Stress: Is it Really a Factor in Peptic Ulcer Disease?
By Patricia McGinley, FNP, MSN
Summary—Peptic ulcer disease (PUD) affects some 25 million Americans at some point in their lifetime.1 For years, stress has been implicated as a cause or precursor to the development of ulcer disease. However, since 1982, when Helicobacter pylori (H. pylori) was discovered as a cause of peptic ulcers, researchers and health care providers have focused treatment on eliminating the bacteria instead of on other risk factors. However, following a severe earthquake in Japan, researchers discovered a dramatic increase in peptic ulcer disease. Additional research confirmed their findings. Primary care clinicians need to address stress as a cofactor in peptic ulcer disease and include appropriate interventions for stress in the patient’s treatment plan.
When an earthquake measuring 7.2 on the Richter scale hit Kobe, Japan, in 1995, the incidence of peptic ulcer disease rose dramatically. Japanese researchers, in a retrospective study, reviewed 10,831 records and results of upper gastrointestinal endoscopy during an eight-week period following the Kobe earthquake.2 They compared results with 16,100 endoscopy results performed during the same eight-week period a year prior to the earthquake.
Results showed an increase in the incidence of peptic ulcers, and gastric ulcers were more prevalent than duodenal ulcers by a ratio of 3.07 to 1.88. The highest incidence was in areas most severely affected by the earthquake, which indicated to researchers a strong correlation between serious emotional stress and development of peptic ulcers.
Too Much Gastric Acid Produces Ulcers
Peptic ulcers are defects of the gastric mucosa that extend through the submucosa and involve the muscle layers.3 Ulceration occurs as a result of overproduction of gastric acid, which damages mucosa in the antrum of the stomach and the duodenum. The most commonly cited risk factors implicated in the development of peptic ulcers are presence of H. pylori and use of nonsteroidal anti-inflammatory drugs (NSAIDs). H. pylori is a spiral shaped organism that attaches itself to the gastric mucosa. It is capable of living there for many years without producing disease. The stimulus that activates H. pylori to induce ulcer is still unknown.
The Centers for Disease Control and Prevention estimates 50% of the worldwide population is infected with H. pylori. In the United States, persons most commonly infected include Hispanics, blacks, the elderly, and those with lower socioeconomic status.1
Despite those numbers, the presence of H. pylori cannot explain all peptic ulcers since only a small proportion of H. pylori-infected individuals develop ulcers. At the same time, there are individuals who are not infected by the bacteria and don’t take NSAIDs yet still develop ulcers.4
Prior to the discovery of H. pylori bacteria as a cause of ulcers, researchers and clinicians focused on other risk factors for ulcer formation. Those included cigarette smoking, alcohol use, poor sleep habits, and stress. Researchers recently reported results of several prospective studies that continue to implicate stress as a factor in the development of PUD. One suggests psychosocial stress probably interacts with H. pylori and other risk factors to induce development of peptic ulcers.4,5
Research Findings
Levenstein and colleagues completed a prospective study investigating the role of psychosocial factors in the development of peptic ulcers. This longitudinal study followed nearly 7,000 subjects through questionnaires sent at 10-year intervals. The prevalence rate of peptic ulcer at the beginning of the study was 4.2% (288 of the 6,923 subjects). At the end of the second year, 4,864 subjects answered a second questionnaire. Five percent (245) reported having an ulcer during the previous year. In addition, 78 recalled having an ulcer they did not report at the onset of the study.
Researchers looked at a variety of life stressors experienced by ulcer sufferers. They concluded that low socioeconomic status, low education levels, inadequate living conditions, and a blue-collar household predisposed an individual to develop peptic ulcers.6
Another longitudinal study suggested a person’s perception of stress might increase the risk of peptic ulcer development. Researchers used data from the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study7 to analyze 4511 adults who had no previous diagnosis of peptic ulcer disease. Using a questionnaire, researchers asked study subjects at a baseline and follow-up interview if they had been under or felt strain, stress, or pressure during the preceding month. The questionnaire included information about smoking, use of aspirin, corticosteroids, age, sex, and education.
In addition, researchers reviewed hospital discharge records and self-reported peptic ulcers diagnosed by a physician to define the incident cases of PUD among the study population. Baseline data revealed 68% of the study cohort reported being stressed. The stressed group included younger persons, women, persons with higher education, smokers, and regular users of aspirin.
Of the initially stressed cohort, 78% continued to feel stressed at the follow-up interview conducted nine years later. In addition, 47% of the baseline non-stressed group reported being stressed at the follow-up interview. During the nine-year study period, 208 persons (4.5%) developed peptic ulcers.
After adjusting for effects of age, aspirin use, sex, education, and smoking, looking at stress alone, the relative risk for developing peptic ulcer was 1.8. That risk increased proportionally as the level of stress increased.7
Implications for Practice
Although there are conflicts in the research data regarding particular factors that produce stress, results show that no matter what the perceived stress, ulcer formation may be the end result. In clinical practice, the standard of care is screening for presence of the H. pylori bacteria in individuals complaining of gnawing, burning stomach or abdominal pain typically occurring:
• between meals;
• in the early morning;
• or when the stomach is empty.
Upon diagnosis, appropriate therapy includes antibiotics and H2 blockers or proton pump inhibitors. Since stress is implicated as a cofactor in development of ulcer disease, screening for stress factors in the patient’s life is also appropriate.
Help Patients Reduce Stressors
Clinicians should help their patients identify what stressors are present in their lives and explore avenues to reduce them. (See patient education handout in this issue: Smoking and Your Digestive System. Also, see patient education handout on peptic ulcer disease included in RN Advanced Practice Alert’s premiere issue [July 1998].) Behavior modification interventions should be explored to reduce perceived stress for each individual patient.
Opportunities for future research studies might include development of a stress rating scale similar to the Zung Depression Scale.8 Using such a scale to screen patients diagnosed with H. pylori infection and ulcer disease could identify patients in whom stress is a cofactor, which indicates a need to include stress education and therapy in the treatment plan.
References
1. Gold B. H. Pylori: The key to cure for most ulcer patients. Information article. Atlanta: Centers for Disease Control and Prevention; www.cdc.gov/ncidod.
2. Aoyama N, Kinoshita Y, Fujimoto S, et al. Peptic ulcers after the Hanshin-Awaji earthquake: Increased incidence of bleeding gastric ulcers. Am J Gastroenterol 93;3:311-17.
3. Walsh J, Fass R. Acid peptic disorders of the gastro intestinal tract. In: Textbook of Internal Medicine. 3rd Edition. Philadelphia: Lippincott-Raven; 1997: 684-87.
4. Levenstein S, Ackerman S, Kkiecolt-Glaser J, et al. Stress and peptic ulcer disease. JAMA 1999;281:10-11.
5. Levenstein S. Stress and peptic ulcer: Life beyond helicobacter. BMJ 1999;316:538-41.
6. Levenstein S, Kaplan G, Smith M. Sociodemographic characteristics, life stressors, and peptic ulcer: A prospective study. J Clin Gastroenterol 1995;21: 185-92.
7. Anda R, Williamson D, Escobedo L, et al. Self-perceived stress and the risk of peptic ulcer disease: A longitudinal study of U.S. adults. Arch Int Med 1992;152:829-833.
8. Zung WWK. A self-rating depression scale. Arch Gen Psychiatry 1965;12:63.
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