Stomach/Gastric Cancer

When is an ulcer not an ulcer?

April 1, 2024 Word for Word Media 0Comment

Dr Leanne Prodehl, a surgical gastroenterologist, outlines when an ulcer is not an ulcer and may be stomach cancer.


You can listen to this article below, or by using your favourite podcast player at pod.link/oncologybuddies

Peptic ulcer disease (PUD) is a benign condition where an imbalance in the production of stomach acid and the protective mechanisms of the stomach result in a break in the mucosa (lining) of the stomach or duodenum. Most ulcers heal completely but some cause complications. PUD is common with 5 – 10% of people having an ulcer in their lifetime globally. Typically, ulcers are a result of helicobacter pylori infection or non-steroidal anti-inflammatories (NSAIDS).

Main symptoms of PUD

  • Pain or discomfort in the upper abdomen
  • Feeling full quickly when eating
  • Discomfort or bloating after eating
  • Heartburn or acid reflux
  • Nausea and vomiting
  • Evidence of bleeding (blood in vomit or stools, or a dark, tarry stool).

Some ulcers, however, can be silent with no symptoms.

Treating an ulcer

PUD is treated by managing the cause: eradicating helicobacter pylori or stopping NSAIDS, and prescribing medication (a proton pump inhibitor). Most ulcers heal in a few weeks and usually people will need medication for a few months with no long-term complications.

Stomach cancer

The presentation of PUD can be similar to stomach cancer, also known as gastric cancer, and it’s important to consider the times when an ulcer may not be an ulcer.

Stomach cancer arises from the mucosa of the stomach. It’s the fifth highest cancer worldwide and the incidence varies worldwide by geographic region. Socioeconomics play a role with the majority of stomach cancers occurring in resource-limited countries. Early stomach cancer is usually asymptomatic, and patients usually present at an advanced stage. Despite advances in diagnosis and treatment, outcomes remain poor.

Signs and symptoms

The commonest presentation is persistent abdominal pain and weight loss. The other symptoms are similar to PUD, such as nausea, difficulty swallowing, dark tarry stools, feeling full early and an ulcer-like pain. Approximately 25% of patients with stomach cancer have a history of PUD likely due to common risk factors.

Risk factors

The two main risk factors for stomach cancer are helicobacter pylori infection and a family history.

Helicobacter pylori is a bacterium found in the mucosa of the stomach and is associated with gastritis or inflammation of the mucosa. Chronic inflammation results in cell damage

and a process leading to change from one cell line to another cell line and eventually cancer.

Obesity and smoking are considered risk factors while there is no conclusive evidence linking alcohol intake to stomach cancer. Other risk factors include Epstein-Barr virus infection and occupational exposure. Medical treatment such as radiation to the abdomen and gastric surgery may result in an increased risk for stomach cancer.

There is an association between stomach cancer and affected family members. True inherited stomach cancer is, however, rare (1 to 3% of stomach cancer globally). The three main syndromes are: hereditary diffuse gastric cancer adenocarcinoma, proximal polyposis of the stomach and familial intestinal gastric cancer.

The association between benign stomach ulcers and stomach cancers probably reflects common risk factors (especially helicobacter pylori infection). Most ulcers aren’t cancer but there are alarm symptoms that indicate the need for further investigation.

Alarm symptoms

  • Symptoms that don’t respond to treatment
  • Unintentional weight loss
  • Poor appetite
  • Fatigue
  • Feeling full early
  • Iron deficiency anaemia or evidence of bleeding
  • Progressive difficulty or pain with swallowing
  • Feeling a mass in the abdomen
  • New symptoms over the age of 55

Further investigations include a gastroscopy, contrast X-ray or CT scan. If the original ulcer was in the upper or body of the stomach, a biopsy should be done at the time of diagnosis and a follow-up gastroscopy at six weeks.

It’s unusual for stomach cancer to present early in countries where there is no screening programme, such as SA, and the outcome of locally advanced or metastatic stomach cancer is improving but remains guarded. It’s important to seek medical help when typical ulcer symptoms become unusual.

Dr Leanne Prodehl

MEET THE EXPERT – Dr Leanne Prodehl


Dr Leanne Prodehl is a upper gastrointestinal and hepatopancreaticobiliar surgeon at Charlotte Maxeke Johannesburg Hospital with a special interest in oesophageal cancer and multi-disciplinary teams. 


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