Stomach ulcers are mostly caused by a bacterium and by painkillers, not by stress

The folk idea that ulcers come from stress or spicy food has been overtaken by evidence. A peptic ulcer is a sore on the lining of the stomach or duodenum, sometimes called a stomach ulcer, a duodenal ulcer, or peptic ulcer disease [s1]. Researchers estimate about 1% to 6% of people in the United States have peptic ulcers, and the two most common causes are an infection with the bacterium Helicobacter pylori and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) [s1].

The two dominant causes

NIDDK is direct about the drivers: people are more likely to develop peptic ulcers if they are infected with H. pylori or are taking NSAIDs such as aspirin, ibuprofen and naproxen, and H. pylori infection and taking NSAIDs are the two most common causes [s1]. Risk is also higher in older adults, in people who have had an ulcer before, and in smokers [s1].

H. pylori is a common worldwide infection and an important cause of both peptic ulcer disease and gastric cancer [s3]. Its reach extends further: the American College of Gastroenterology notes the organism may also have a role in uninvestigated and functional dyspepsia, in ulcer risk among patients taking low-dose aspirin or starting an NSAID, in unexplained iron-deficiency anaemia, and in idiopathic thrombocytopenic purpura [s3].

An epidemiology in flux

The disease is not what it was. A Lancet seminar describes a rapidly declining prevalence of H. pylori infection, which together with the widespread use of potent anti-secretory drugs means peptic ulcer disease has become substantially less prevalent than it was two decades ago [s2]. But the authors argue management has become more challenging than ever, because of the threat of increasing antimicrobial resistance worldwide and the widespread use of complex anti-thrombotic therapy in an ageing population [s2].

There is also a residual group that fits neither classic cause. Peptic ulcers not associated with H. pylori infection or with NSAID use are now imposing substantial diagnostic and therapeutic challenges of their own [s2].

Why treatment is getting harder

Curing an H. pylori ulcer means eradicating the bacterium, and resistance has changed how that is done. The ACG guideline states that clarithromycin triple therapy should be confined to patients with no previous history of macrolide exposure who live where clarithromycin resistance among H. pylori isolates is known to be low [s3]. Most patients, it says, will be better served by first-line treatment with bismuth quadruple therapy or with concomitant therapy consisting of a proton pump inhibitor, clarithromycin, amoxicillin and metronidazole [s3]. When first-line therapy fails, the salvage regimen should avoid antibiotics that were previously used [s3].

That is a meaningful shift from the reflex prescription of a single standard triple therapy, and it is driven by the same resistance the Lancet seminar flags [s2][s3]. The choice of regimen now depends on a patient's prior antibiotic exposure and on local resistance patterns rather than on a one-size-fits-all script [s3].

The complications that make ulcers serious

An ulcer is dangerous mainly through what it can lead to. NIDDK lists the complications of peptic ulcers as bleeding in the stomach or duodenum; a perforation, or hole, in the wall of the stomach or duodenum, which can lead to peritonitis, an infection of the lining of the abdominal cavity; penetration of the ulcer into a nearby organ; and a blockage that can stop food moving from the stomach into the duodenum [s1]. These are the events that turn a treatable sore into an emergency.

The honest position

Stomach ulcers are, for most people, a consequence of a treatable infection or of common painkillers rather than of temperament or diet [s1]. That matters because it points to real actions — testing for and eradicating H. pylori, and reviewing NSAID use — rather than to vague lifestyle blame [s1][s3]. It also means self-treatment with over-the-counter acid reducers can mask a problem that has a specific, testable cause.

This article is informational and is not medical advice, and the regimens above are not a prescription. Peptic ulcer disease and its treatment should be managed by a clinician. Seek urgent care for signs of a bleeding or perforated ulcer — vomiting blood, black or tarry stools, or sudden severe abdominal pain [s1].

Sources

• Definition & Facts for Peptic Ulcers (Stomach or Duodenal Ulcers) — National Institute of Diabetes and Digestive and Kidney Diseases
• Peptic ulcer disease — The Lancet, 2017-08-01
• ACG Clinical Guideline: Treatment of Helicobacter pylori Infection — American Journal of Gastroenterology, 2017-02-01