Peptic ulcers

Ulcers may go unnoticed for a long time, particularly if they are caused by painkillers. Because of this, many people don't know that they have an ulcer – or only find out when complications such as bleeding occur.

If an ulcer does lead to symptoms, they are often non-specific. In other words, they could also be caused by other health problems or illnesses. Examples of these non-specific symptoms include:

• a feeling of pressure and fullness
• nausea and vomiting
• lack of appetite and a strong dislike of certain foods
• flatulence ("gas") and irregular bowel movements
• acid regurgitation (belching), heartburn

Ulcers can cause a variety of symptoms, depending on where they are:

• Gastric (stomach) ulcers may cause symptoms in the middle-to-left upper belly area – straight after eating, or sometimes independently of meals.
• In people with a duodenal ulcer, the symptoms tend to occur when their stomach is empty, and then get better after eating. These symptoms are sometimes accompanied by nausea and vomiting.

Most peptic ulcers are caused by one of two things:

• Helicobacter pylori: These are bacteria that can infect mucous membranes, causing an inflammation. The inflammation damages the membranes lining the stomach or duodenum and leads to an increase in stomach acid production. Over time, this breaks down the protective barrier usually provided by the membrane lining.
• The long-term use of anti-inflammatory drugs (NSAIDs): This group of drugs includes acetylsalicylic acid (the drug in medicines like Aspirin), diclofenac, ibuprofen and naproxen. They decrease the production of the hormone prostaglandin, which regulates the production of gastric (stomach) mucus and substances that neutralize stomach acid. If there is too little prostaglandin, the stomach lining becomes more susceptible to damage from stomach acid and germs. Taking painkillers together with steroids can make this harmful effect worse.

Sometimes an ulcer develops because someone has a Helicobacter infection and is taking NSAIDs too.

Ulcers can be caused by other things as well, such as a disease known as Zollinger-Ellison syndrome (where too much stomach acid is made) or stomach surgery that damaged the lining of the stomach. But peptic ulcers can also develop for no known reason.

The risk of getting a peptic ulcer increases with age. It is somewhat more common in men than in women:

Peptic ulcers occur in about 1 to 2 out of 100 people between the ages of 18 and 29 years. Over the age of 45, they occur in 8 to 10 out of 100 women, and in 9 to 14 out of 100 men.

A peptic ulcer can lead to serious complications. The most common type of complication is bleeding. So it's important to see a doctor as soon as possible if you have any of the following symptoms:

• Black-colored stool (poo)
• Vomit with blood in it (red or black vomit)
• Anemia symptoms such as exhaustion, dizziness, shortness of breath during physical activity, or pale skin

You should also see a doctor as soon as possible if you often vomit after eating: Sometimes the opening of the stomach into the bowel gets smaller because ulcers keep developing there and scar tissue builds up. Then the contents of the stomach can no longer pass into the bowel, and are vomited out instead.

Much more rarely, ulcers can lead to the development of a hole (perforation) in the wall of the stomach or bowel. This complication is associated with sudden and very strong stomach pain. It is a life-threatening condition, so these symptoms should be taken seriously and the emergency services should be called immediately (112 in Germany and many other countries, 911 in the U.S.).

To find out whether you have an ulcer, the doctor will first feel your abdomen (belly) with their hands. If it is thought that someone has a peptic ulcer, they will usually have an examination using a gastroscope. This allows the doctor to look at the inside of the food pipe, stomach and first part of the intestine (duodenum). They can also take a tissue sample during this procedure. The sample is then checked for Helicobacter pylori bacteria, an inflammation or abnormal tissue such as cancer cells.

There is no clear scientific proof that factors such as your diet, smoking or chronic stress can increase the risk of peptic ulcers. But it can still be helpful to observe for yourself whether things like fatty or spicy foods cause stomach problems, or whether these problems tend to occur during stressful times.

If you notice that something is triggering your stomach problems, you can try to avoid it. This may include things like alcohol and cigarettes. It can also be worth trying to change your diet, cope differently with stress, relax more and find balance in everyday life.

If you have long-term treatment with anti-inflammatory painkillers such as acetylsalicylic acid (the drug in medicines like Aspirin), ibuprofen, diclofenac or naproxen, it's best to talk with your doctor about whether to also take acid-lowering medication.

Some peptic ulcers go away without treatment after 2 to 3 months. But they often come back.

Gastric ulcers and duodenal ulcers are treated with a type of medication known as proton pump inhibitors (PPIs), for instance with omeprazole or pantoprazole. PPIs reduce the production of stomach acid and are taken for 4 to 8 weeks.

If the ulcer was caused by painkillers, it can be a good idea to stop taking the painkillers for a while so the lining of the stomach can recover. There may be alternatives that are more gentle on the stomach.

If a peptic ulcer is being caused by a Helicobacter pylori infection, a combination of three medications (triple therapy) is generally used to treat it:

• one proton pump inhibitor (PPI),
• one antibiotic drug containing the active ingredient clarithromycin, and
• another antibiotic drug containing the active ingredient metronidazole or amoxicillin.

Sometimes quadruple therapy is used instead. This approach involves taking all four drugs: the three antibiotic drugs and a proton pump inhibitor. It is a treatment option if the bacteria are resistant to some antibiotics. People who are allergic to the antibiotic penicillin can use metronidazole instead of amoxicillin. In both triple and quadruple therapy, the drugs are taken together over a period of 1 to 2 weeks. If you still have symptoms after that, treatment with the proton pump inhibitor can be continued.

After four weeks at the earliest, a special breath test is done to see whether the treatment worked. If it wasn't effective, it can be repeated using a different combination of antibiotics and a proton pump inhibitor.

If the ulcer causes heavy bleeding, it is treated using a minimally invasive (endoscopic) procedure. Various approaches can be used. These include injecting epinephrine (adrenaline), placing a small clip to clamp off the bleeding vessel, or cauterizing it (burning the bleeding vessel to close it off). Sometimes open surgery is needed instead.

When people are ill or need medical advice, they usually go to see their family doctor first. In our topic "Health care in Germany" you can read about how to find the right doctor – and our list of questions can help you to prepare for your visit to the doctor.