Stomach ulcers, also referred to as gastric ulcers are open sores that form on the lining

of the stomach. These ulcers are sometimes called peptic ulcers named after pepsin, a
digestive juice in the stomach that may contribute to peptic ulcer disease. [1]

Gastric ulcers arise when the protective mucous lining in the stomach is eroded,
allowing gastric acids and digestive enzymes to damage the walls of these organs. This
erosion leads to persistent irritation and the development of open sores. If left
untreated, stomach ulcers can give rise to serious complications, including internal
bleeding, and in advanced cases, they may perforate the organ, posing a medical
emergency. The thick layer of mucus that shields the stomach from digestive juices
diminishes in stomach ulcers, enabling these acids to harm the stomach lining tissues
and form ulcers.

The main causes of gastric ulcers are infection with the bacterium Helicobacter pylori (H.
pylori) and prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs) like
ibuprofen and naproxen sodium. Contrary to popular belief, stress and spicy foods do
not directly cause peptic ulcers, although they can exacerbate symptoms.

Citations:

[1] NHS inform. (2023, December 13). Stomach ulcer (gastric ulcer) | NHS inform. NHS

Inform. https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-

gastrointestinal-tract/stomach-ulcer/

[2] NHS inform. (2023b, December 13). Stomach ulcer (gastric ulcer) | NHS inform. NHS

Inform. https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-

gastrointestinal-tract/stomach-ulcer/

[4] Professional, C. C. M. (n.d.). Stomach ulcer. Cleveland Clinic.

https://my.clevelandclinic.org/health/diseases/22314-stomach-peptic-ulcer

[5] Peptic ulcer - Symptoms and causes - Mayo Clinic. (2022, June 11). Mayo Clinic.

https://www.mayoclinic.org/diseases-conditions/peptic-ulcer/symptoms-causes/syc-

20354223
PREVALENCE
Studies conducted in various regions of India have investigated the prevalence of gastric ulcers.
In urban Kashmir, a study revealed a point prevalence of 4.72% and a lifetime prevalence of
11.22% for peptic ulcers. The prevalence of peptic ulcers showed an age-related increase,
reaching a peak of 28.8% in the fifth decade of life. Interestingly, socio-economic status did not
show a significant correlation with the occurrence of peptic ulcers. Additionally, the prevalence
of complications such as bleeding, stenosis, or perforation was comparable to rates reported in
Western populations.
Another study conducted in northern India reported a point prevalence of 3.4% and a lifelong
prevalence of 8.8% for active peptic ulcers.
These findings highlight regional variations in the prevalence of gastric ulcers in India, with
certain demographic groups experiencing a higher prevalence. Age was identified as a factor
influencing the prevalence, and the duodenal to gastric ulcer ratio was notably elevated.

Khuroo, M. S., Mahajan, R., Zargar, S. A., Javid, G., & Munshi, S. (1989). Prevalence of
peptic ulcer in India: an endoscopic and epidemiological study in urban
Kashmir. Gut, 30(7), 930–934. https://doi.org/10.1136/gut.30.7.930

Etiology of Gastric Ulcer

The primary culprits behind peptic ulcers are Helicobacter pylori (H. pylori) infection and
the use of nonsteroidal anti-inflammatory drugs (NSAIDs). These causes overshadow
less common or rare factors contributing to peptic ulcers.

Risk factors increase the likelihood of ulcer development, and two main causes are:

1. H. pylori Infection: H. pylori infection is a prevalent trigger for peptic ulcers.

Possibilities including person-to-person spread through vomit, stool, or saliva contact,
contaminated food or water may also facilitate bacterial transfer. [2] H. pylori bacteria
live in the stomach lining. The bacteria can irritate the stomach lining and make it more
vulnerable to damage from stomach acid. Infections are common. It’s possible to be
infected without realising it because the infection doesn’t usually cause symptoms.
People of all ages can be infected. [1]

2. NSAIDs: Nonsteroidal anti-inflammatory drugs widely used to treat pain, a high

temperature (fever) and inflammation (swelling), such as aspirin, ibuprofen, diclofenac
and naproxen, are another major cause. While these medications alleviate pain, they
render the stomach lining more susceptible to damage and ulcer formation. Certain
types of NSAIDs pose a higher risk, especially when taken in high doses, for an extended
period, or in conjunction with other medications that amplify ulcer risks. [2]
Many people take NSAIDs without having any side effects. But there’s always a risk the
medication could cause problems, such as stomach ulcers, particularly if taken for a
long time or at high doses.

Additional risk factors and less common causes of peptic ulcers include:

a. Infections: Peptic ulcers can be triggered by viral infections such as CMV, fungi, or
bacteria other than H. pylori.
b. Medications: Certain drugs, including corticosteroids, those prescribed for low
bone mass, and certain antidepressants, can elevate the risk of developing ulcers,
especially when taken alongside NSAIDs.
c. Surgery or Medical Procedures: Interventions affecting the stomach or
duodenum may contribute to ulcer formation.
d. Diseases and Health Conditions: Conditions such as stomach-related diseases,
injuries, blockages, or compromised blood flow to the stomach or duodenum can
lead to ulcers. Life-threatening conditions requiring critical care, severe chronic
diseases like cirrhosis or chronic obstructive pulmonary disease, and Zollinger-
Ellison syndrome, where tumors prompt excessive acid production in the
stomach, are also potential triggers.
e. Lifestyle Factors:

 stress: Stress is not a direct cause of peptic ulcers, but it can exacerbate the
symptoms and delay the healing process [1][2][5]. While stress does not directly
cause ulcers, it can lead to an increase in stomach acid production, which may
worsen existing ulcers[3]. Additionally, stress can weaken the immune system
and slow down the body's ability to fight infections, potentially impacting the
healing of ulcers[5]. Therefore, while stress is not a primary cause of peptic
ulcers, it can play a role in the worsening of symptoms and the healing process.
 Citations:
[1] What to know about stress ulcers. (2019, April 17).

https://www.medicalnewstoday.com/articles/32499

[2] Lee, Y. B., Yu, J., Choi, H. H., Jeon, B. S., Kim, H., Kim, S. W., Kim, S. S., Park, Y.

G., & Chae, H. S. (2017). The association between peptic ulcer diseases and mental

health problems. Medicine, 96(34), e7828. https://doi.org/10.1097/md.000000000000782

[3] Clinic, C. (2023, December 11). Can stress give you a stomach ulcer? Cleveland Clinic.

https://health.clevelandclinic.org/can-stress-give-you-an-ulcer

[5] Can stress cause stomach ulcers? Get the facts from a gastroenterologist. (n.d.). Scrubbing in

by BSWHealth. https://www.bswhealth.com/blog/can-stress-cause-ulcers

 Alcohol- Alcohol does not directly cause gastric ulcers, but it can worsen existing
ulcers and hinder the healing process. The consumption of alcohol, including
beer and wine, can lead to increased stomach acid production, which may
exacerbate the symptoms of ulcers and interfere with their healing[1][3][4]. While
there is no clear evidence to suggest that alcohol consumption is a direct cause
of peptic ulcers, heavy drinking is considered a risk factor for the development of
stomach ulcers[2][4]. Therefore, it is recommended to avoid or limit alcohol
consumption if you have a gastric ulcer, as it can make the ulcers more painful
and prevent them from healing[1][3].

 Citations:
[1] Tarr, J. (2023, August 10). Alcohol and ulcers: Signs, symptoms & treatment. The Recovery

Village Drug and Alcohol Rehab.

https://www.therecoveryvillage.com/alcohol-abuse/ulcer-from-drinking/

[2] Msw, C. R. H. (2024, January 16). Alcohol and the digestive system. American Addiction

Centers. https://americanaddictioncenters.org/alcohol/risks-effects-dangers/

gastrointestinal

[3] Ferguson, S. (2023, January 12). Is there a connection between alcohol use and ulcers?

Healthline. https://www.healthline.com/health/alcohol-and-ulcers

[4] Rees, M. (2023, October 6). What to know about alcohol and ulcers.

https://www.medicalnewstoday.com/articles/alcohol-and-ulcers

[5] Alcohol drinking and cigarette smoking: a “partner” for gastric ulceration. (2000, December

1). PubMed. https://pubmed.ncbi.nlm.nih.gov/11195134/

Smoking: increase your risk of developing stomach ulcers and make treatment less
effective as it adversely affects the gastroduodenal mucosal protective mechanisms,
increases the risk of H. pylori infection, and allows the reflux of harmful duodenal
contents back into the stomach. Smokers are also more likely to develop ulcers that are
more difficult to heal. The risk of peptic ulcers is associated with the quantity of tobacco
use, and smokers may benefit immediately by stopping or reducing cigarette
consumption (Eastwood, 1988)

Eastwood G. L. (1988). The role of smoking in peptic ulcer disease. Journal of clinical
gastroenterology, 10 Suppl 1, S19–S23. https://doi.org/10.1097/00004836-198812001-
00005

Ko, J. K., & Cho, C. H. (2000). Alcohol drinking and cigarette smoking: a "partner" for
gastric ulceration. Zhonghua yi xue za zhi = Chinese medical journal; Free China
ed, 63(12), 845–854.

Ma, L., Chow, J. Y., & Cho, C. H. (1998). Effects of cigarette smoking on gastric ulcer
formation and healing: possible mechanisms of action. Journal of clinical
gastroenterology, 27 Suppl 1, S80–S86. https://doi.org/10.1097/00004836-199800001-
00013

Smoking and the digestive system. (2020, July 20). Johns Hopkins Medicine.

https://www.hopkinsmedicine.org/health/conditions-and-diseases/smoking-and-the-

digestive-system

In rare instances, peptic ulcers have no discernible cause, leading to their classification
as idiopathic peptic ulcers. [1]

[1] Symptoms & Causes of Peptic Ulcers (Stomach or Duodenal Ulcers). (2022, November

15). National Institute of Diabetes and Digestive and Kidney Diseases.

https://www.niddk.nih.gov/health-information/digestive-diseases/peptic-ulcers-stomach-

ulcers/symptoms-causes
[2] Woolf, A. (2023, November 3). Gastric ulcer. StatPearls - NCBI Bookshelf.

https://www.ncbi.nlm.nih.gov/books/NBK537128/

[3] NHS inform. (2023c, December 13). Stomach ulcer (gastric ulcer) | NHS inform. NHS

Inform. https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-

gastrointestinal-tract/stomach-ulcer/#stomach-ulcer-causes

Pathophysiology

Peptic ulcers, which encompass gastric ulcers, are characterized by disruptions in the gastric or
duodenal mucosa, extending through the muscularis. The epithelial cells of the stomach and
duodenum respond to mucosal irritation by secreting protective mucus. A gel layer in the
superficial part of the gastric and duodenal mucosa acts as a barrier impermeable to acid and
pepsin. Additionally, certain cells in the gastric and duodenal lining release bicarbonate,
contributing to acid buffering near the mucosa. Under normal conditions, a balance exists
between the secretion of gastric acid and the defense mechanisms of the gastroduodenal mucosa.

The pathophysiology of gastric ulcers arises when this delicate balance is disrupted. Aggressive
factors such as nonsteroidal anti-inflammatory drugs (NSAIDs), H. pylori infection, alcohol, bile
salts, acid, and pepsin can alter mucosal defense. This alteration allows the back diffusion of
hydrogen ions, leading to mucosal injury and subsequent peptic ulcer formation. Defensive
mechanisms encompass tight intercellular junctions, bicarbonate and mucus secretion, and
prostaglandin synthesis.
The mechanism of peptic ulcer disease (PUD) results from an imbalance between protective and
destructive factors in the gastric mucosa. Risk factors that predispose individuals to PUD include
H. pylori infection, NSAID use, a first-degree relative with PUD, emigration from a developed
nation, and African American/Hispanic ethnicity.
In the context of peptic ulcers, mucosal defects extending to the muscularis mucosa are common.
Once the protective superficial mucosal layer is compromised, the inner layers become
vulnerable to acidity. The ability of mucosal cells to secrete bicarbonate is also compromised in
the presence of peptic ulcers. H. pylori, known to colonize the gastric mucosa and induce
inflammation, further impairs bicarbonate secretion, fostering the development of acidity and
gastric metaplasia. (Malik, 2023)
Malik, T. F. (2023, June 5). Peptic ulcer disease. StatPearls - NCBI Bookshelf.

https://www.ncbi.nlm.nih.gov/books/NBK534792/
Peptic ulcer - Symptoms and causes - Mayo Clinic. (2022b, June 11). Mayo Clinic.

https://www.mayoclinic.org/diseases-conditions/peptic-ulcer/symptoms-causes/syc-

20354223

NHS inform. (2023d, December 13). Stomach ulcer (gastric ulcer) | NHS inform. NHS Inform.

https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-

tract/stomach-ulcer/#stomach-ulcer-symptoms

Anand, B., MD. (n.d.). Peptic Ulcer Disease: background, anatomy, pathophysiology.

https://emedicine.medscape.com/article/181753-overview?form=fpf

DIAGNOSIS

The diagnosis of gastric ulcers involves a combination of tests and procedures to confirm the
presence of an ulcer and identify the underlying cause. The main diagnostic methods include:

1. Testing for Helicobacter pylori (H. Pylori) infection: If a healthcare professional suspects
that your symptoms are caused by an H. Pylori infection, they may recommend one of the
following tests:

a. Urea breath test: You’ll be given a drink containing urea (a chemical that’s broken down
by H. Pylori), and your breath is then checked after a short period to see whether you
have an H. Pylori infection.
b. Stool antigen test: A small stool sample is tested for the bacteria.
c. Blood test: A sample of your blood is tested for antibodies to the H. Pylori bacteria
(antibodies are proteins produced naturally in your blood and help to fight the infection)
[1][2].

2. Gastroscopy: This is a procedure to look inside your stomach directly and see whether you
have a stomach ulcer. It involves passing a thin, flexible tube (an endoscope) with a camera
through your mouth and into your stomach. The images taken by the camera will usually confirm
or rule out an ulcer. A small tissue sample may also be taken from your stomach or duodenum to
test for the H. Pylori bacteria[1][2].
If you test positive for H. Pylori, you’ll need treatment to clear the infection, which can heal the
ulcer and prevent it from returning. If an ulcer is confirmed, treatment will be provided based on
the underlying cause, such as antibiotics for H. Pylori infection or medications to reduce acid
production[1][2].

Citations:
[1] https://www.nhs.uk/conditions/stomach-ulcer/diagnosis/
[2] https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-
tract/stomach-ulcer/
[3] https://www.nhs.uk/conditions/stomach-ulcer/
[4] https://emedicine.medscape.com/article/181753-overview
[5] https://www.mayoclinic.org/diseases-conditions/peptic-ulcer/symptoms-causes/syc-20354223

SIGNS AND SYMPTOMS

The signs and symptoms of a gastric ulcer, also known as a stomach ulcer, can include:

1. **Burning or gnawing pain**: The most common symptom is a burning or gnawing pain in
the center of the abdomen.
2. **Indigestion and heartburn**: This may include a feeling of fullness, bloating, or belching.
3. **Nausea**: Some individuals may experience feelings of sickness or a loss of appetite.
4. **Other less common symptoms**: These can include weight loss, intolerance to fatty foods,
and in some cases, vomiting blood or passing dark, sticky, tar-like stools, which could indicate a
serious complication[1][2][3][4].

It’s important to seek medical advice if you experience persistent symptoms of a stomach ulcer,
especially if you have any of the less common or more severe symptoms mentioned above. A
healthcare professional can conduct tests to diagnose a stomach ulcer, which may involve
checking for Helicobacter pylori (H. Pylori) infection and performing a gastroscopy to look
inside the stomach directly[5].

Citations:
[1] https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-
tract/stomach-ulcer/
[2] https://www.nhs.uk/conditions/stomach-ulcer/symptoms/
[3] https://www.mayoclinic.org/diseases-conditions/peptic-ulcer/symptoms-causes/syc-20354223
[4] https://www.nhs.uk/conditions/stomach-ulcer/
[5] https://www.nhs.uk/conditions/stomach-ulcer/diagnosis/

MNT
The management of gastric ulcers typically involves a combination of medical treatment and
dietary modifications. While medical treatment is essential to heal the ulcer and address the
underlying cause, dietary changes can help alleviate symptoms and support the healing process.
Some common dietary recommendations for individuals with gastric ulcers include:

1. **Avoiding irritants**: It is often suggested to avoid spicy foods, coffee, and alcohol, as
these can exacerbate symptoms and potentially contribute to mucosal damage[1].

2. **Increasing consumption of bland foods**: Bland foods are generally easier on the
stomach and may help reduce discomfort. Examples of bland foods include bananas, rice,
applesauce, and toast (BRAT diet).

3. **Avoiding or limiting milk**: While milk was previously recommended for its potential
to provide gastric alkalinization and relieve pain, it is now generally not recommended
due to its buffering effect and the significant gastric acid[2].

4. **Testing and treating for H. Pylori infection**: If H. Pylori infection is present,

treatment to clear the infection is essential for healing the ulcer and preventing its
recurrence[5].
 5. **Gastroscopy**: This procedure is often performed to confirm the presence of a
stomach ulcer and, if necessary, to take a tissue sample for testing. It is an important step
in the diagnosis and management of gastric ulcers[5].

It’s important for individuals with gastric ulcers to work closely with healthcare professionals to
develop a comprehensive treatment plan that addresses both medical and dietary needs. This may
involve consultation with a registered dietitian or nutritionist to ensure that dietary
recommendations are tailored to the individual’s specific needs and preferences.

Citations:
[1] https://nutritionguide.pcrm.org/nutritionguide/view/Nutrition_Guide_for_Clinicians/
1342027/all/Gastritis_and_Peptic_Ulcer_Disease
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4743227/
[3] https://www.webmd.com/digestive-disorders/ss/slideshow-stomach-ulcers-best-worst-foods
[4] https://www.ncbi.nlm.nih.gov/books/NBK537128/
[5] https://www.nhs.uk/conditions/stomach-ulcer/diagnosis/
Fiber supplementation can play a role in the treatment of gastric ulcers. The physicochemical
properties of fiber fractions produce different physiological effects in the gastrointestinal tract.
Soluble fibers, found in foods like apples, oatmeal, and pears, increase viscosity in the intestinal
content, while insoluble fibers (whole grains, granola, flaxseed) increase stool bulk, reduce
transit time in the large intestine, and make fecal elimination easier and quicker[1].

A diet rich in fibers is advisable for individuals with gastric ulcers, with a recommended intake
of 20 to 30 g/day[1]. Fibers act as buffers, reducing concentrations of bile acids in the stomach
and the intestinal transit time, resulting in less abdominal bloating and decreasing discomfort and
pain in the gastrointestinal tract[1].

Research shows that a high-fiber diet decreases the risk of developing ulcer disease, with both
insoluble and soluble fibers demonstrating this association[2]. Foods high in soluble fiber
include oats, psyllium husk, legumes, flax seeds, barley, and nuts[2].
While fiber supplementation can be beneficial for gastric ulcers, it is essential to investigate the
individual’s nutritional status and address any nutritional deficiencies[1]. In some cases, vitamin
A supplementation may also be beneficial, as it increases the production of mucus in the
gastrointestinal tract, which can protect against the development of ulcer disease[2].

Citations:
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4743227/
[2] https://badgut.org/information-centre/health-nutrition/diet-for-ulcer-disease/
[3] https://pubmed.ncbi.nlm.nih.gov/8303206/
[4] https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-
tract/stomach-ulcer/
[5] https://my.clevelandclinic.org/health/diseases/22314-stomach-peptic-ulcer

PREBIOTICS
Prebiotics are non-digestible food ingredients that promote the growth of beneficial bacteria in
the gut. They can be beneficial for individuals with gastric ulcers, as they can help improve gut
health and reduce the risk of complications. Some studies have shown that prebiotics can play a
role in the management of gastric ulcers:

1. **Probiotics**: Probiotics are live bacteria and yeasts that are beneficial for gut health.
They can help protect against the development of ulcers and play a role in their
prevention or treatment. Some studies have identified probiotic strains effective in H.
Pylori eradication via immunological and non-immunological mechanisms[1].

2. **VSL#3**: The probiotic mixture VSL#3, a mixture of eight probiotic strains, has been
shown to accelerate gastric ulcer healing by stimulating vascular endothelial growth
factor[3].

3. **Lactobacillus rhamnosus GG**: This probiotic strain has been found to enhance
gastric ulcer healing in rats[3].
While prebiotics are not directly mentioned in the search results, they can be beneficial for
individuals with gastric ulcers by promoting the growth of beneficial bacteria in the gut. A diet
rich in fibers, which can act as prebiotics, is advisable for individuals with gastric ulcers, with a
recommended intake of 20 to 30 g/day[5]. Fibers act as buffers, reducing concentrations of bile
acids in the stomach and the intestinal transit time, resulting in less abdominal bloating and
decreasing discomfort and pain in the gastrointestinal tract[5].

Citations:
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4906699/
[2] https://www.sciencedirect.com/science/article/pii/S0924224421001783
[3] https://pubmed.ncbi.nlm.nih.gov/23484048/
[4] https://healthnews.com/nutrition/vitamins-and-supplements/best-probiotics-for-ulcers/
[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4743227/