Psychological Stress – Peptic Ulcers
A new study published in the journal Clinical Gastroenterology and Hepatology provides new evidence that stress is related to an increased risk of peptic ulcers.
Since the pioneering work of Hans Selye in the 1930s, psychological stress was often linked to the induction and progression of peptic ulcers.
In the 1950s-60s, Selye began to promote stress as the major cause of most human ills, and soon the idea that many diseases are an expression of the “failure of adaptation to non-specific stress” became widely popular. Some “examples of the diseases thought to result from stress are high blood pressure, peptic ulceration and coronary thrombosis” (cf. H. Simpson, Stress: Studies in Antarctica, 1959, New Scientist, 12 Nov. 927).
In 1982, however, the Helicobacter pylori bug was discovered (Marshall and Warren, Nobel Prize in Physiology & Medicine, 2005). This rapidly blurred the importance of psychological stress as a causative agent in peptic ulcers, and soon the Helicobacter became the single, monocausal explanation of this disease. Yet, in the 1990s several studies re-investigated the stress-ulcers link, including one large longitudinal population report, studies related to family and job difficulties and major societal disasters (cf. Susan Levenstein, BMJ 1998; 316:538–41).
Fascinatingly, in 1995, Barry Marshall, discussing whether or not Koch’s postulates have been fulfilled for H. pylori and peptic ulceration, concluded, quote: “only one of the many steps required for the development of peptic ulceration has so far been fulfilled, i.e. the ability of H. pylori to produce histological gastritis in a susceptible host” (BJ Marshall, Ann Med. 1995; 27:565).
In the Clinical Gastroenterology and Hepatology study, Susan Levenstein and colleagues, from the Aventino Medical Group, Rome, Italy, hypothesized that life stress would be a pre-dictor of documented incident ulcer, that the association between stress and ulcer would be attributable in part to health risk behaviors and in part to confounding by low socioeconomic status, and that psychological stress and H. pylori would be additive, independent ulcer risk factors.
As part of the world health organization’s MONICA study, examined a 10 year follow up of 3379 Danish adults without a history of ulcer diagnosis. Blood samples, psychological status and medical data were gathered from this population in 1982-83 and compared to 1993-94 samples.
At the end of the study, 76 participants were diagnosed as having peptic ulcer. The authors report that, based on a stress index scale, subjects in the highest tertile of stress scores, had significantly higher ulcer incidence. Also, their risk to develop ulcer was doubled, when compared to the lowest tertile patients’ group.
Of note, the risk to develop stress-related ulcer was similar in H. pylori seropositive or seronegative subjects. Exposition to NSAIDs did not influence the risk to develop stress-related ulcer either.
These results provide new evidence that psychological stress can increase the risk of peptic ulcer, independently of the presence of H. pylori or NSAIDs use. This also suggests that treatment of psychological stress may represent a therapeutic tool for peptic ulcers.
In conclusion, in this study, life stress at baseline increased the risk of subsequent confirmed peptic ulcer in a population-based cohort without a history of ulcer at baseline. The increased risk was not fully explained by confounding by socioeconomic status or by associations with nonsteroidal anti-inflammatory drugs and smoking, although the impact of stress on these health risk behaviors accounted for a portion of the increased risk.
Stress is increasing worldwide, and gastrointestinal disabilities are common problems observed during chronic stressful situations. The study of Levenstein et al., reformulates the actual knowledge about stress as a contributor, trigger and/or cause of peptic ulcer diseases.
Source: Clinical Gastroenterology and Hepatology, 2015. DOI: 10.1016/j.cgh.2014.07.052
Read More: Clinical Gastroenterology and Hepatology
Updates
In a 2016 study by Ulrik Deding et al., published in BMC Gastroenterology, Cohen’s perceived stress scale measured the level of stress in a general health survey in 2010 of 17,525 residents of northern Jutland, Denmark, and was linked with National Danish registers on prescription drugs and hospital diagnoses.
Cox proportional hazard regression was used to estimate the risk of either receiving a triple treatment or being diagnosed in a hospital with a peptic ulcer, in relation to quintiles of stress levels.
Background/Interesting: Governmental health agencies in the United States and Denmark claimed that stress was not a cause for peptic ulcer disease. And, peptic ulcer as a psychosomatic disorder was not consistently supported (cf. Refs. No. 6, 8. 29, 31, 32, study by Ulrik Deding et al.).
The study found that participants with the highest self-perceived stress level had a 2.2-fold higher risk of peptic ulcer treatment in 33 months of follow-up compared to participants with the lowest level of stress.
Compared with that of the lowest stress group, those in the highest stress group had a 2.2-fold increase in risk of either receiving triple treatment or being diagnosed with peptic ulcer after adjustment for age, gender, socioeconomic status, non-steroid anti-inflammatory drug use, former ulcer and health behaviors.
The authors of this study concluded that the highest level of perceived everyday life stress raised the risk of either receiving triple treatment or being diagnosed with peptic ulcer during the following 33 months more than twice compared with that of the lowest level of perceived stress.
A 2017 study by Bhagawati Saxena and Sanjay Singh, published in Drug Discoveries & Therapeutics aimed to choose the best model, which reproduces the pathophysiology of SRMD, among previously established stress models. Stress-related mucosal disease (SRMD) is highly prevalent in intensive care patients leading to increasing treatment cost and mortality.
Macroscopic pictures of the ulcerogenic stomach explain that in contrast to other models, cold-restraint stress (CRS) exposure produced marked ulcers on the fundic area of the stomach. Results of the present study depicted that each stress model significantly increased ulcer index, microvascular permeability and decreased hexosamine level, however, the maximum in the case of CRS-exposed rats.
The overall results revealed that the CRS resembles the pathophysiology of SRMD closely. It is the best and feasible model among all the models to evaluate drugs for the treatment of SRMD.
A 2018 study by Katsunori Matsueda et al. published in Internal Medicine presented a Case Report of a 1-year-old girl brought to hospital with acute hematemesis with vomitus resembling coffee grounds. She was born at full-term with a birth weight of 2.56 kg through vaginal delivery and without birth asphyxia. Early endoscopy was performed under general anesthesia, revealing a gastric ulcer with exposed vessels in the supra-angular region.
Background: Gastric bleeding from a stress-induced ulcer is an uncommon, but previously documented entity in neonates. However, the occurrence of severe stress-induced lesions of the upper GI tract in the neonatal period of life, mainly in preterm newborn babies or in neonates treated in intensive-care units is relatively frequent.
The authors of this study concluded that hemorrhagic stress-induced gastric ulcers should always be considered in the differential diagnosis of healthy toddlers under psychological stress who present with massive upper gastrointestinal bleeding (UGIB).
A 2019 study by Ping-Yi Lin et al. assessed the interactional effects between burnout and job support on the prevalence of peptic ulcer diseases (PUD) among firefighters and policemen in Taiwan. Policemen and firefighters frequently encounter emergencies at a higher rate than other public service workers, which leads to burnout and affects their physical and mental health.
Overall, prevalence rates of self-reported and self-reports of physician-diagnosed PUD were 8.3% and 6.5% for policemen and 7.1% and 5.5% for firefighters, respectively. There was a 22% reduced odds ratio of PUD as diagnosed by physicians for the group with low burnout and high job support, but an increased odds ratio of 53% for the group with high burnout and low job support, after adjusting for lifestyle and demographic variables.
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