What Really Causes Peptic Ulcers? The Truth About H. pylori, NSAIDs, and Common Myths

For decades, people believed stress, hunger, worrying too much, eating too much pepper, or a type A personality caused peptic ulcer disease. But modern medicine has completely changed that narrative. Today, we understand the real causes of peptic ulcer disease — and they have nothing to do with spicy food.

Let’s break it all down in clear, evidence-based terms.

What Is Peptic Ulcer Disease?

A peptic ulcer is an open sore that develops in the lining of the stomach or duodenum, part of the digestive tract. It can occur in:

• The stomach → gastric ulcer
  
   
• The duodenum (first part of the small intestine) → duodenal ulcer
  
   
• Rarely, the lower oesophagus
  
   

Your stomach contains hydrochloric acid — a powerful corrosive chemical capable of digesting food and even the stomach itself. To prevent this, the digestive tract is lined with a protective mucosal layer.

When something damages this protective barrier, acid begins to erode the lining, causing an ulcer to form.

How Common Is Peptic Ulcer Disease?

Peptic ulcer disease affects millions globally and is especially common in low-income regions. When untreated, ulcers can lead to bleeding, perforation, obstruction, and even death. Early diagnosis and treatment significantly reduce complications.

Real Causes of Peptic Ulcers

1. Helicobacter pylori (H. pylori) Infection

H. pylori is a gram-negative bacterium now known to be the leading cause of ulcers.

Before its discovery, people were told by their doctors to avoid pepper and stress, but scientists have now proven that:

• H. pylori survives the acidic stomach by producing urease, which neutralises acid
  
   
• It attaches firmly to the stomach lining.
  
   
• It causes inflammation and erosion of the mucosa.
  
   
• Not everyone infected with the bacteria develops ulcers, but overgrowth increases the risk.
  
   
• It spreads through saliva, stool, vomit, contaminated food, or water.
  
   

This bacterial infection is responsible for a significant percentage of recurring ulcer cases worldwide.

2. NSAIDs (Non-steroidal Anti-Inflammatory Drugs)

Drugs such as:

• Ibuprofen
  
   
• Diclofenac
  
   
• Piroxicam (Feldene)
  
   
• Naproxen
  
   

…are common causes of ulcers when used for back pain, arthritis, or menstrual cramps.

NSAIDs damage the protective mucosal barrier by:

• Reducing prostaglandins (which protect the stomach lining)
  
   
• Increasing acid injury
  
   
• Slowing healing
  
   

Risk increases when:

• Taken for long periods
  
   
• Taken in high doses
  
   
• Combined with steroids (prednisolone, dexamethasone)
  
   
• Combined with antidepressants
  
   

H. pylori-induced ulcers differ from NSAID-induced ulcers in recurrence rate, appearance on endoscopy, and cancer risk.

Factors That Worsen Existing Ulcers

These do not cause ulcers but aggravate symptoms:

• Stress
  
   
• Prolonged hunger
  
   
• Spicy food
  
   
• Coffee and caffeine
  
   
• Alcohol
  
   
• Smoking
  
   

Symptoms of Peptic Ulcers

Symptoms differ depending on whether the ulcer is gastric or duodenal:

Gastric Ulcer Symptoms

• Burning upper abdominal pain is worse with food
  
   
• Food fear → weight loss
  
   
• Bloating
  
   
• Early satiety
  
   
• Nausea or vomiting
  
   

Duodenal Ulcer Symptoms

• Pain is relieved by eating.
  
   
• Pain worsens when hungry or at night (2–3 hours after meals)
  
   
• Weight gain (because eating relieves pain)
  
   

Other Possible Symptoms

• Pain radiating to the back
  
   
• Bitter taste
  
   
• Indigestion
  
   

Complications of Peptic Ulcer Disease

If untreated, ulcers can become life-threatening.

1. Bleeding

• Vomiting blood (hematemesis)
  
   
• Passing black, tarry stool (melena)
  
   
• Risk of severe anaemia
  
   

2. Perforation

A hole forms in the stomach or duodenal wall, leading to leakage of gastric contents into the abdomen. This is a surgical emergency and accounts for many ulcer-related deaths.

3. Gastric Outlet Obstruction

Scarring narrows the outlet of the stomach, causing:

• Persistent vomiting
  
   
• Inability to digest food
  
   
• Severe dehydration

4. Malignancy

Chronic gastric ulcers can rarely undergo malignant transformation, leading to gastric cancer.

How are Peptic Ulcers Diagnosed?

The gold standard is endoscopy, which visualises:

• Number of ulcers
  
   
• Location
  
   
• Size
  
   
• Appearance
  
   
• Signs of bleeding or malignancy
  
   

Other tests include:

• H. pylori stool antigen test
  
   
• Urea breath test
  
   
• H. pylori blood antibody test
  
   
• Upper GI contrast X-ray
  
   

Conditions That Mimic Peptic Ulcers

Not all upper abdominal pain is an ulcer.

Differentials include:

• Gastric cancer
  
   
• Pancreatic cancer
  
   
• Gastritis
  
   
• Gastroesophageal reflux disease (GERD)
  
   
• Pancreatitis
  
   
• Cholecystitis
  
   

A proper medical evaluation is essential for an accurate diagnosis.

How to Treat Peptic Ulcers

Treatment has two parts: drugs and lifestyle changes.

Drug Treatment

1. Antibiotics
   
    
   • Used for the eradication of H. pylori
     
      
   • Typically, triple or quadruple therapy
     
      
2. Proton Pump Inhibitors (PPIs)
   
    
   • Reduce acid production
     
      
   • Examples: omeprazole, esomeprazole, pantoprazole
     
      
3. H2-Receptor Blockers
   
    
   • Ranitidine, famotidine
     
      
4. Cytoprotective Agents
   
    
   • Sucralfate, misoprostol
     
      
   • Help coat and protect the stomach lining.
     
      

Non-Drug & Lifestyle Treatment

• Stop NSAIDs or switch to safer alternatives (e.g., acetaminophen, celecoxib)
  
   
• Quit smoking
  
   
• Reduce or avoid alcohol.
  
   
• Avoid trigger foods until healing occurs.
  
   
• Manage stress effectively
  
   
• Eat smaller, frequent meals if symptoms worsen with hunger.
  
   

Bottom line

The real causes of peptic ulcer disease are Helicobacter pylori infection and the use of NSAIDs, not pepper, stress, or skipping meals. Understanding this helps ensure proper treatment, prevent recurrence, and avoid life-threatening complications.