A peptic ulcer is erosion in the lining of the stomach or duodenum (the first part of the small intestine). The word “peptic” refers to pepsin, a stomach enzyme that breaks down proteins. If a peptic ulcer is located in the stomach it is called a gastric ulcer.

Small ulcers may not cause any symptoms. Large ulcers can cause serious bleeding. Most ulcers occur in the first layer of the inner lining. A hole that goes all the way through is called a perforation of the intestinal lining. A perforation is a medical emergency.

Normally, the lining of the stomach and small intestines have protection against the irritating acids produced in your stomach. For a variety of reasons, the protective mechanisms may become faulty, leading to a breakdown of the lining. This results in inflammation (gastritis ) or an ulcer.

The most common cause of such damage is infection of the stomach with a bacterium called Helicobacter pylori (H.pylori). Most people with peptic ulcers have this organism living in their gastrointestinal (GI) tract. On the other hand, many people have this organism living in their GI tract but they don't get an ulcer.

Other factors can make it more likely for you to get an ulcer, including:

• Using aspirin, ibuprofen, or naproxen
• Drinking alcohol excessively
• Smoking cigarettes and using tobacco

In addition, if you have a family history of ulcers or you are blood type O, you are more likely to get a duodenal ulcer. There is also a rare condition called Zolliger-Ellison syndrome in which a tumor in the pancreas secretes a substance that causes ulcers throughout the stomach and duodenum.

Many people believe that stress causes ulcers. It is not clear if this is true. While critically ill patients who are on a breathing machine are at risk of so-called “stress ulceration,” everyday stress at work or home doesn't appear to cause peptic ulcers.

Abdominal pain  is a common symptom but it may not always be present. The abdominal pain from peptic ulcers can differ a lot from person to person. For example, the pain may get better or worse after eating a meal.

Other possible symptoms include:

• Nausea, vomiting
• Weight loss
• Fatigue
• Heartburn, indigestion, belching
• Chest pain
• Vomiting blood
• Bloody or dark tarry stools

It is important to note that you may have no symptoms at all from an ulcer.

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

• An upper GI -- a series of x-rays taken after you drink a substance called barium.
• An esophagogastroduodenoscopy (EGD) -- a special test performed by a gastroenterologist in which a thin tube is inserted through your mouth into the gastrointestinal tract to look at your stomach and small intestines.

During an EGD, the doctor may take a biopsy from the wall of the intestines to test for H. pylori.

Your doctor may also order:

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

You should see a doctor if you have symptoms of an ulcer. Treatment often involves a combination of medications to kill the Helicobacter pylori bacteria, reduce acid levels, and protect the GI tract. This combination strategy allows your ulcer to heal and reduces the chance it will come back. Take all of your medications exactly as prescribed.

• Antibiotics to kill Helicobacter pylori
• Acid blockers (like cimetidine, ranitidine, or famotidine)
• Proton pump inhibitors (such as omeprazole)
• Medications that protect the tissue lining (like sucralfate)
• Bismuth (may help protect the lining and kill the bacteria)

If a peptic ulcer bleeds a lot, an EGD may be needed to stop the bleeding. If bleeding cannot be stopped using an EGD procedure or the ulcer has caused a perforation, then surgery may be required.

Peptic ulcers tend to come back if untreated. If you follow the treatment instructions from your doctor and take all of your medications, the Helicobacter pylori infection will be eliminated and you are much less likely to get another ulcer. Your symptoms will also improve if you follow some preventive lifestyle steps.

• Bleeding internally
• Perforation of the intestine and peritonitis
• Bowel obstruction

Call 911 if you:

• Suddenly develop sharp abdominal pain.
• Have symptoms of shock like fainting, excessive sweating, or confusion.
• Are vomiting blood or have blood in your stool (especially if maroon or dark, tarry black)
• Have a rigid, hard abdomen that is tender to touch.

Call your doctor if:

• You have ulcer symptoms.
• You feel dizzy or lightheaded.

• Don't smoke or chew tobacco.
• Limit alcohol.
• Avoid aspirin, ibuprofen, and naproxen. Try acetaminophen instead.

Spechler, SJ. Peptic Ulcers. In: Feldman, M, Friedman, LS, Sleisenger, MH, eds. Gastrointestinal and Liver Disease, 7th ed. Philadelphia, PA; WB Saunders Company; 2002:747-772.

Noble J. Textbook of Primary Care Medicine. 3rd ed. St. Louis, MO: Mosby; 2001:910-918.

Mahachai V, Thomson AB, Vilaichone RK. Effect of Helicobacter pylori infection and NSAIDs on the risk of peptic ulcer bleeding. J Med Assoc Thai. 2004 Sep;87 Suppl 2:S295-9. Review.