A peptic ulcer is erosion in the lining of the stomach or the first part of the small intestine, an area called the duodenum.

If the peptic ulcer is located in the stomach it is called a gastric ulcer.

Normally, the lining of the stomach and small intestines are protected against the irritating acids produced in your stomach. But for a variety of different reasons, the protective process can stop working correctly, and the lining breaks down. The results in inflammation (gastritis) or an ulcer.

Most ulcers occur in the first layer of the inner lining. A hole that goes all the way through is called a perforation. A perforation is a medical emergency.

The most common cause of such damage is infection of the stomach by bacteria called Helicobacter pylori (H.pylori). Most people with peptic ulcers have these bacteria living in their gastrointestinal (GI) tract. Yet, many people who have such bacteria in their stomach do not develop an ulcer.

The following also raise your risk for peptic ulcers:

• Drinking too much alcohol
• Regular use of aspirin, ibuprofen, naproxen, or other nonsteroidal anti-inflammatory drugs (NSAIDs)
• Smoking cigarettes or using tobacco

If you have a family history of ulcers or the blood type O, you are more likely to get a duodenal ulcer.

A rare condition called Zollinger-Ellison syndrome causes stomach and duodenal ulcers. Persons with this disease have a tumor in the pancreas that releases high levels of a hormone, which causes an increase in stomach acid.

Many people believe that stress causes ulcers. It is not clear if this is true, at least for everyday stress at home. However, a very ill patient who is on a breathing machine is at risk for so-called “stress ulceration.”

Small ulcers may not cause any symptoms. Large ulcers can cause serious bleeding.

Abdominal pain is a common symptom but it doesn't always occur. The pain can differ a lot from person to person. For example, it may get better or worse after eating a meal.

Other possible symptoms include:

• Belching
• Bloody or dark tarry stools
• Chest pain
• Fatigue
• Heartburn
• Indigestion
• Nausea
• Vomiting, possibly bloody
• Weight loss

To diagnose an ulcer, your doctor will order one of the following tests:

• Esophagogastroduodenoscopy (EGD) is a special test performed by a gastroenterologist in which a thin tube with a camera on the end is inserted through your mouth into the GI tract to see your stomach and small intestine. During an EGD, the doctor may take a biopsy from the wall of your stomach to test for H. pylori.
• Upper GI is a series of x-rays taken after you drink a thick substance called barium.

Your doctor may also order these tests:

• Hemoglobin blood test to check for anemia
• Stool guaiac to test for blood in your stool

Treatment involves a combination of medications to kill the H. pylori bacteria (if present), reduce acid levels, and protect the GI tract. This strategy allows your ulcer to heal and reduces the chance it will come back.

Take all of your medications exactly as prescribed.

• Acid blockers (such as cimetidine, ranitidine, or famotidine)
• Antibiotics to kill H. pylori
• Bismuth to help protect the lining and kill the bacteria
• Medications that protect the tissue lining (such as sucralfate)
• Proton pump inhibitors such as omeprazole (Prilosec), lansoprazole (Prevacid), or esomeprazole (Nexium)

If a peptic ulcer bleeds a lot, an EGD may be needed to stop the bleeding. Surgery may be needed if bleeding cannot be stopped with an EGD, or if the ulcer has caused a perforation.

Peptic ulcers tend to come back if untreated. If you follow your doctor's treatment instructions and take all of your medications as directed, the H. pylori infection will be cured and you'll be much less likely to get another ulcer.

• Bleeding inside the body (internal bleeding)
• Gastric outlet obstruction
• Inflammation of the tissue that lines the wall of the abdomen (peritonitis)
• Perforation of the stomach and intestines

Call 911 if you:

• Develop sudden, sharp abdominal pain
• Have a rigid, hard abdomen that is tender to touch
• Have symptoms of shock such as fainting, excessive sweating, or confusion
• Vomit blood or have blood in your stool (especially if it's maroon or dark, tarry black)

Call your doctor if:

• You feel dizzy or lightheaded
• You have ulcer symptoms

Lifestyle changes may help prevent peptic ulcers:

Tips include:

• Avoid aspirin, ibuprofen, naproxen, and other NSAIDs. Try acetaminophen instead. If you must take such medicines, talk to your doctor first.
• Don't smoke or chew tobacco.
• Limit alcohol to no more than two drinks per day.

Ramakrishnan K, Salinas RC. Peptic ulcer disease. Am Fam Physician. 2007;76(7):1005-12.

Chey WD, Wong BC. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. Aug 2007;102(8):1808-25.

Malagelada JR, Kuipers EJ, Blaser MJ. Acid peptic disease: clinical manifestations, diagnosis, treatment, and prognosis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 142.