Stomach Ulcers: Symptoms, Treatment, and When Surgery Is Needed

Few diagnoses worry patients more than being told they have an ulcer. Many people picture a lifetime of bland food, constant antacids or, worse, a big operation. The reality today is far more reassuring. Most stomach and duodenal ulcers heal with medication once we find and remove the cause, and surgery has become the exception rather than the rule. But "the exception" still matters: a small number of ulcers bleed, burst through the stomach wall or block the stomach outlet, and those situations need fast, expert care.

As a foregut surgeon, I spend a lot of my time on the far end of this spectrum, taking care of the ulcers that did not behave. Here is the whole picture: why ulcers form, which symptoms mean you need help today, how we diagnose and treat them, and exactly when an operation becomes the right answer.

What Is a Peptic Ulcer?

A peptic ulcer is a break in the inner lining of the digestive tract that goes deeper than a simple scrape or erosion. "Peptic" refers to pepsin, one of the digestive enzymes that, together with stomach acid, keeps the wound from healing on its own. There are two main locations:

• Gastric ulcers sit in the stomach itself.
• Duodenal ulcers sit in the duodenum, the first few inches of the small intestine just past the stomach outlet.

People often call both "stomach ulcers," but the distinction matters, because the two types differ in who gets them and how closely they need to be followed. You can find a detailed medical overview on our peptic ulcer disease condition page.

Understanding the Biology Behind the Condition

Your stomach makes enough acid to dissolve a piece of meat, yet it does not digest itself. That is because the lining protects itself with a layer of mucus, a steady supply of bicarbonate that neutralizes acid right at the surface, a rich blood flow and rapid repair of any damaged cells. Chemical messengers called prostaglandins help keep all of these defenses running.

An ulcer forms when that balance tips: either the defenses are weakened, or the acid attack becomes stronger than the lining can handle. In practice, two culprits account for the vast majority of ulcers, and both work by attacking the defenses rather than by simply adding acid (Lanas & Chan, Lancet, 2017).

Helicobacter pylori

H. pylori is a spiral-shaped bacterium that lives under the stomach's mucus layer. It is one of the most common chronic infections in the world, with an estimated 4.4 billion people infected worldwide (Hooi et al., Gastroenterology, 2017). Most infected people never develop an ulcer, but the infection keeps the lining in a state of low-grade inflammation, and in some people that inflammation, combined with changes in acid production, is enough to open a sore. Because the infection is so common and so often silent, I want every ulcer patient tested for it.

NSAIDs and aspirin

Ibuprofen, naproxen, diclofenac, aspirin and similar anti-inflammatory drugs relieve pain by blocking prostaglandins, the same messengers that protect your stomach lining. That is why these widely available, over-the-counter pills are such a common cause of ulcers. The danger is greatest in people who take them regularly, take high doses, are older, have had an ulcer before, or also take blood thinners or steroids (Lanza et al., American Journal of Gastroenterology, 2009).

Less common causes

A minority of ulcers have neither H. pylori nor NSAIDs behind them. Smoking slows healing and raises the chance of recurrence. Rarely, a tumor that overproduces the hormone gastrin drives the stomach to make huge amounts of acid, a condition called Zollinger-Ellison syndrome; I think about it whenever ulcers are multiple, in unusual locations or keep coming back despite good treatment. Ulcers linked to neither main cause are a growing share of cases and call for a more careful search for the reason (Lanas & Chan, Lancet, 2017).

Symptoms: What an Ulcer Usually Feels Like

The classic ulcer symptom is a burning or gnawing ache in the upper middle part of the abdomen, just below the breastbone. Other common complaints include:

• Pain that wakes you up at night
• Pain that changes with meals, either easing or getting worse after eating
• Feeling full quickly, bloating or nausea
• A poor appetite

None of these symptoms is unique to ulcers. Reflux, gallbladder disease, pancreatitis, functional indigestion and even heart problems can feel similar, which is one reason we test rather than guess. Equally important, many ulcers hurt very little or not at all. For some patients, the first sign of an ulcer is a complication.

Warning Signs: When an Ulcer Becomes an Emergency

Ulcers become dangerous in three ways.

1. Bleeding

Bleeding is the most frequent serious complication. When an ulcer erodes into a blood vessel, blood enters the stomach and passes through the intestine. Warning signs include:

• Black, sticky, tar-like stools
• Vomiting blood or material that looks like coffee grounds
• Dizziness or fainting, especially when standing up
• A racing heart, shortness of breath or unusual paleness and fatigue

A fast bleed can be life-threatening within hours. If you have any of the signs above, go to an emergency department; do not wait for an office appointment.

2. Perforation

A perforation happens when the ulcer eats completely through the wall of the stomach or duodenum, letting stomach contents leak into the abdominal cavity. The hallmark is sudden, severe abdominal pain, often described as the worst pain of the patient's life, which may spread across the entire belly or up to the shoulder. The abdomen usually becomes rigid and very tender, and fever and a fast heart rate may follow (Søreide et al., Lancet, 2015). This is a true surgical emergency, and time matters: guidelines recommend operating as soon as possible, and delays are particularly harmful in older patients (Tarasconi et al., World Journal of Emergency Surgery, 2020).

3. Obstruction

Ulcers near the stomach outlet (the pylorus) or in the duodenum can cause swelling and, over time, scarring that narrows the passage. Food then has trouble leaving the stomach. Patients notice:

• Feeling full after only a few bites
• Repeated vomiting, sometimes of food eaten many hours earlier
• Bloating and upper abdominal swelling
• Weight loss and dehydration

This complication, called gastric outlet obstruction or duodenal obstruction, tends to develop over weeks rather than minutes, but it should be evaluated promptly.

How We Diagnose an Ulcer

The most reliable way to find an ulcer is to look at it directly. During an upper endoscopy (EGD), a thin, flexible camera is passed through the mouth into the stomach and duodenum while you are sedated. Endoscopy lets us:

• Confirm whether there is an ulcer and exactly where it is
• Take small tissue samples (biopsies) to check for H. pylori and, for stomach ulcers, to make sure the ulcer is not a cancer
• Judge how risky the ulcer looks, for example whether there is a visible vessel at its base
• Treat bleeding on the spot (Kavitt et al., American Journal of Medicine, 2019)

For patients without warning signs, your doctor may first test for H. pylori with a breath or stool test, which do not require a scope. Some medications, especially acid reducers, can make those tests falsely negative, so tell your doctor everything you are taking before the test (Chey et al., American Journal of Gastroenterology, 2024). When perforation is suspected, a CT scan is usually the fastest way to confirm it in the emergency room (Tarasconi et al., World Journal of Emergency Surgery, 2020).

Medical Treatment: How Most Ulcers Heal

For the uncomplicated ulcer, treatment rests on three steps.

Step 1: Lower the acid

Proton pump inhibitors (PPIs) such as omeprazole, pantoprazole and esomeprazole reduce acid production dramatically and give the lining the chance to repair itself. They are the backbone of ulcer treatment (Lanas & Chan, Lancet, 2017).

Step 2: Treat H. pylori if it is present

If the bacterium is found, it has to be eradicated, because leaving it in place invites the ulcer to return. Antibiotic resistance has changed how we do this. The most recent American College of Gastroenterology guideline recommends a 14-day course of bismuth quadruple therapy (a PPI, bismuth and two antibiotics) as the preferred first treatment for most patients, and recommends against the older clarithromycin-based triple therapy unless testing shows the strain is sensitive (Chey et al., American Journal of Gastroenterology, 2024). After treatment, a follow-up test confirms that the infection is truly gone. Please finish every pill, even if you feel better.

Step 3: Remove the injury

If an NSAID caused the ulcer, the best option is to stop it. Acetaminophen is generally a gentler choice for pain. When a patient truly needs an NSAID or aspirin, for example for heart protection, the usual approach is to continue it with protective acid suppression and the lowest effective dose rather than to stop it on your own (Lanza et al., American Journal of Gastroenterology, 2009). Never stop a prescribed aspirin or blood thinner without talking to the doctor who prescribed it. And if you smoke, quitting is one of the most powerful things you can do for healing.

Stomach ulcers usually get a second look with endoscopy after treatment, to make sure they have healed completely and that nothing was missed. Duodenal ulcers that respond well often do not need a repeat scope.

Endoscopic Treatment: Stopping Bleeding Without an Incision

Even when an ulcer bleeds, the first step today is almost never an operation. Guidelines suggest endoscopy within 24 hours for patients admitted with upper GI bleeding, and the endoscopist can treat high-risk ulcers during the same procedure (Laine et al., American Journal of Gastroenterology, 2021). Tools include small metal clips that pinch the vessel closed, heat probes that seal it, injections and hemostatic powders. After successful treatment, patients receive high-dose PPI therapy to prevent rebleeding (Laine et al., American Journal of Gastroenterology, 2021). If bleeding comes back, a second endoscopy is usually the next step. You can read more on our endoscopic ulcer management page.

Many cases of outlet narrowing from ulcer scarring can be improved by stretching the narrowed area with a balloon passed through the endoscope, combined with acid suppression and treatment of H. pylori.

When Does a Stomach Ulcer Need Surgery?

In the era of PPIs and H. pylori treatment, operations for ulcers that are merely painful have become rare. Surgery is now reserved mainly for complications. These are the situations in which I recommend it:

A perforated ulcer

A hole in the stomach or duodenum almost always needs to be closed surgically and the abdomen washed out. In carefully selected cases, when imaging shows the leak has already sealed itself, non-operative treatment can be considered, but that is the exception (Tarasconi et al., World Journal of Emergency Surgery, 2020). When the patient is stable and the expertise is available, I prefer to do the repair laparoscopically, through a few small incisions; open surgery remains the safer choice for a patient who is unstable (Tarasconi et al., World Journal of Emergency Surgery, 2020). The repair usually consists of closing the hole with sutures, often reinforced with a piece of nearby fatty tissue (omentum). Details are on our surgical repair of perforated ulcer page.

Bleeding that endoscopy cannot control

When endoscopic treatment fails, guidelines suggest transcatheter arterial embolization, in which an interventional radiologist threads a catheter through an artery and blocks the bleeding vessel from the inside (Laine et al., American Journal of Gastroenterology, 2021). Surgery is the next step when embolization is not available, does not work or the patient is too unstable to wait (Tarasconi et al., World Journal of Emergency Surgery, 2020). In the operating room, the bleeding vessel is tied off directly, and in some cases part of the stomach is removed. Learn more on our surgical management of bleeding ulcer page.

An obstruction that does not respond

If the stomach outlet remains blocked despite medication and repeated balloon dilation, surgery creates a new, reliable path for food. Depending on the anatomy, this may mean widening the outlet or creating a bypass that connects the stomach directly to a loop of small intestine. See our gastric outlet obstruction surgery page.

A stomach ulcer that will not heal or may be cancer

A gastric ulcer that persists despite full treatment, or whose biopsies raise concern for cancer, may need to be removed together with part of the stomach. This is uncommon, but it is the reason follow-up endoscopy for stomach ulcers matters.

Whatever the operation, surgery does not replace medical treatment. After any ulcer operation, patients still need H. pylori testing and treatment, an honest look at NSAID and tobacco use, and acid suppression as directed.

A Special Case: Ulcers After Gastric Bypass

Because I have performed more than 9,000 bariatric operations, I want to mention a type of ulcer that is specific to my bariatric patients. After a gastric bypass, an ulcer can form where the small stomach pouch is joined to the intestine. This is called a marginal ulcer. A systematic review of nearly 17,000 patients found that about 4.6% developed one, with smoking, NSAID use and the size and position of the pouch identified as risk factors (Coblijn et al., Obesity Surgery, 2014). That is why I ask every gastric bypass patient to avoid NSAIDs for life and to stop smoking completely. Marginal ulcers can bleed, perforate or narrow just like ordinary ulcers, and they require a surgeon who understands the altered anatomy.

Can Ulcers Be Prevented?

Many can. The most effective steps are simple:

• Be thoughtful about pain relievers. Read labels, because NSAIDs hide in many combination products, and ask your doctor before using them regularly.
• Ask about protection. If you need long-term NSAIDs or aspirin and you have risk factors, ask whether you should take a PPI alongside them.
• Get tested for H. pylori if you have had an ulcer before or have ongoing indigestion, and confirm the cure after treatment.
• Do not smoke, and keep alcohol moderate.
• Do not ignore anemia or black stools. They can be the only signs of a quietly bleeding ulcer.

When to See a Specialist

Make an appointment if you have upper abdominal pain that keeps returning, indigestion that does not settle with a short course of over-the-counter treatment, or symptoms that began after starting an NSAID or aspirin. Seek emergency care right away for vomiting blood, black stools, fainting or sudden severe abdominal pain.

In over 25 years of practice and over 15,000 minimally invasive procedures, I have learned that ulcers are among the most treatable problems we see in the upper digestive tract, as long as the cause is identified and the warning signs are taken seriously. Most patients will never need an operation. For those who do, modern minimally invasive techniques and a coordinated team approach make recovery faster and safer than ever. If you have questions about an ulcer or a complication, my office can be reached at 305-692-0392.