Peptic Ulcers, H. pylori & GORD: How PPI Treatment Works
Stomach ulcers, H. pylori and NSAID damage explained — the symptoms, how they’re tested and treated, and where the PPI fits in.
Part of the Complete Acid Reflux Guide.
Key fact: Most stomach ulcers are caused by H. pylori infection or anti-inflammatory painkillers — not stress or spicy food. Treating the cause, with a PPI to reduce acid and let the ulcer heal, cures the great majority.
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Start Your Consultation →Stomach ulcer symptoms
A peptic ulcer — an open sore in the stomach (gastric) or upper small intestine (duodenal) — most often announces itself as a burning or gnawing pain in the upper abdomen. The pattern is a clue: duodenal ulcer pain often comes between meals or at night and eases with food, while gastric ulcer pain can be brought on by eating. Around it you may notice:
- Bloating, wind or a feeling of fullness after modest meals
- Nausea, and sometimes heartburn or an acidic taste
- Loss of appetite or slight weight loss
- Pain that wakes you in the early hours
Seek emergency help (999 or A&E) for signs of a bleeding or perforated ulcer: vomiting blood or material like coffee grounds, black tarry stools, sudden severe or spreading abdominal pain, faintness, or a rapid heartbeat. These are surgical emergencies.
Peptic ulcer disease and how it’s treated
The old belief that ulcers come from stress and spicy food is largely a myth — the two dominant causes are H. pylori infection and long-term use of NSAIDs (ibuprofen, naproxen, aspirin, diclofenac). Treatment therefore has two parts: remove the cause, and reduce acid with a PPI so the ulcer can heal. NICE sets clear course lengths:
| Situation | PPI course |
|---|---|
| Duodenal ulcer (no H. pylori, no NSAID) | 4 weeks full-dose PPI |
| Gastric ulcer (no H. pylori, no NSAID) | 8 weeks full-dose PPI |
| NSAID-associated ulcer | 8 weeks PPI — and stop/switch the NSAID if possible |
| H. pylori-positive ulcer | 7-day triple therapy, then further PPI where appropriate |
NSAID-induced ulcers
Anti-inflammatory painkillers cause ulcers by stripping away the prostaglandins that maintain the stomach’s protective mucus — up to 1 in 4 long-term NSAID users develops an ulcer, with older adults most at risk. If an NSAID ulcer is found, the NSAID should ideally be stopped or switched, and a full-dose PPI given for 8 weeks. Where NSAIDs must continue, a PPI is co-prescribed for protection. NICE recommends this gastroprotection for anyone taking regular NSAIDs who is 65 or over, has a previous ulcer, or also takes anticoagulants, antiplatelets, steroids or SSRIs.
H. pylori: testing and triple therapy
Helicobacter pylori is a bacterium that colonises the stomach lining and drives most peptic ulcers worldwide. Clearing it heals ulcers, stops them recurring, and reduces long-term stomach cancer risk.
Getting tested in the UK
- Urea breath test — drink a solution, breathe into a bag; accurate and widely used
- Stool antigen test — equally reliable, done on a sample at home
- Where — via your GP, and through some pharmacies
- Prepare correctly — stop PPIs for 2 weeks and antibiotics for 4 weeks beforehand, or you may get a false negative
Triple therapy (first-line eradication)
| Regimen | Components (all twice daily) | Duration |
|---|---|---|
| Standard | PPI + amoxicillin 1g + clarithromycin 500mg | 7 days |
| Penicillin-allergic | PPI + metronidazole 400mg + clarithromycin 500mg | 7 days |
| Second-line | Bismuth-based quadruple therapy (specialist guidance) | 10–14 days |
Eradication is confirmed with a breath or stool test at least 4 weeks after finishing — a blood antibody test cannot confirm cure, as antibodies stay raised for months.
What triple therapy is actually like to take
Knowing what to expect helps people finish the course — which is what makes it work. It is seven days of three medicines twice a day: swallow a lot of tablets, morning and evening. Side effects are common but usually tolerable: a metallic or bitter taste, nausea, loose stools, and tiredness. Two practical points matter most:
If your regimen contains metronidazole, avoid all alcohol during the course and for 48 hours after the last dose — the combination causes severe flushing, nausea and vomiting. And finish the full seven days even if you feel better: stopping early lets surviving bacteria develop resistance, making the next attempt harder.
GORD maintenance and step-down
For GORD, PPI treatment follows a structured path aimed at the lowest effective dose. A 4–8 week full-dose course settles symptoms and heals oesophagitis; then most people either step down to a lower dose, move to on-demand use, or — for severe oesophagitis, Barrett’s oesophagus or rapid relapse — continue maintenance treatment. Stopping should be gradual to avoid rebound acid; the full method is in our stopping PPIs guide, and the condition itself in our GORD guide.
Choosing the right PPI
All five UK-licensed PPIs work well across these conditions — NICE assumes a class effect at equivalent doses. Omeprazole or lansoprazole is the usual first choice (well-evidenced, low cost), with the decision often turning on interactions — pantoprazole or lansoprazole over omeprazole for people on clopidogrel — or formulation. For a full comparison see Omeprazole vs Lansoprazole vs Esomeprazole.
Long-term PPI use and review
PPIs are very safe short and medium term. Beyond 12 months, keep in view the class-wide considerations — low magnesium, vitamin B12 deficiency, a modest fracture-risk increase, and greater susceptibility to certain gut infections. NICE recommends reviewing long-term PPI use at least annually, using the lowest effective dose and attempting step-down where appropriate. The full safety picture is in the complete PPI guide.
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What are the warning signs of a stomach ulcer?
The classic sign is a burning or gnawing pain in the upper abdomen, often between meals or at night, sometimes eased or worsened by eating. Others include bloating, feeling full quickly, nausea and heartburn. The signs that need urgent attention are vomiting blood or material like coffee grounds, black tarry stools, sudden severe pain, or unexplained weight loss — these can mean a bleeding or perforated ulcer and are a 999 or A&E situation.
How do I get tested for H. pylori in the UK?
Two accurate tests are used: a urea breath test (you drink a solution and breathe into a bag) and a stool antigen test. Both are available through your GP, and testing kits are also offered by some pharmacies. You need to be off PPIs for two weeks and antibiotics for four weeks before testing, or the result can be falsely negative. A blood antibody test is not used to confirm eradication, as antibodies stay raised for months.
What is H. pylori triple therapy actually like to take?
It is a 7-day course of a PPI plus two antibiotics, all twice daily. Most people manage it, but side effects are common: a metallic taste, nausea, loose stools and tiredness. If your regimen contains metronidazole, you must avoid all alcohol during the course and for 48 hours after, as the combination causes severe flushing and vomiting. Finishing the full week matters — stopping early risks the infection surviving and becoming resistant.
Can you treat H. pylori without antibiotics?
No — H. pylori is a bacterial infection, and clearing it reliably requires antibiotics, always combined with a PPI. Diet, probiotics and remedies like manuka honey may ease symptoms or support the gut, but they do not eradicate the bacterium, and leaving it untreated risks ongoing ulcers and, over many years, a raised stomach cancer risk. Proper eradication is the only dependable cure.
How do I know if my ulcer is healing?
The main sign is that the pain settles — usually within a week or two of starting a PPI, with full healing over 4 to 8 weeks. For gastric ulcers, and where H. pylori was involved, a follow-up test (and sometimes a repeat endoscopy) confirms healing and eradication. Do not assume healing from symptom relief alone if your clinician has arranged follow-up; ulcers can improve symptomatically while still needing the full course.
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Omeprazole
The UK’s most prescribed PPI — first-line for ulcers and GORD.
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Lansoprazole
A comparable PPI, including an orodispersible option.
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Esomeprazole
A stronger option for severe or persistent symptoms.
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Start consultation →References
- National Institute for Health and Care Excellence. Gastro-oesophageal reflux disease and dyspepsia in adults (CG184). Updated 2023. nice.org.uk
- National Institute for Health and Care Excellence. Helicobacter pylori: eradication in adults with a confirmed peptic ulcer. NICE CKS. 2023. cks.nice.org.uk
- NHS. Stomach ulcer. 2022. nhs.uk
- Scally B, Emberson JR, Spata E et al. Effects of gastroprotective co-prescription with NSAIDs on the risk of adverse gastrointestinal outcomes. Lancet. 2018. pubmed.ncbi.nlm.nih.gov
- Freedberg DE, Kim LS, Yang YX. The risks and benefits of long-term use of proton pump inhibitors: expert review. Annals of Internal Medicine. 2017. pubmed.ncbi.nlm.nih.gov
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment. In a medical emergency, call 999.