A gastric ulcer is an open sore in the lining of the stomach. Most gastric ulcers are not cancer and heal completely with treatment. Your doctor takes biopsies of a gastric ulcer mainly to make sure that it is not caused by cancer. Biopsies can also help identify the cause of the ulcer, such as an infection with Helicobacter pylori.
A gastric ulcer is also called a stomach ulcer or a peptic ulcer. This article explains what a gastric ulcer is, what causes it, what a pathologist looks for in the biopsies, and what the findings in your pathology report mean.
What is a gastric ulcer?
A gastric ulcer is an area where the inner lining of the stomach, called the mucosa, has been completely worn away. The damage goes deeper than the lining, into the stomach wall. Stomach acid and digestive enzymes then irritate the exposed tissue, which keeps the ulcer from healing on its own.
A gastric ulcer is different from an erosion, which is a shallow area of damage that affects only the surface of the lining. Erosions are often seen in erosive gastritis and usually heal quickly.
What causes a gastric ulcer?
A gastric ulcer develops when something weakens the stomach’s natural protection against acid. Together, the two most common causes account for most gastric ulcers.
- Helicobacter pylori infection. A long-lasting infection with the bacterium Helicobacter pylori causes inflammation, called Helicobacter gastritis, that weakens the stomach lining. It causes about 4 in 10 peptic ulcers, although only a small number of people with the infection develop an ulcer.
- Aspirin and anti-inflammatory medications. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, reduce the stomach’s ability to protect itself and cause about one-third of peptic ulcers. The risk is higher with high doses, older age, and when they are taken with steroids or blood thinners.
- Smoking. Smoking increases the risk of developing an ulcer and slows the healing of an ulcer that is already present.
- Less common causes. Rarely, ulcers are caused by viral infections such as cytomegalovirus (CMV) in people with a weak immune system. Other rare causes include Crohn disease and conditions that make the stomach produce too much acid.
- No cause found. In some people, no cause is found, even after testing.
Spicy food, coffee, and stress alone do not cause stomach ulcers, although they can make symptoms worse.
What are the symptoms of a gastric ulcer?
The symptoms of a gastric ulcer vary, and some people have no symptoms until a complication occurs. Common symptoms of a gastric ulcer include:
- Pain. A burning or gnawing pain in the upper abdomen, which may get worse after eating.
- Indigestion and nausea. Some people have bloating, feel full quickly, or develop nausea or a loss of appetite.
- Bleeding. Bleeding is the most common complication of an ulcer and can cause black or tarry stools, vomiting blood or material that looks like coffee grounds, or anemia with tiredness.
- Perforation. Rarely, an ulcer goes all the way through the stomach wall. This causes sudden, severe abdominal pain and needs emergency treatment.
Why are gastric ulcers biopsied?
Gastric ulcers are biopsied because a small number of them are caused by stomach cancer rather than by ordinary ulcer disease. A cancer can look very similar to a benign ulcer during an endoscopy. In studies, between about 2% and 6% of gastric ulcers turned out to be cancer, and the risk is higher for very large ulcers. For this reason, most experts recommend taking several biopsies from the edges and base of every gastric ulcer.
Taking several biopsies makes it much less likely that a cancer will be missed. The biopsies also allow the pathologist to look for H. pylori and other causes of the ulcer.
What does the pathologist look for?
When a pathologist examines biopsies of a gastric ulcer under a microscope, the main question is whether the ulcer is benign or caused by cancer. The pathologist also looks for the ulcer’s cause and any precancerous changes in the nearby lining. Your report may describe some of the following findings.
- Ulcer debris and fibrinopurulent exudate. The ulcer surface is covered by dead tissue (necrosis) mixed with inflammatory cells and protein, a material called fibrinopurulent exudate. Seeing it confirms that the biopsy came from an ulcer.
- Granulation tissue. Granulation tissue is new, healing tissue with many small blood vessels. It forms at the base of an ulcer as the body repairs the damage.
- Reactive changes. The cells at the edge of an ulcer often look larger and darker than normal because they are working to repair the damage. Pathologists call these reactive changes, and they are not cancer or a precancerous change.
- Helicobacter pylori. The report will say whether H. pylori bacteria were seen in the biopsies. Some laboratories use a special stain or immunohistochemistry to look for the bacteria.
- Viral changes. In people with a weak immune system, the pathologist may look for changes caused by viruses such as CMV, sometimes using additional tests.
Negative for malignancy
“Negative for malignancy” means the pathologist did not find any cancer cells in the biopsies of the gastric ulcer. Your report may also say “negative for dysplasia,” which means no precancerous changes were seen. These reassuring results are the most common outcome when a gastric ulcer is biopsied.
Biopsies are small samples, so a negative result is most reliable when several biopsies were taken from different parts of the ulcer. If the biopsies contained mostly ulcer debris, the report may say that the sample is limited. In this case, or if the ulcer looked suspicious during the endoscopy, your doctor may repeat the endoscopy and take more biopsies.
Indefinite for dysplasia
Indefinite for dysplasia means the pathologist saw changes in the cells near the ulcer but could not tell whether they were caused by healing or by a precancerous change. This can happen because healing cells next to an ulcer can look abnormal. Your doctor will usually treat the ulcer and any H. pylori infection and then repeat the endoscopy with new biopsies to check for gastric dysplasia.
Other findings in the nearby lining
Biopsies of a gastric ulcer often include some of the nearby stomach lining. Your report may describe changes in this lining that help explain the cause of the ulcer or your future risk.
- Gastritis. Inflammation in the nearby lining, often described as chronic active gastritis, may be caused by H. pylori.
- Reactive gastropathy. Damage to the lining with little inflammation, called reactive gastropathy, is often caused by NSAIDs.
- Intestinal metaplasia. After long-term inflammation, the normal stomach lining may be replaced by intestine-type cells, a change called intestinal metaplasia.
What happens after the diagnosis?
Most gastric ulcers heal completely with treatment that focuses on reducing stomach acid, removing the cause of the ulcer, and ensuring the ulcer heals.
- Acid-reducing medication. A proton pump inhibitor, such as omeprazole or pantoprazole, reduces stomach acid and lets the ulcer heal. Most ulcers heal within 4 weeks, but ulcers larger than 2 cm may need 8 weeks of treatment.
- Treating H. pylori. If H. pylori is present, it is treated with a combination of antibiotics and other medications. Clearing the infection lowers the chance of recurrence from about half of people to almost none.
- Stopping NSAIDs. If possible, stop aspirin and NSAIDs while the ulcer heals. If you need to keep taking one of these medications, your doctor may recommend a proton pump inhibitor to protect your stomach.
- Repeat endoscopy. Some doctors repeat the endoscopy after treatment to confirm that the ulcer has healed and to take more biopsies. Guidelines differ on who needs a repeat endoscopy. The British Society of Gastroenterology recommends a repeat endoscopy within 8 weeks. The American Society for Gastrointestinal Endoscopy recommends it mainly for ulcers that are large or look suspicious. A repeat endoscopy is especially important if the first biopsies were limited or if the ulcer does not heal.
Questions to ask your doctor
- What caused my ulcer?
- Was H. pylori found, and how will it be treated?
- How many biopsies were taken, and were they enough to rule out cancer?
- Did the ulcer look suspicious during the endoscopy?
- Was any dysplasia or intestinal metaplasia found?
- How long should I take acid-reducing medication?
- Do I need to stop any of my medications?
- Will I need a repeat endoscopy to make sure the ulcer has healed?
- What symptoms should make me seek urgent care?
Related articles on MyPathologyReport.com