Most stomach ulcers are diagnosed and increasingly treated through upper endoscopy, a procedure in which a thin, flexible camera is passed through the mouth and into the stomach. Depending on whether the ulcer is bleeding, perforated, or simply needs identification, the specific procedures range from a straightforward scope-and-biopsy exam to emergency surgery. The majority of people with a stomach ulcer will only ever need endoscopy and medication, but understanding the full range of interventions helps make sense of what doctors are looking for and why.
The Diagnostic Endoscopy
An upper endoscopy (also called an esophagogastroduodenoscopy, or EGD) is the standard first step for evaluating a suspected stomach ulcer. The scope lets the doctor see the ulcer directly, assess its size and location, and take tissue samples. Those tissue samples, or biopsies, serve two purposes: checking for the bacterium H. pylori, which causes many ulcers, and ruling out cancer. The American Gastroenterological Association recommends that endoscopists follow standardized biopsy protocols for foregut conditions like gastric ulcers.1PubMed. AGA Clinical Practice Update on High-Quality Upper Endoscopy: Expert Review
How many biopsies are needed depends on the ulcer’s appearance. A recent systematic review found that four well-targeted biopsies may be enough for ulcers that look depressed or raised, but more extensive sampling is often warranted for infiltrative or otherwise suspicious-looking lesions.2BMJ Open. Endoscopic biopsy strategies for gastric ulcers: an updated systematic review The concern driving all this sampling is gastric cancer: in one study of 795 patients with gastric ulcers, about 7% turned out to have a malignancy, with the vast majority (83%) caught at the first endoscopy. A small number of cancers, however, were only found at a follow-up scope.3Journal of Clinical Gastroenterology. Evaluation of Endoscopic Practices and Outcomes in Follow-up of Gastric Ulcers That possibility is what motivates repeat endoscopy for many gastric ulcers, typically within about 12 weeks.
Testing for H. pylori
Because H. pylori infection is one of the leading causes of stomach ulcers, detecting it is a key part of the diagnostic workup. During endoscopy, a rapid urease test can be performed on biopsy tissue right in the procedure room. The tissue is placed in a solution that changes color if the bacterium’s enzymes are present. A study comparing several diagnostic methods found that the stool antigen test had the highest overall diagnostic accuracy among noninvasive options, while the rapid urease test performed well among invasive methods.4PubMed Central. Diagnostic values of Helicobacter pylori diagnostic tests: stool antigen test, urea breath test, rapid urease test, serology and histology
For patients who do not need endoscopy for other reasons, two noninvasive tests avoid the scope entirely. The urea breath test has the patient swallow a special capsule or drink and then breathe into a collection device; the stool antigen test simply analyzes a stool sample. Both perform well enough to be recommended in settings where endoscopy is not immediately available.5Journal of Nepalgunj Medical College. Diagnostic Accuracy of Stool Antigen Test and Urea Breath Test Compared with Histopathology for Detection of Helicobacter pylori Infection Among Dyspeptic Patients Knowing whether H. pylori is present changes the treatment plan substantially, because eradicating the infection with antibiotics is one of the most effective ways to prevent ulcer recurrence.
Stopping a Bleeding Ulcer
When a stomach ulcer is actively bleeding or shows signs of recent bleeding, the endoscopy shifts from purely diagnostic to therapeutic. The doctor can treat the bleed during the same procedure, and several tools are available. The oldest and simplest is injection therapy: a solution of diluted epinephrine is injected around the bleeding site to compress the vessel and slow the flow. This works well as a first step, but using epinephrine alone leads to rebleeding in roughly one in five patients. Adding a second method, such as a thermal probe or a clip, cuts the rebleeding rate roughly in half and also reduces the chance of needing emergency surgery and the risk of death.6Gastroenterology. Meta-analysis: Efficacy of Endoscopic Injection Therapy for Bleeding Peptic Ulcer After Epinephrine Injection Versus Epinephrine Alone A trial comparing combination treatment directly to injection alone found that rebleeding dropped from about 20% to under 5% with the addition of a mechanical device.7PubMed. A prospective, randomized trial comparing mechanical methods of hemostasis plus epinephrine injection to epinephrine injection alone for bleeding peptic ulcer
The two main “second methods” are thermal coagulation and hemostatic clips. Thermal coagulation uses heat delivered through a probe to seal the vessel. Clips are tiny metal devices deployed through the endoscope to physically clamp the vessel shut. A meta-analysis found that clips and thermal coagulation produce similar rates of definitive hemostasis, around 81% for each.8PubMed Central. Endoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal bleeding: a meta-analysis Clips can be tricky when the ulcer is in a hard-to-reach spot; one trial found that heater probe coagulation had a clear advantage over clips in those difficult-to-approach cases.9The American Journal of Gastroenterology. A prospective, randomized trial of endoscopic hemoclip versus heater probe thermocoagulation for peptic ulcer bleeding A newer option, monopolar hemostatic forceps with soft coagulation, achieved initial hemostasis in about 98% of patients in one trial, compared with about 80% for clips, and also shortened both procedure time and hospital stay.10Gastrointestinal Endoscopy. Comparison of monopolar hemostatic forceps with soft coagulation versus hemoclip for peptic ulcer bleeding: a randomized trial
Hemostatic Powders and Over-the-Scope Clips
When traditional clip-and-burn methods fail or when a bleed is in a location that makes precise tool placement difficult, newer options can help. Hemostatic powders are sprayed through the endoscope and form a barrier over the bleeding surface. A review of multiple powder products found immediate hemostasis rates above 90%.11Clinical Endoscopy. Precise and optimal delivery techniques of hemostatic powders in gastrointestinal bleeding The most studied powder, Hemospray, achieved immediate hemostasis in about 91% of peptic ulcer cases in one analysis, though rebleeding within 30 days occurred in about 12%.12International Journal of Gastrointestinal Intervention. Topical hemostatic powders in the management of gastrointestinal bleeding A separate multicenter prospective study using Hemospray as the sole treatment for peptic ulcer bleeding reported an immediate hemostasis rate of 88%, but a higher rebleeding rate of 26%.13PubMed Central. Hemospray® (hemostatic powder TC-325) as monotherapy for acute gastrointestinal bleeding: a multicenter prospective study That gap highlights why many experts view powders as a bridge or rescue tool rather than a standalone fix.
Over-the-scope clips (OTSCs) are larger, bear-trap-like devices that can grasp more tissue than a standard clip. They have proven particularly useful for ulcers that have already rebled after initial treatment. In a randomized trial of patients with recurrent peptic ulcer bleeding, further bleeding occurred in only about 15% of the OTSC group compared with nearly 58% in the standard-therapy group.14Gastroenterology. Over-the-Scope Clips Are More Effective Than Standard Treatment for Recurrent Peptic Ulcer Bleeding: A Randomized Controlled Trial A separate trial focused on large ulcers (1.5 cm or bigger) found that among patients where initial hemostasis succeeded, 30-day rebleeding was about 4% with OTSCs versus about 19% with conventional methods.15Gut. Use of over-the-scope clip (OTSC) versus standard therapy for the prevention of rebleeding in large peptic ulcers OTSCs are not always the first choice because they cost more, require specific training, and can be difficult to deploy in certain anatomical spots, but they have become an important escalation option.
Arterial Embolization When Endoscopy Fails
If endoscopic treatment cannot control a bleeding ulcer, the next step before surgery is usually transcatheter arterial embolization (TAE). An interventional radiologist threads a catheter through the groin or wrist artery into the vessel feeding the ulcer and blocks it with tiny coils, particles, or glue. This is a minimally invasive alternative to emergency surgery and is considered fast, safe, and effective when endoscopy has not worked.16PubMed. Transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding: Indications, techniques and outcomes
A study of patients with massive duodenal ulcer bleeding treated by embolization reported immediate hemostasis in 90% of cases and a 93% clinical success rate at 30 days.17PubMed Central. Emergency transcatheter arterial embolization for patients with acute massive duodenal ulcer hemorrhage Factors that make embolization less likely to succeed include a long delay between the failed endoscopy and the embolization procedure, a heavy burden of other medical conditions, and visible dye leaking from the artery during the procedure.18Journal of Clinical Imaging Science. Gastroduodenal artery embolization for peptic ulcer hemorrhage refractory to endoscopic intervention: A single-center experience The takeaway for patients is that embolization is a real, well-established option and not some experimental last resort. Many hospitals with interventional radiology capability can offer it around the clock.
Surgery for Stomach Ulcers
Surgery was once the mainstay of ulcer treatment. Today it is reserved for complications that endoscopy and embolization cannot handle: uncontrolled bleeding, perforation (a hole through the stomach wall), or severe gastric outlet obstruction. The most common emergency operation for a perforated ulcer is a simple patch repair, where the hole is covered with a piece of omentum (the fatty apron that hangs over the intestines) and sutured closed.
This repair can be done as open surgery or laparoscopically. A meta-analysis comparing the two approaches found that laparoscopic repair produced less postoperative pain and fewer wound infections, though it carried a slightly higher reoperation rate.19PubMed. Laparoscopic repair of perforated peptic ulcer: a meta-analysis A more recent comparison at a community hospital found that laparoscopic patients had dramatically shorter hospital stays, averaging about 4 days compared with 16 days for open repair, and resumed eating much sooner.20PubMed Central. Outcomes of laparoscopic modified Cellan-Jones repair versus open repair for perforated peptic ulcer at a community hospital
More extensive surgeries, such as partial gastrectomy (removing part of the stomach), have become uncommon for benign ulcers but are not extinct. A long-term follow-up of patients who had a Billroth I partial gastrectomy for benign gastric ulcers found that 84% had an excellent or good outcome at an average of over nine years, though a small number developed recurrent ulcers and needed additional procedures.21PubMed Central. The long-term outcome of Billroth I partial gastrectomy for benign gastric ulcer Vagotomy, the surgical cutting of the vagus nerve to reduce acid secretion, was once standard but has largely been replaced by acid-suppressing drugs. Interestingly, a Taiwanese population study found that complicated ulcer patients who had an acid-reducing vagotomy had a lower subsequent risk of ischemic heart disease compared with those managed by simple suture or nonsurgical hemostasis.22PubMed Central. Acid-reducing vagotomy is associated with reduced risk of subsequent ischemic heart disease in complicated peptic ulcer The mechanism behind that association is still debated, but it is a curious footnote in the history of ulcer surgery.
Balloon Dilation for Gastric Outlet Obstruction
Chronic or recurrent ulcers near the pylorus (the exit of the stomach) can scar and narrow the passage so much that food cannot get through. The classic symptoms are vomiting of undigested food, severe bloating, and weight loss. The traditional treatment was surgery, but endoscopic balloon dilation has become an effective alternative for many patients. A through-the-scope balloon is inflated at the narrowed site to stretch it open.
In one series, 80% of patients with ulcer-induced obstruction achieved sustained symptom relief, with most needing only a single dilation session.23PubMed. Endoscopic balloon dilation for ulcer-induced gastric outlet obstruction Dilation does carry a risk of perforation, particularly when balloons larger than 15 mm are used.24PubMed Central. Endoscopic balloon dilation for benign gastric outlet obstruction in adults A critical companion step is eradicating H. pylori if the infection is present, because without treating the underlying cause, the stricture tends to recur.
Medications That Go Hand-in-Hand With Procedures
No procedure for a bleeding ulcer is complete without aggressive acid suppression afterward. The standard protocol is an intravenous proton pump inhibitor (PPI) given as a loading dose followed by a continuous high-dose infusion for 72 hours after successful endoscopic hemostasis.25PubMed Central. Intravenous proton pump inhibitors for peptic ulcer bleeding: Clinical benefits and limits A meta-analysis of high-risk patients with acute peptic ulcer bleeding found that high-dose IV PPIs reduced rebleeding by about 15 percentage points, the need for surgery by about 5 points, and mortality by about 3 points compared with placebo.26PubMed. Meta-analysis: proton-pump inhibition in high-risk patients with acute peptic ulcer bleeding After the IV phase, patients typically switch to oral PPIs for weeks to months.
For people who take low-dose aspirin and have had an ulcer complication, the long-term strategy involves both eradicating H. pylori and often continuing a daily PPI alongside the aspirin. In a 12-month trial, adding lansoprazole to aspirin after ulcer healing and H. pylori eradication reduced the recurrence of ulcer complications from about 15% to under 2%.27PubMed. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use For aspirin users with H. pylori, eradicating the infection alone is about as effective as daily PPI therapy at preventing rebleeding. But for people on other anti-inflammatory drugs, the PPI is clearly better than eradication alone.28PubMed. Preventing recurrent upper gastrointestinal bleeding in patients with Helicobacter pylori infection who are taking low-dose aspirin or naproxen
Follow-Up Endoscopy and Whether You Need One
Guidelines have traditionally recommended a repeat endoscopy within about 8 to 12 weeks to confirm that a gastric ulcer has healed and to re-biopsy the site.29Gut. A REVIEW OF GASTRIC ULCER FOLLOW-UP PRACTICES IN A TERTIARY CARE GASTROENTEROLOGY SERVICE The original rationale was the worry that a benign-looking ulcer might actually be cancer. But this recommendation is gradually softening for low-risk patients. In the study of 795 patients mentioned earlier, among those whose initial biopsies were benign, only about 1% were found to have cancer at repeat endoscopy.30Journal of Clinical Gastroenterology. Evaluation of Endoscopic Practices and Outcomes in Follow-up of Gastric Ulcers Some gastroenterologists now argue that routine follow-up endoscopy may not be necessary for ulcers that looked clearly benign and had benign biopsies, especially in populations where H. pylori-related cancer rates are low.31American Journal of Gastroenterology. Determining the Endoscopic Follow-Up for Gastric Ulcers Based Upon Endoscopic Appearance and Histology
Whether you get a follow-up scope depends on several factors: how suspicious the ulcer looked at the first exam, whether initial biopsies were benign, and whether you have risk factors for gastric cancer. If the ulcer appeared suspicious, was large, or if the initial biopsies came back with worrisome findings, a repeat endoscopy is harder to justify skipping. A cost-effectiveness analysis of routine second-look endoscopy for bleeding ulcers found that while the second scope did reduce the absolute risk of rebleeding by about 6 percentage points, all other outcomes (surgery, complications, mortality, and costs) favored not doing it. Preventing one additional bleed required scoping 16 extra patients, at a cost of roughly $13,000 per bleed prevented.32Centre for Reviews and Dissemination / NIHR (NHS EED). Second-look endoscopy for bleeding peptic ulcer disease: a decision-effectiveness and cost-effectiveness analysis
Sedation During Endoscopic Procedures
If you are scheduled for an upper endoscopy, one of the first questions is likely about sedation. Most diagnostic and therapeutic endoscopies use moderate sedation (sometimes called “conscious sedation”) or propofol-based deeper sedation. You are not fully under general anesthesia in most cases, but you are sedated enough that the procedure feels like a hazy nap.
Propofol sedation produces better patient cooperation and faster recovery compared with traditional midazolam-based sedation. In a trial of high-risk patients over 80 years old undergoing interventional endoscopy, propofol led to better cooperation scores despite causing slightly larger drops in blood pressure and oxygen levels. No procedures in either group had to be stopped because of serious side effects.33PubMed. Sedation with propofol for interventional endoscopy by trained nurses in high-risk octogenarians: a prospective, randomized, controlled study Emergency endoscopies for active bleeding are a higher-risk scenario for sedation because blood loss can lower blood pressure further. A study of nurse-administered propofol during emergency endoscopies for gastrointestinal bleeding found that low blood pressure occurred in about 8% of patients and low oxygen in about 7%, both higher than in elective cases, but no patients required intubation and there were no sedation-related deaths.34PubMed. Efficacy and safety of nurse-administered propofol sedation during emergency upper endoscopy for gastrointestinal bleeding: a prospective study
Endoscopy for Children
Stomach ulcers are far less common in children, but they do occur, particularly in critically ill children or those taking certain medications. The European Society for Paediatric Gastroenterology Hepatology and Nutrition has published guidelines covering both diagnostic and therapeutic endoscopy in patients from birth through age 18.35PubMed. Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines Pediatric endoscopy uses smaller-diameter scopes and typically requires deeper sedation or general anesthesia because children are less able to cooperate. The indications and techniques mirror adult practice in principle but differ in the specifics of equipment sizing, sedation protocols, and the clinical scenarios that prompt the procedure.
Artificial Intelligence in Ulcer Endoscopy
One of the more interesting developments in ulcer procedures is the integration of artificial intelligence into the endoscopy suite. AI models are being trained to do two things in real time: distinguish benign from malignant gastric ulcers, and classify bleeding ulcers by severity. A multicenter study developed an AI model for differentiating benign from malignant gastric ulcers that achieved about 91% precision and 91% recall on validation data, processing endoscopy video at over 100 frames per second with no meaningful delay.36PubMed Central. Development and validation of a real-time AI model for differentiating benign and malignant gastric ulcers: a multicenter retrospective study
A separate multicenter study built an AI system for classifying the severity of bleeding ulcers using the Forrest classification, the standard grading system that determines whether endoscopic treatment is needed. The system achieved about 92% accuracy on real-time video and outperformed less experienced endoscopists while performing on par with senior ones.37PubMed. Artificial intelligence-assisted system for the assessment of Forrest classification of peptic ulcer bleeding: a multicenter diagnostic study These tools are not replacing doctors, but they could reduce the number of cancers missed at initial endoscopy and help less experienced endoscopists make quicker, more accurate decisions about whether a bleeding ulcer needs immediate intervention.
Endoscopic Removal of Early Gastric Cancer Found in an Ulcer
Occasionally, biopsies taken from what was thought to be a benign ulcer come back showing early-stage cancer. When the cancer is caught very early and has not invaded deep into the stomach wall, it can sometimes be removed endoscopically rather than surgically. Endoscopic submucosal dissection (ESD) is the technique used for this: the abnormal tissue is cut away layer by layer through the endoscope. In a small series from Peru, curative resection was achieved in 75% of patients with early gastric adenocarcinoma treated by ESD.38Revista de GastroenterologÃa de México. Endoscopic submucosal dissection as treatment for early gastric cancer: Experience at two centers in Lima, Peru ESD requires highly specialized training and is more common in countries with high rates of gastric cancer, such as Japan and South Korea, where screening programs catch cancers at stages amenable to this approach. In Western countries, the technique is growing but still concentrated at academic medical centers.