Peptic Ulcer: Causes, Symptoms, and Treatment


Peptic ulcer is a common condition that affects the lining of the stomach or the upper part of the small intestine. Peptic ulcer can cause discomfort, pain, and various other symptoms. In this article, we will delve into the causes, symptoms, and treatment options for peptic ulcers, providing valuable information to help patients better understand this condition and manage their symptoms effectively.

I. What is a Peptic Ulcer?

A peptic ulcer is an open sore that forms on the inner lining of the stomach (gastric ulcer) or the upper part of the small intestine (duodenal ulcer). Peptic ulcer is primarily caused by the erosion of the protective mucous layer that lines these digestive organs. The most common cause of peptic ulcers is the infection with a bacterium called Helicobacter pylori (H. pylori), but they can also result from long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen.

II. Symptoms of Peptic Ulcer

Peptic ulcer can present with various symptoms, and some individuals may not experience any symptoms at all. However, common signs and symptoms include:

  1. Abdominal pain: This is the most prevalent symptom of peptic ulcers. The pain is often described as a burning or gnawing sensation in the upper abdomen, occurring between meals or during the night.
  2. Nausea and vomiting: Some individuals may experience feelings of nausea and may even vomit, particularly if the ulcer is located in the stomach.
  3. Indigestion: Patients with peptic ulcers often complain of indigestion, bloating, and a feeling of fullness after consuming meals.
  4. Appetite changes: Peptic ulcers can affect appetite, causing loss of appetite or early satiety.
  5. Gastrointestinal bleeding: In severe cases, peptic ulcers can lead to gastrointestinal bleeding, resulting in dark, tarry stools or vomiting of blood. If you experience any signs of bleeding, seek immediate medical attention.

III. Diagnosis of Peptic Ulcer

If you suspect you may have a peptic ulcer, it is essential to consult a gastroenterologist for an accurate diagnosis. Diagnosis may involve:

  1. Medical history: Your doctor will inquire about your symptoms, medical history, and any medications you may be taking.
  2. Physical examination: A physical examination may be conducted to assess any tenderness or abnormalities in the abdomen.
  3. Diagnostic tests: Tests such as blood tests, stool tests, breath tests, and endoscopic procedures (gastroscopy) may be recommended to detect the presence of H. pylori infection or identify the presence of an ulcer.

IV. Peptic Ulcer Classification

Peptic ulcers can be classified based on various factors, including their etiology (cause), location, and characteristics. Here are the commonly used classifications for peptic ulcers:

  1. Etiology-based Classification:

  • Helicobacter pylori (H. pylori) related ulcers: These ulcers are primarily caused by infection with the bacterium H. pylori. It is estimated that H. pylori infection is responsible for the majority of peptic ulcers.
  • Nonsteroidal anti-inflammatory drug (NSAID) induced ulcers: Prolonged use of NSAIDs, such as aspirin, ibuprofen, or naproxen, can irritate the stomach lining and lead to the development of ulcers.
  • Stress-related ulcers: These ulcers are often associated with severe physical stress, critical illness, or major trauma. They are more commonly found in hospitalized patients.
  • Other rare causes: In some cases, peptic ulcers can result from conditions such as Zollinger-Ellison syndrome (gastrin-secreting tumor) or hyperparathyroidism (excessive parathyroid hormone [PTH] production).
  1. Location-based Classification:

  • Gastric ulcers: These ulcers develop in the inner lining of the stomach.
  • Duodenal ulcers: Duodenal ulcers occur in the first part of the small intestine called the duodenum.
  • Esophageal ulcers: These ulcers form in the lining of the esophagus, typically due to gastroesophageal reflux disease (GERD) or other esophageal disorders.
  1. Morphological Classification:

  • Active ulcers: These ulcers are actively eroding and have not yet healed.
  • Healing ulcers: Healing ulcers show signs of regenerating tissue and granulation, indicating the natural healing process.
  • Scarring or healed ulcers: These ulcers have completely healed, leaving behind scar tissue.
  1. Complication-based Classification:

  • Bleeding ulcers: These ulcers have eroded into blood vessels, leading to gastrointestinal bleeding. Bleeding ulcers can result in symptoms such as vomiting blood or passing black, tarry stools (melena).
  • Perforated ulcers: In severe cases, ulcers can penetrate through the entire thickness of the stomach or duodenal wall, causing a hole (perforation). This condition requires emergency medical attention.
  • Obstructive ulcers: These ulcers can cause narrowing or blockage in the digestive tract, leading to symptoms such as severe abdominal pain, bloating, and difficulty swallowing.

These classifications are not mutually exclusive, and an ulcer can fall into multiple categories based on its characteristics and underlying causes.

V. Treatment of Peptic Ulcer

The treatment of peptic ulcer typically involves a combination of endoscopic procedures, medications and lifestyle modifications. The main goals of treatment are to relieve symptoms, promote healing of the ulcer, and prevent complications. Here are some common treatment options:

Endoscopic procedures:

Endoscopic procedures play a crucial role in the management of active peptic ulcers. They allow direct visualization of the ulcer and offer various therapeutic interventions. Here are some common endoscopic procedures used for active peptic ulcer:

  1. Endoscopic Hemostasis: If the peptic ulcer is actively bleeding, endoscopic hemostasis aims to stop the bleeding and prevent further complications. Techniques used include:
    • Injection Therapy: The endoscopist injects a solution (e.g., epinephrine or saline) into and around the ulcer base to constrict blood vessels and promote clot formation.
    • Thermal Therapy: Heat energy is applied to the ulcer base using techniques like heater probe coagulation or argon plasma coagulation to achieve hemostasis.
    • Mechanical Therapy: Endoscopic clips or bands can be applied to the bleeding vessel or ulcer base to achieve hemostasis.
  2. Endoscopic Ulcer Adrenalization: This procedure involves injecting a sclerosing agent (e.g., ethanolamine oleate) into the base of the ulcer to induce ulcer scarring and promote healing. It is typically reserved for refractory ulcers or cases with high rebleeding risk.
  3. Endoscopic Mucosal Resection (EMR): EMR is performed for larger ulcers or suspected malignancies. It involves resecting the ulcer and a surrounding margin of healthy tissue for pathological evaluation.
  4. Endoscopic Submucosal Dissection (ESD): ESD is a more advanced technique used for larger and deeply infiltrating ulcers. It allows en bloc resection of the ulcer and precise histopathological examination.
  5. Band Ligation: This procedure is primarily used for the treatment of bleeding gastric varices. However, it can also be utilized for actively bleeding ulcers by placing bands over the ulcer base to achieve hemostasis.
  6. Over-the-Scope Clip (OTSC): OTSC is a newer endoscopic technique used for difficult-to-treat ulcers or cases of refractory bleeding. The clip, mounted on an applicator, is deployed over the ulcer to achieve hemostasis or closure.


  • Antibiotics: If H. pylori infection is detected, a course of antibiotics will be prescribed to eradicate the bacteria.
  • Proton pump inhibitors (PPIs): These medications reduce stomach acid production, allowing the ulcer to heal. PPIs are often prescribed for a few weeks or months.
  • H2 receptor blockers: These medications reduce the production of stomach acid, promoting healing and symptom relief.

Lifestyle modifications:

  • Avoid triggers: Certain foods, such as spicy or fatty foods, alcohol, and caffeine, may worsen ulcer symptoms. It is advisable to avoid these triggers.
  • Stress management: Stress does not cause ulcers but can aggravate symptoms. Engaging in stress-reducing activities like exercise and relaxation techniques can be beneficial.

Follow-up and monitoring:

Regular follow-up appointments with your healthcare provider are essential to evaluate the effectiveness of the treatment, monitor healing, and make any necessary adjustments to your medication regimen.

VI. Can a Peptic Ulcer Rebleed?

Yes, peptic ulcers can rebleed based on the endoscopic picture as shown in the Table below. This is the so-called Forrest Classification which is used as a tool to identify patients who are at an increased risk for bleeding, rebleeding and mortality.

GradeEndoscopic pictureRebleed risk (%)
IActive hemorrhage
IISigns of recent hemorrhage
IIANon-bleeding visible vessel40-50
IIBAdherent blood clot20-30
IICHematin covered flat spot7-10
IIINo signs of hemorrhage – clean base ulcer3-5

VII. Prevention of Peptic Ulcer

While some risk factors for peptic ulcers, such as H. pylori infection, may be beyond your control, you can take certain steps to minimize the risk of developing ulcers or experiencing a recurrence:

  1. Practice good hygiene: Wash your hands thoroughly to minimize the risk of H. pylori infection.
  2. Limit NSAID use: If you need to take NSAIDs, discuss the appropriate dosage and duration with your doctor to minimize the risk of ulcers.
  3. Manage stress: Adopt stress management techniques to reduce the impact of stress on your digestive system.

Bottom line

Peptic ulcer can cause discomfort and impact daily life. However, with proper diagnosis, treatment, and lifestyle modifications, most ulcers can be effectively managed and healed. If you suspect you have a peptic ulcer or experience persistent symptoms, seek medical attention for a thorough evaluation. Working closely with your gastroenterologist will help you navigate through the treatment process and promote your overall well-being.

How can I contact gastroenterologist Dr. Zavos for an appointment?

Dr. Chris Zavos is a board-certified gastroenterologist and hepatologist, located in Thessaloniki Greece, and specifically in Kalamaria suburb, about 7 kilometres (4 miles) southeast of downtown Thessaloniki. His private office is at: Fanariou 8 street (near Aigaiou and Adrianoupoleos avenues), Kalamaria (Thessaloniki), Greece.

Thessaloniki International Airport is only 10 km away from his private office in Kalamaria and can be reached by taxi within 13 minutes from the airport.

Dr. Chris Zavos performs endoscopies at Bioclinic private hospital in downtown Thessaloniki (Mitropoleos 86 street).

You can contact Dr. Zavos at phone numbers: (+30)-6976596988 and (+30)-2311283833, or you can email him at Dr. Zavos responds to Greek and English languages.

Last update: 21 April 2024, 22:02


Gastroenterologist - Hepatologist, Thessaloniki

PhD at Medical School, Aristotle University of Thessaloniki, Greece

PGDip at Universitair Medisch Centrum Utrecht, The Netherlands

Ex President, Hellenic H. pylori & Microbiota Study Group