Peptic Ulcers : Causes, Risks, and the Red-Flag Symptoms

Written by: Wendy Haaf

Updated: September 24th, 2025

Gastroenterology experts Dr. Sander Veldhuyzen van Zanten and Dr. Keith McIntosh explain what peptic ulcers are, why they develop, and the warning signs that should never be ignored. They discuss common causes, serious complications, and how treatment and prevention strategies have evolved- offering clear guidance on recognizing risks, managing symptoms, and benefiting from the latest advances in care. Let’s jump in!

What is a peptic ulcer?

Normally, a layer of mucous protects the inner lining of the stomach and the first part of your small intestine (duodenum) from the strong stomach acid and enzymes that break down food. But if something damages or weakens the mucous barrier, those fluids can reach the lining. Over time, this can cause an open sore—an ulcer—to form.

Common symptoms

Many ulcers don’t cause any symptoms. When they do, the most common is pain in the upper abdomen (above the belly button and below the sternum or breastbone) that may get better after eating. Some people also feel a burning sensation, feel bloated, or burp a lot. The medical term for these symptoms is dyspepsia.

It’s important to note that dyspepsia isn’t always caused by an ulcer. Among people with dyspepsia who undergo a test called gastroscopy, “about five to seven percent will turn out to have a peptic ulcer,” Dr. Sander Veldhuyzen van Zanten, an Emeritus Professor of Medicine in the Division of Gastroenterology at the University of Alberta in Edmonton. (During a gastroscopy, a flexible tube with a tiny camera on the end is passed from the mouth into the stomach.)

When to investigate

Frequent dyspepsia that interferes with your ability to do normal activities doesn’t always require gastroscopy investigation. Your doctor will decide whether you need this test based on a number of factors. If you’re young and otherwise healthy, your doctor may decide to prescribe a medication that reduces stomach acid. In addition to helping to ease symptoms, these drugs are also used to treat ulcers. If your symptoms fail to improve after taking the prescribed medication for eight to sixteen weeks, the next step is gastroscopy.

On the other hand, gastroscopy will usually be recommended if you have any of the following:

A family history of stomach or colorectal cancer
Age 50 or older
Unexplained weight loss
Food getting stuck on the way to the stomach
Feeling full after a few bites of food
Repeated vomiting
Vomiting blood or material that looks like coffee grounds
Bloody or black stool

Causes and risk factors

Bacteria

A type of bacteria called Helicobacter pylori or H pylori, “is one of the major causes of stomach ulcers located inside the stomach or just outside of the stomach,” says Dr. Veldhuyzen van Zanten. In fact, approximately 60% of peptic ulcers are caused by H pylori infection, he adds.

H pylori can disrupt the stomach’s mucous lining and increase production of stomach acid. The infection, which people usually acquire during childhood, is very common, affecting an estimated one in five Canadians, and up to 75% of the members of some Indigenous communities. That said, having the infection doesn’t mean you’ll develop ulcers. Only about 10–20% of people with H pylori infection will go on to develop pan ulcer.

Pain Medications

“The other very important risk factor for ulcers is the use of pain medications called NSAIDs, which are painkillers such as ibuprofen (Advil), naproxen (Aleve) and piroxicam (Apo-Piroxicam),” says Dr. Veldhuyzen van Zanten. About five to 10% of people who take NSAIDs regularly will develop ulcers, he adds.

Some other medications used to prevent heart attacks and stroke increase the risk of peptic ulcers, too, though not as strongly. “Aspirin, in a small percentage of people, can cause ulcers,” Dr. Veldhuyzen van Zanten explains. So can other drugs that interfere with blood clotting, such as clopidogrel. Blood thinners, such as warfarin, and newer anti-clotting agents like apixaban and dabigatran, increase the risk that ulcers will bleed.

Smoking is also an important risk factor. “If you smoke, you’re more likely to get dyspepsia and you’re more likely to get ulcers,” Dr. Veldhuyzen van Zanten notes.

Smoking

Age over 65, frailty or poor overall health, and physical stress are each linked with an increased risk of ulcers as well.

Other

A subset of people who develop bleeding peptic ulcers, however, have none of these known risk factors. These are described as idiopathic, meaning there is no known cause. “We’re not quite sure why, but we see more ulcers than in the past that are not Helicobacter related, and not NSAID related,” says Dr. Veldhuyzen van Zanten. It’s hard to say exactly how common idiopathic peptic ulcers are, but some studies suggest approximately 20 to 25 percent of peptic ulcers are not related to either H pylori or NSAIDs.

Bleeding and other complications

In some cases, peptic ulcers can cause serious complications. Over the long term, H pylori-infections that go untreated or persist for years can sometimes lead to stomach cancer. Overall, this is rare, occurring in less than one in 1,000 people. Patients with stomach ulcer have a higher risk of cancer (less than five percent).

The most common complication that can cause immediate danger is bleeding, which occurs in approximately five to 10% of people who are diagnosed with peptic ulcers. “The more risk factors a patient has, the more likely he or she is to present with a bleeding ulcer,” says Dr. Veldhuyzen van Zanten.

Bleeding from a peptic ulcer, “can range from very minor to life-threatening,” explains Dr. Keith McIntosh, an Associate Professor of Medicine at Western University and Gastroenterology Site Director at St. Joseph’s Health Care London (Ontario). There are complications other than bleeding,” Dr. McIntosh adds. Peptic ulcers can perforate or eat a hole through the stomach. They can also cause so much swelling and inflammation that the opening where food normally exits becomes blocked (obstruction).

Symptoms of bleeding

The main clues that this bleeding is taking place, are “either you vomit blood, or you poop black stool, which we call melena,” Dr. Veldhuyzen van Zanten explains. “Those people should be seen urgently by a physician who can decide what they need.” But slow bleeding can also occur, leading to anemia (low blood count).

Managing a bleeding-related crisis

An ulcer that’s been bleeding heavily can cause a medical emergency known as hypovolemic shock. This means the heart and other organs are in danger of becoming damaged from lack of enough blood. The treatment for this is called resuscitation. “People need a lot of intravenous fluids and potentially, blood transfusions,” Dr. McIntosh explains. “If someone is very unstable, they may need to go to the intensive care unit.”

In addition to receiving resuscitation measures, someone in this situation will usually be given an intravenous (IV) medication that’s used to treat peptic ulcers. This class of drugs, called proton pump inhibitors (PPIs), strongly reduces the production of stomach acid. This gives the ulcer a chance to heal.

Diagnosing and managing bleeding

Once a patient is stablized, a gastroscopy is usually performed. This procedure can fill several roles. It typically allows the gastroenterologist to definitively diagnose the cause of bleeding—such as a bleeding ulcer— and gauge its size and the amount of damage to the stomach lining. “When someone comes in with a bleed, we don’t necessarily know it’s an ulcer,” Dr. McIntosh explains. For example, bleeding can also be due to tears in the lining of the esophagus (food pipe), abnormal blood vessels, or even cancer.

Managing bleeding after diagnosis

If a lesion or ulcer is actively bleeding, interventions to try and stop it can be done at the same time. There are a variety of techniques we can use,” Dr. McIntosh explains. “We can inject, clip, or burn the ulcer.” If the area where the bleeding is occurring appears unusual, the gastroenterologist can also take a small tissue sample.(This biopsy is used to rule out cancer and determine whether an individual is infected with H pylori.)

If these approaches don’t work or aren’t suitable, “our sort of last-ditch endoscopic treatment is a powder that we can spray on that acts like a liquid band-aid,” says Dr. McIntosh. “Often, we’ll use a combination of techniques, not only to stop the bleeding, but to try and prevent (the ulcer) from re-bleeding.”

When the above treatments fail to stop the bleeding, or aren’t possible to carry out (for instance, if the ulcer’s location makes it too awkward to manipulate with endoscopic tools), “we have other modalities we can use,” says Dr. McIntosh. A different type of specialist, called an interventional radiologist, can thread a fine tube from an artery in the groin up to where the bleeding is occurring. Then, different methods can be used to stop the bleeding. For instance, wire coils may be placed in an artery to block it off. If all else fails, surgery may sometimes be required.

If the bleeding is relatively mild, however, medication may be the only treatment needed.

Image showing a doctor writing a prescription

Preventing further bleeding

After a procedure to stop severe bleeding, “usually the patient will be in hospital for a couple of days to make sure the bleeding is controlled,” Dr. Veldhuyzen van Zanten says. “After that, they continue on the PPI, and will be assessed for H pylori and other risk factors.” (Since there is still a risk of re-bleeding in the first 30 days after diagnosis and treatment of a bleeding ulcer, during that time, “we’re mindful and watch for any signs of that,” says Dr. McIntosh. These signs can include further visible bleeding, or subtle signs, including a drop in levels of hemoglobin (a protein in red blood cells) or a drop in blood pressure.)

Medication

Research shows that, “proton pump inhibitors are very effective for regular treatment,” says Dr. Veldhuyzen van Zanten. These acid-blocking drugs can heal ulcers in 80 to 100% of patients within four weeks. However, some people—for example, those with larger ulcers—may need to take these medications for eight weeks or longer.

The underlying cause of the ulcer needs to be addressed, too.

“We now know that if you test for and then successfully treat for this Helicobacter bug that lives in the stomach, you can basically cure rather than control ulcers,” Dr. Veldhuyzen van Zanten explains.

Treatment consists of a combination of strong antibiotics to get rid of the infection, plus a proton pump inhibitor (PPI) to heal the damaged stomach lining. If someone with H pylori-related ulcers only takes a PPI, “the ulcers tend to come back if you stop the PPI,” notes Dr. Veldhuyzen van Zanten.

On the other hand, if an NSAID is the likely culprit, “then you remove that NSAID as a risk factor,” he says.

Lifestyle

It’s also important to work with your health care team to change any risk factors it’s possible to change, such as smoking and excessive alcohol use. PPI medications don’t work as well if you smoke, so stopping is especially critical.

Some groups of people need to take extra precautions to reduce the risk of future bleeding episodes.

If you’ve ever had a bleeding ulcer, do not take an NSAID without consulting a health care professional first. “You need to see a physician or pharmacist to give you a PPI,” explains Dr. Veldhuyzen van Zanten. “If you start an NSAID and a PPI at the same time, most of these ulcers will not occur. We call that gastroprotection.”

Similarly, if you’re above the age of 65, or in poor health, and you’re on Aspirin, or other medications that interfere with blood clotting, “you should be considered for prevention of ulcers by taking a PPI once a day,” Dr. Veldhuyzen van Zanten says.

Treatable, but still serious

“We’ve come a long way in the treatment of bleeding ulcers,” Dr. Veldhuyzen van Zanten says.

“Fortunately, the rates of mortality from bleeding ulcers have significantly declined because of advances in treatment and management,” adds Dr. McIntosh. That’s good, but ulcers still cause morbidity,” or ill health. “It’s still something to be taken seriously.”

Hospitalizations and deaths

Fortunately, advancements in ulcer treatment have led to a steady decline in hospitalizations for bleeding peptic ulcers. A 2023 study^[1] using data on emergency room visits for upper gastrointestinal bleeding (UGIB) in Alberta resulting in hospital admission found the hospitalization rate fell by nearly a third between 2010/11 and 2019/20—from 75.72 per 100,000 population to 49.74 per 100,000. (While not all cases of UGIB are bleeding peptic ulcers, most are.)

Of the 99,331 emergency department visits for UGIB that were identified, 24,573 resulted in hospital admission for that diagnosis.

Overall, 4.48% of people hospitalized for UGIB died within 30 days of being discharged from hospital. “Not always, but quite often, people who have died have other serious medical conditions,” notes Dr. Veldhuyzen Van Zanten, an Emeritus Professor of Medicine in the Division of Gastroenterology at the University of Alberta in Edmonton. However, it’s important to remember that this is not always the case- ulcers can still have serious and sometimes fatal outcomes even in otherwise healthy individuals, so early detection and treatment remain essential.

Peptic ulcers are open sores on the lining of the stomach or first part of the intestine.
The two main known causes of peptic ulcers are an infection caused by H pylori, and NSAID medications such as ibuprofen and naproxen. However, peptic ulcers and complications from them can affect people with no known risk factors.
Bleeding is the most common complication of peptic ulcers.
Severe bleeding from peptic ulcers can cause a medical emergency.
Someone who is vomiting blood, or passing black or bloody stool should seek urgent medical attention.
Several different techniques can be used to stop bleeding from peptic ulcers.
Medications that reduce stomach acid can help heal peptic ulcers.
Treating H pylori infection reduces the chance of getting another ulcer in future.
Bleeding peptic ulcers can usually be treated successfully, but unfortunately, they are fatal in about 5% of cases.

^[1] Buie, Michael J.; Coward, Stephanie; Lang, Eddy; Novac, Kerry Lynn; van Zanten, Sander, Jelinski, Susan E; Heitman, Steven J.; Kaplan, Gilaad G. (2023) Hospitalization Rates for Upper Gastrointestinal Bleed are Decreasing Over Time: a Population-Based Cohort Study. Gastroenterology. 164(6):S-838-S-839 DOI:10.1016/S0016-5085(23)02937-2