H. pylori and 


Peptic Ulcers
 

National Digestive Diseases Information Clearinghouse 

U.S. Department 

of Health and 

Human Services 

NATIONAL 

INSTITUTES 

OF HEALTH 

What is a peptic ulcer? 

A peptic ulcer is a sore on the lining of the 

stomach or duodenum, the beginning of the 

small intestine. Less commonly, a peptic 

ulcer may develop just above the stomach 

in the esophagus, the tube that connects the 

mouth to the stomach. 

A peptic ulcer in the stomach is called a gastric ulcer. One that occurs in the duodenum 

is called a duodenal ulcer. People can have 

both gastric and duodenal ulcers at the same 

time. They also can develop peptic ulcers 

more than once in their lifetime. 

Peptic ulcers are common. Each year in the 

United States, about half a million people 

develop a peptic ulcer.1 

What causes peptic ulcers? 

A bacterium called Helicobacter pylori 

(H. pylori) is a major cause of peptic ulcers. 

Nonsteroidal anti-infl ammatory drugs 

(NSAIDs), such as aspirin and ibuprofen, 

are another common cause. Rarely, cancerous or noncancerous tumors in the stomach, 

duodenum, or pancreas cause ulcers. 

Peptic ulcers are not caused by stress or 

eating spicy food, but both can make ulcer 

symptoms worse. Smoking and drinking 

alcohol also can worsen ulcers and prevent 

healing. 

1Ramakrishnan K, Salinas RC. Peptic ulcer disease. 

American Family Physician. 2007;76(7):1005–1012. 

Ulcer 

Stomach 

Large 

intestine 

Esophagus 

Gallbladder Liver 

Duodenum 

Anus Rectum 

Small 

intestine 

Pancreas 

H. pylori bacteria can cause peptic ulcers—sores on 

the lining of the stomach or duodenum. 

What is H. pylori? 

H. pylori is a type of bacteria—a germ 

that may cause infection. H. pylori infection is common, particularly in developing 

countries, and often begins in childhood. 

Symptoms usually don’t occur until adulthood, although most people never have any 

symptoms. 
H. pylori causes more than half of peptic 

ulcers worldwide.2 The bacterium causes 

peptic ulcers by damaging the mucous coating that protects the stomach and duodenum. 

Damage to the mucous coating allows powerful stomach acid to get through to the sensitive lining beneath. Together, the stomach 

acid and H. pylori irritate the lining of the 

stomach or duodenum and cause an ulcer. 

Yet, most people infected with H. pylori 

never develop ulcers. Why the bacterium 

causes ulcers in some people and not in 

others is not known. Most likely, development of ulcers depends on characteristics 

of the infected person; the type, or strain, 

of H. pylori present; and factors researchers 

have yet to discover. 

How is H. pylori spread? 

Researchers are not certain how H. pylori is 

transmitted, although they think it may be 

spread through contaminated food or water. 

People may pick up the bacterium from food 

that has not been washed well or cooked 

properly or from drinking water that has 

come from an unclean source. 

Other research is exploring how infection 

spreads from an infected person to an uninfected person. Studies suggest that having 

contact with the stool or vomit of an infected 

person can spread H. pylori infection. And 

H. pylori has been found in the saliva of some 

infected people, which means infection could 

be spread through direct contact with saliva. 

2Helicobacter pylori and peptic ulcer disease; 

economics of peptic ulcer disease and H. pylori 

infection. Centers for Disease Control and Prevention 

website. www.cdc.gov/ulcer/economic.htm. Accessed 

February 23, 2009. 

2 	 H. pylori and Peptic Ulcers 

What are the symptoms of a 

peptic ulcer? 

Abdominal discomfort is the most common 

symptom of both duodenal and gastric ulcers. 

Felt anywhere between the navel and the 

breastbone, this discomfort usually 

• 	 is a dull or burning pain 

• 	 occurs when the stomach is empty—
 

between meals or during the night
 

• 	 may be briefly relieved by eating food, 

in the case of duodenal ulcers, or 

by taking antacids, in both types of 

peptic ulcers 

• 	 lasts for minutes to hours 

• 	 comes and goes for several days or 


weeks 


Other symptoms of a peptic ulcer may 

include 

• weight loss 

• poor appetite 

• bloating 

• burping 

• nausea 

• vomiting 

Some people experience only mild symptoms 

or none at all. 

Emergency Symptoms 

A person who has any of the following symptoms should call a doctor right away: 

• 	sharp, sudden, persistent, and severe 

stomach pain 

• 	 bloody or black stools 

• 	 bloody vomit or vomit that looks like 

coffee grounds 
These “alarm” symptoms could be signs of a 

serious problem, such as 

• 	 bleeding—when acid or the peptic ulcer 

breaks a blood vessel 

• 	 perforation—when the peptic ulcer burrows completely through the stomach or 

duodenal wall 

• 	 obstruction—when the peptic ulcer 

blocks the path of food trying to leave 

the stomach 

How is an H. pylori-induced 

ulcer diagnosed? 

Noninvasive Techniques 

If a patient has peptic ulcer symptoms, 

the doctor first asks about use of over-thecounter and prescription NSAIDs. Patients 

who are taking an NSAID are asked to 

stop, reduce the dose, or switch to another 

medication. 

Then the doctor tests to see if H. pylori 

is present. Testing is important because 

H. pylori-induced ulcers are treated differently than ulcers caused by NSAIDs. 

Doctors use one of three simple, noninvasive 

tests to detect H. pylori in a patient’s blood, 

breath, or stool. Because the breath test and 

stool test more accurately detect H. pylori 

than the blood test, some doctors prefer 

to use one of these two tests. Each test 

described below is easily performed, often in 

an outpatient setting such as a doctor’s offi ce 

or lab. 

Blood test. A blood sample is taken from 

the patient’s vein and tested for H. pylori 

antibodies. Antibodies are substances the 

body produces to fight invading harmful 

substances—called antigens—such as the 

H. pylori bacterium. 

Urea breath test. The patient swallows a 

capsule, liquid, or pudding that contains urea 

“labeled” with a special carbon atom. After 

a few minutes, the patient breathes into a 

container, exhaling carbon dioxide. If the 

carbon atom is found in the exhaled breath, 

H. pylori is present, as this bacterium contains large amounts of urease, a chemical 

that breaks urea down into carbon dioxide 

and ammonia. 

Stool antigen test. The patient provides a 

stool sample, which is tested for H. pylori 

antigens. 

Invasive Techniques 

If a patient has any alarm symptoms, the 

doctor orders an endoscopy or upper gastrointestinal (GI) series. Many doctors also 

recommend these tests for patients who fi rst 

experience peptic ulcer symptoms around 

age 50. Often performed as outpatient 

procedures in a hospital, both procedures are 

painless and allow the doctor to look inside 

the patient’s stomach and duodenum. 

For an endoscopy, the patient is lightly 

sedated. The doctor passes an endoscope— 

a thin, lighted tube with a tiny camera on the 

end—into the patient’s mouth and down the 

throat to the stomach and duodenum. With 

this tool, the doctor can closely examine 

the lining of the esophagus, stomach, and 

duodenum. 

The doctor can use the endoscope to take 

photos of ulcers or remove a tiny piece of 

tissue—no bigger than a match head—to 

view with a microscope. This procedure 

is called a biopsy. The biopsied tissue is 

examined to see if H. pylori is present. 

3 	 H. pylori and Peptic Ulcers 
If an ulcer is bleeding, the doctor can use the 

endoscope to inject medicines that help the 

blood clot or to guide a heat probe that burns 

tissue to stop bleeding—a process called 

cauterization. 

For an upper GI series, the patient drinks 

a white, chalky liquid called barium. The 

barium makes the esophagus, stomach, 

and duodenum and any ulcers show up on 

an x ray. Sedation is not necessary for this 

procedure. 

How is an H. pylori-induced 

ulcer treated? 

Peptic ulcers caused by H. pylori are treated 

with drugs that kill the bacteria, reduce 

stomach acid, and protect the stomach and 

duodenal lining. 

Antibiotics are used to kill H. pylori. Antibiotic regimens may differ throughout the world 

because some strains of H. pylori have become 

resistant to certain antibiotics—meaning that 

an antibiotic that once destroyed the bacterium is no longer effective. Doctors closely 

follow research on antibiotic treatments for 

H. pylori infection to know which treatment 

strategy will destroy which strain. 

Medicines that reduce stomach acid include 

proton pump inhibitors (PPIs) and histamine receptor blockers (H2 blockers). Both 

acid-reducing medicines help relieve peptic 

ulcer pain after a few weeks and promote 

ulcer healing. PPIs and H2 blockers work in 

different ways: 

• 	 PPIs suppress acid production by halting the mechanism that pumps acid into 

the stomach. 

• 	 H2 blockers work by blocking histamine, 

which stimulates acid secretion. 

While PPIs cannot kill H. pylori, research 

shows they do help fi ght the H. pylori infection. Research also shows that after 4 weeks 

of treatment, patients taking PPIs had earlier 

pain relief and better healing rates than 

those taking H2 blockers. 

Bismuth subsalicylate (Pepto-Bismol) coats 

ulcers, protecting them from stomach acid. 

Although bismuth subsalicylate may kill 

H. pylori, it is used with—not in place of— 

antibiotics in some treatment regimens. 

In the United States, clarithromycin-based 

triple therapy—triple therapy, for short—is 

the standard treatment for an ulcer caused 

by H. pylori. The doctor prescribes the 

antibiotic clarithromycin, a PPI, and the 

antibiotics amoxicillin or metronidazole 

for 10 to 14 days. Because research shows 

higher cure rates with 14 days of treatment, 

some doctors now prescribe triple therapy 

for this longer period. 

Bismuth quadruple therapy is another treatment strategy used in the United States. The 

patient takes a PPI, bismuth subsalicylate, 

and the antibiotics tetracycline and metronidazole for 10 to 14 days. Bismuth quadruple 

therapy is used to treat patients in one of 

several situations, including if the patient 

• 	 cannot take amoxicillin—a penicillinlike antibiotic—because of a penicillin 

allergy 

• 	 has been treated before with a macrolide antibiotic, such as clarithromycin 

• 	 is still infected with H. pylori because 

triple therapy failed to kill the bacteria 

4 	 H. pylori and Peptic Ulcers 
 

Triple therapy and bismuth quadruple 

therapy may cause nausea and other side 

effects, including 

• stomach upset 

• diarrhea 

• headache 

• 	 a metallic taste 

• 	 a darkened tongue or stools 

• flushing when drinking alcohol 

• 	sensitivity to the sun 

Patients should discuss any bothersome side 

effects with their doctor, who may prescribe 

other medicines to kill the bacteria and cure 

the ulcer. 

Although antibiotics can cure 80 to 90 percent of ulcers caused by H. pylori, eliminating 

the bacteria can be difficult. Patients must 

take all medicines exactly as prescribed, even 

when the peptic ulcer pain is gone. 

At least 4 weeks after treatment, doctors test 

patients using a breath or stool test to be 

sure the H. pylori infection has been cured. 

Blood tests are not useful after treatment 

because a patient’s blood can test positive for 

H. pylori even after the bacteria have been 

eliminated. 

If infection is still present, ulcers could recur 

or, less commonly, stomach cancer could 

develop. Thus, some patients need to take 

more than one round of medicines to kill 

the H. pylori bacteria. Bismuth quadruple 

therapy is one of several treatments used 

after initial treatment has failed—a strategy 

called “rescue” or “salvage” therapy. In 

the second round of treatment, the doctor 

prescribes different antibiotics than those 

used in the first round. Amoxicillin, however, can be used again to treat H. pylori 

infection because H. pylori resistance to this 

antibiotic is rare. 

Can antacids or milk help a 

peptic ulcer heal? 

An antacid may make the ulcer pain go away 

temporarily, but it will not kill H. pylori. 

People being treated for an H. pylori ulcer 

should check with their doctor before taking 

antacids. Some of the antibiotics used to kill 

H. pylori may not work as well if combined 

with an antacid. 

People used to believe drinking milk helped 

peptic ulcers heal. But doctors know now 

that while milk may make an ulcer feel better 

briefly, it also increases stomach acid, which 

can make ulcers worse. Patients should talk 

with their doctor about drinking milk while 

an ulcer is healing. 

Can H. pylori infection be 

prevented? 

No one knows for sure how H. pylori spreads, 

so prevention is difficult. Researchers are 

trying to develop a vaccine to prevent—and 

even cure—H. pylori infection. To help prevent infection, doctors advise people to 

• 	 wash their hands with soap and water 

after using the bathroom and before 

eating 

• 	 eat food that has been washed well and 

cooked properly 

• 	 drink water from a clean, safe source 

5 	 H. pylori and Peptic Ulcers 
6 H. pylori and Peptic Ulcers

Points to Remember

• A peptic ulcer is a sore in the lining of 

the stomach or duodenum.

• Most peptic ulcers are caused by 

H. pylori. Use of NSAIDs—such as 

aspirin and ibuprofen—is another 

common cause.

• Neither stress nor spicy food causes 

ulcers. Smoking or drinking alcohol, 

however, each can worsen ulcers and 

prevent their healing.

• The abdominal discomfort of peptic 

ulcers 

– feels like a dull or burning pain

– occurs when the stomach is empty—

between meals or during the night

– may be briefl y relieved by eating 

food, in the case of duodenal ulcers, 

or by taking antacids, in both types of 

peptic ulcers 

– lasts for minutes to hours

– comes and goes for several days or 

weeks

• A combination of antibiotics and acidreducing medicines is the most effective 

treatment for H. pylori-induced peptic 

ulcers.

• Testing after treatment is needed to be 

sure the H. pylori infection is gone.

• To help prevent an H. pylori infection, 

people should

– wash their hands after using the 

bathroom and before eating

– eat properly prepared food

– drink water from a clean, safe source

Hope through Research

While H. pylori infection is becoming less 

common in developed countries, some 

strains of the bacteria have become resistant 

to antibiotics that are used to destroy it. 

Researchers have identifi ed and continue to 

study new antibiotic combinations that can 

kill these types of H. pylori.

Other promising research may help identify 

treatments that

• kill the H. pylori bacteria with fewer 

medicines in less time

• use different antibiotic combinations in 

back-to-back treatment

• better protect the stomach lining when 

eliminating H. pylori

Researchers also are studying

• characteristics of H. pylori bacteria

• traits of people who develop H. pylori

ulcers

• transmission of H. pylori infection

• vaccines to prevent and cure H. pylori

infection

Participants in clinical trials can play a more 

active role in their own health care, gain 

access to new research treatments before 

they are widely available, and help others 

by contributing to medical research. For 

information about current studies, visit 

www.ClinicalTrials.gov.

 

 

 
For More Information 

American College of Gastroenterology 

P.O. Box 342260 

Bethesda, MD 20827–2260 

Phone: 301–263–9000 

Internet: www.acg.gi.org 

American Gastroenterological Association 

4930 Del Ray Avenue 

Bethesda, MD 20814 

Phone: 301–654–2055 

Fax: 301–654–5920 

Email: member@gastro.org 

Internet: www.gastro.org 

Acknowledgments 

Publications produced by the Clearinghouse 

are carefully reviewed by both NIDDK scientists and outside experts. This publication 

was reviewed by Sheila Crowe, M.D., and 

David Peura, M.D., University of Virginia 

School of Medicine, Charlottesville, VA. 

You may also find additional information about this 

topic by visiting MedlinePlus at www.medlineplus.gov. 

This publication may contain information about 

medications. When prepared, this publication 

included the most current information available. 

For updates or for questions about any medications, 

contact the U.S. Food and Drug Administration 

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or visit www.fda.gov. Consult your doctor for more 

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document are used only because they are considered 

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If a product is not mentioned, the omission does not 

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7 H. pylori and Peptic Ulcers 
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AND HUMAN SERVICES 

National Institutes of Health 

NIH Publication No. 10–4225 

April 2010