Upper abdominal pain, bloating, H. pylori and stomach ulcer

What do “stomach ache” and “indigestion” mean?

For pain in the upper abdomen, below the breastbone, patients use different words: heaviness, burning, bloating, feeling full quickly, belching. The NHS describes indigestion as a group of these symptoms: heartburn, a feeling of fullness and bloating, nausea, belching and sour regurgitation. The cause is often simple. The NHS names fatty and spicy food, coffee, alcohol, obesity, smoking, stress, pregnancy and some medicines (especially anti-inflammatory painkillers). Sometimes a stomach ulcer or, less often, stomach cancer is in the background. For this reason a symptom that persists, or comes with a warning sign, is worth assessing.

If your main symptom is burning behind the breastbone and a sour taste in the mouth, see also the page on reflux, heartburn and swallowing problems.

What is Helicobacter pylori?

Helicobacter pylori is a spiral-shaped bacterium that lives in the stomach. NIDDK says the infection usually starts in childhood and often stays for years or for life unless it is treated. This bacterium is one of the two main causes of stomach and duodenal ulcers (the other is non-steroidal anti-inflammatory painkillers). The ACG, in the abstract of its 2024 guideline, writes that the infection is common worldwide and can lead to indigestion, peptic ulcer and stomach cancer.

One point needs to be stated alongside this: having the bacteria is not the same as having a disease. NIDDK says an untreated infection causes chronic inflammation of the stomach and raises the risk of stomach cancer and a type of stomach lymphoma. But “higher risk” means a probability, not a fate. The right approach is to find the infection and treat it when needed.

What does a stomach ulcer look like?

The NHS considers pain in the upper abdomen the main symptom. The pain may be burning and often gets worse at night. Indigestion, heartburn, bloating, nausea and vomiting also occur. NIDDK says ulcers affect about one to six percent of people in the United States; this figure is not for Iran and only shows roughly how common they are.

Risk factors: H. pylori infection, regular use of anti-inflammatory painkillers, smoking, older age, and a history of a previous ulcer.

If an ulcer is not treated, the NHS and NIDDK list several complications: bleeding from the stomach or bowel, iron-deficiency anaemia from slow bleeding, a hole in the stomach wall that leads to a serious abdominal infection, and blockage of the passage out of the stomach. For this reason, signs of worsening must be taken seriously.

What tests are there?

The NHS and NIDDK name these:

• Breath test (urea breath test): you swallow a substance containing labelled urea and, a few minutes later, breathe out into a container. If the bacteria are present, they turn the urea into a gas that is found in your breath.
• Stool test.
• Blood test. It shows the body has met the bacteria at some point. It does not prove an active infection and is not used to check whether treatment worked.
• Endoscopy, if the doctor considers it necessary, in which the inside of the stomach is viewed as an image and a sample can be taken. NIDDK regards it as a way to confirm an ulcer and find its cause.

Which test suits you depends on your symptoms, age, medicines and history. Tell your doctor about the medicines you take; NIDDK says the doctor asks what medicines you use, especially anti-inflammatory painkillers. Some medicines, such as antibiotics and acid-reducing medicines, can change the test result. Ask your doctor or the laboratory what to do before the test, and do not stop any medicine on your own.

What does treatment look like?

For a stomach ulcer, the NHS says treatment includes an antibiotic (to clear the H. pylori infection) and medicines that reduce stomach acid. Treatment usually lasts from about a week to two months, and afterwards a test is done to find out whether it worked. The ACG abstract indicates that treatment is usually a combination of several medicines and that the choice of regimen depends on the bacteria’s sensitivity to antibiotics. It also says a confirmation test after treatment is needed for everyone.

A few practical points:

• Complete the treatment. The doctor tells you the type of medicine and how long. Do not start or stop medicine on your own, and do not use other people’s medicine.
• Tell the doctor about side effects. For problems such as nausea or diarrhoea, contact them before stopping the medicine. But if you get a widespread rash, swelling of the lips or face, or shortness of breath, do not take the medicine again and call 115.
• Do not forget the test after treatment. The doctor sets its timing and method.
• If symptoms come back, the NHS advises seeing a doctor so the medicine or the length of treatment can be changed.

If you are pregnant, breastfeeding, allergic to any medicine or have another illness, tell the doctor from the start.

What can you do yourself?

• Eat smaller meals and finish dinner 3 to 4 hours before sleep (NHS).
• Learn which foods and drinks cause problems for you. The NHS gives fatty and spicy food, coffee and chocolate as examples.
• Stop smoking and limit alcohol (if you drink).
• A healthy weight and calming the mind are also among the NHS recommendations.
• Do not take anti-inflammatory painkillers, such as ibuprofen, without speaking to a doctor first (NHS). If a doctor prescribed aspirin or a painkiller for another condition, do not stop it yourself; tell them about your stomach symptoms.
• Keeping a record of symptoms (timing, relation to food, severity) helps the doctor. See the guide.

One caution: the NHS considers changing habits helpful, not a substitute for assessment and treatment. If symptoms continue, do not rely on dieting alone.

Which symptoms are serious?

The NHS names these for stomach ulcers and says they should be reported to a doctor promptly: pain that gets worse or does not stop, loss of appetite or feeling full after a little food, unexplained weight loss, a feeling of a lump in the abdomen, painful or difficult swallowing, persistent vomiting and constant tiredness. In its indigestion section, the NHS also counts iron-deficiency anaemia as a reason to see a doctor.

When to act urgently

Call 115 (Iran’s emergency number) right now (NHS, for stomach ulcers): vomiting bright red blood or material that looks like coffee grounds, black, sticky, foul-smelling stools or stools with blood, severe abdominal pain or pain when the abdomen is touched, sudden chest pain. Do not drive yourself, and take your medicines with you.

The same day (the NHS treats these as urgent for stomach ulcers): worsening pain, persistent vomiting, new loss of appetite or weight loss, and painful swallowing.

Book an appointment soon: indigestion that does not improve with changes in habits and simple treatment, stomach ache that keeps returning, or a positive H. pylori result.

See the full list in urgent signs.

This page is for information and does not replace an examination.