drug Resistance Patterns of Commonly Used Antibiotics for the Treatment of Helicobacter pylori Infection among South Asian Countries: A Systematic Review and Meta-Analysis (2023).

Prepared from the sources listed below by the MedInfoBase team. Last reviewed 16 October 2026. This page is general health information, not medical advice. It gives no doses and does not replace a doctor: talk to your doctor or pharmacist before starting, stopping or changing any medicine. How we write and check our pages.

Related conditions

Helicobacter pylori infectionGastro-oesophageal reflux disease (GERD)Iron-deficiency anaemia

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