Does Stress Cause Ulcers?

What causes ulcers? Is it stress, your diet, or something else? Join us as we navigate through medical theories and outlandish treatments to the surprising revelations of the true cause of peptic ulcers.

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Transcript

Today we’re talking all about peptic ulcers, from their often mistaken cause to a medical breakthrough worthy of the Nobel Prize. Discover the true culprit behind this painful affliction and how to treat it.

M: I’m Professor Megan 

S: and I’m Professor Susan, and we’re

Both: Your Nutrition Profs!

M: We are registered dietitians and college professors who have taught more than 10,000 students about health and nutrition. We have answered a LOT of questions about nutrition over the years – 

S: Some questions we get asked every year and some are rarely asked but very interesting.

M: We’re here to share our answers to these common (and uncommon) nutrition questions with you.

S: So bring your curiosity and let’s get started. 

Both: Welcome to our class!

M: You wake in the middle of the night with severe abdominal pain just above your belly button. Your abdomen is very tender to the touch. You almost can’t breathe and you feel like you’re going to vomit. 

S: This is not a new pain. Lately you’ve noticed a dull, gnawing pain in the same place that comes and goes. You get some relief from the pain after eating, but it always returns. You’ve had heartburn, felt bloated and you’ve been belching - a lot. You’ve also noticed that your stool was very dark the last few days. It sometimes looked like coffee grounds. 

M: But tonight it’s worse. You’ve been ignoring the symptoms – attributing them to how stressed you’ve been lately. You were hoping they would go away on their own. But it looks like you’re headed to the ER tonight. What could it be?

S:  drumroll please… The answer is – a peptic ulcer. But did stress cause it?

M: Before we get to causes - what actually is a peptic ulcer?... It’s a raw, open sore in the lining of the upper gastrointestinal or GI tract. There are a few types of peptic ulcers based on location: gastric ulcers occur in the stomach, and duodenal ulcers occur in the first part of the small intestine. 

S: Ulcers occur when the mucus lining of the GI tract breaks down. This allows the strong stomach acid to reach the stomach walls. 

M: Stomach acid is very strong, about the same pH as battery acid in your car, so when the acid touches the stomach walls, it burns into it causing damage. 

S: yea - Students always ask why this doesn’t happen all the time. Like Why doesn’t the stomach just digest itself?

M: Well the answer is that although there is mucus lining the entire length of the GI tract, the mucus lining the stomach is double-layered making it particularly unique. Under normal conditions this extra layer is going to protect our stomach walls from this acid. 

S: But sometimes that extra layer will break down, and that allows the acid to basically damage part of the stomach walls or the lining of the first section of the small intestine , and that first section is called the duodenum. So these are peptic ulcers. 

M: Although some believe ulcers to be a modern disease, peptic ulcers were well known in antiquity. And while we don’t know for sure, it’s thought that a Greek physician, Diocles  of Carystos  wrote about peptic ulcers in the 4th century BCE.

S: One of earliest descriptions that we know of  is carved on a pillar of the temple of Aesculapius  at Epidaurus also in the 4th century BCE.

M: The first definite peptic ulcer identified in a human was from the autopsy of a mummy from the Western Han dynasty, a man who died in 167 BCE. His autopsy showed a clearly visible perforated ulcer which resulted in acute peritonitis which is a sciencey word for inflammation of the lining of the abdomen. So in other words, his ulcer went completely through the stomach wall and caused infection and inflammation of his abdominal cavity.

S: Ouch.

M: Yeah. 

S: Several descriptions were found in the 16th-19th century, with much interest in stomach and gastric physiology in the late 1800s in Europe and in other Western nations. That’s when ulcer disease became more frequently diagnosed.

M: In 1825, Dr William Beaumont, an army doctor in a frontier military outpost in Fort Mackinac, Michigan, was the first to really identify how the human stomach functions. 

S: Ok this is such a crazy story. 

M: Yes

S: So one of the soldiers at the outpost, his name was Alexis St. Martin, he was shot in the abdomen…but he survived – with a hole in his stomach. Dr Beaumont was able to observe him over several decades…in fact, St. Martin lived to be 83!

M: So Dr Beaumont was able to view a lot through this opening into St Martin’s stomach. It was literally like a window into the gut! He wrote up his findings, describing stomach secretions including stomach acid, other gastric juices, the digestive process of different foods, and the stomach’s very strong muscular contractions. And that really marked the beginning of a period of great interest in stomach physiology.

S: Right - I mean before that they had no way to know how it worked at all. And then after the 1860s, life expectancy improved due to all kinds of improvements in diets, sanitation, living conditions and so this reduced deaths from infections so people started to live longer.  But longer life also meant you were more likely to get an ulcer. 

M: So if your great grandfather complained to his doctor of symptoms of a peptic ulcer, he was probably told to avoid spicy foods, alcohol, and coffee, and to manage his stress. The goals of ulcer treatment in the late 19th and early 20th centuries were  1. to reduce the acid and  2. to coat the ulcer to protect it from further irritation and allow it some time to heal

S: In 1915, Dr. Bertram W. Sippy of Chicago devised what he called the “Sippy diet” (great name)  for treating peptic ulcers. And so he advised patients to drink small amounts of cream and milk every hour on the hour to help neutralize the stomach acid. 

M: Then they were to drink on every half hour one of 2 antacid powders to reduce stomach acidity. One caused a laxative effect, and then the other was given to counteract that first laxative effect. 

S: That seems so weird!

M: And then, increasingly, begin to introduce soft bland foods with frequent meal times. 

S: And for a while this diet sometimes worked, fooling both the doctors and the patients. But it did have some side effects. The sippy antacid powders contained sodium bicarbonate which is baking soda and that produced lots of gas, CO2. That means lots of bloating, lots of belching, lots of uncomfortable symptoms. 

M: Yeah that doesn’t sound fun at all. And there’s also a lot of calories from the milk and cream they’re drinking every hour!

S:Yeah, they were drinking about 4.5 cups every day of this milk/cream mixture. And so weight gain was common, and it was also theorized that the high levels of saturated fat in the dairy may have contributed to plaque buildup in their arteries. 

M: Wow. But some people did feel better. However, the reduction of peptic ulcer symptoms was likely the result of having a full stomach all the time, I mean they were dinking milk and cream, they were introducing bland foods, so the symptoms of peptic ulcer are really more prevalent when the stomach is empty. 

S: Right. Well the Sippy diet was basically discontinued in the 1960s because of all of these side effects that we just talked about. But I do remember a friend in high school who had an ulcer and the doctor had told him to drink milk any time he had stomach pain. And so this would have been in the 1980s! So doctors were still prescribing at least the dairy part.

M: They still thought that a diet high in spicy foods and an inability to manage stress were causes even if so

S: In the 1980s!

M: Yeah.

S: In the meantime, other “treatments” were created and some are still with us. So in 1930 TUMS were created by pharmacist James Howe.  He was looking for a way to treat his wife’s indigestion. 

M: Awe, well that was nice of him!

S: That is nice of him! He used calcium carbonate to make a chewable tablet that was an antacid. It was primarily for heartburn relief – and you still see that

M: Oh yeah

S: It’s still used for that today! And because it’s made from calcium carbonate, some people also use it as a calcium supplement. 

M: Well in the 1950s and 60s, products like Milk of Magnesia and Maalox were developed. These were liquids containing magnesium and other minerals like aluminum that also work as an antacid – and as a laxative. Now there are many OTC antacids available! We’ve actually got an episode in a few weeks all about magnesium coming up.

S: Right that will be a good one!

M: But the cause of ulcers was still thought to be spicy foods and stress. A paper published in 1967 even reported that peptic ulcers appeared most often in families with dominant and obsessive mothers! 

S: Wow - you know they always blame the moms…

M: So rude!

S: It is. 

M: Well doctors thought that stress and spicy foods and domineering mothers apparently caused an overproduction of stomach acid and that’s what caused the ulcers. So treatment was a bland diet, bed rest, taking medications that blocked new acid production or neutralized existing stomach acid like milk of magnesia, and managing your stress.

S: Right. In the 1970s and 80s pharmaceutical companies began developing more treatments for GI issues like heartburn and peptic ulcers and so they came up with a group of medications called proton pump inhibitors or PPIs. And you’ve most likely heard of some of these like Prilosec, Prevacid, Protonix, and there are several others. There are over-the-counter and prescription versions available.

M: PPIs, these proton pump ihhibitors, all work by reducing acid production within the stomach. They block the hydrogen-potassium ATPase enzyme or gastric proton pump which is required for stomach acid secretion. So PPIs should be taken 30-60 minutes before eating for optimal effectiveness. And consistent use for several days or weeks is necessary for maximum benefit. 

S: Another option are H2 blockers. These block the action of histamine on certain cells in the stomach which also reduce acid production. But these are more often used for heartburn and gastroesophageal reflux disease or GERD. And we’ll talk more about these in an upcoming episode. They’re also used to treat duodenal ulcers, but less often for gastric ulcers. Some H2 blockers you’ve likely heard of are Tagamet and Pepcid. 

M: Ok, so we’ve discussed some of the theorized causes of ulcers and some of the first treatments, but let’s get to the question: does stress cause ulcers?  

S: Well in the 1980s, two Australians Doctors Robin Warren and Barry Marshall, proposed a radical hypothesis—that the cause of ulcers was bacteria. 

M: Bacteria causing ulcers?? That’s crazy!

S: I know. That’s what everybody thought. So here’s what happened. In 1982, they observed bacteria in inflamed regions of the human gut from stomach lining biopsies of a 100 different patients. In 58 of those patients they found spiral shaped or curved bacteria – and most of these 58 patients had active gastritis, or ulcers of the stomach or duodenum. 

M: They isolated the bacteria and named it Helicobacter pylori or H. pylori. “Helico” refers to the bacteriums’ helix or twisted shape and “pylori” refers to the lower part of the stomach, which is called the pylorus. 

S: They actually weren’t the first to see bacteria like this. In the late 1800s a researcher from Poland and a researcher from Italy both observed these spiral-shaped microorganisms in the gut mucus of both humans and dogs, but both of them thought their samples had just gotten contaminated. There was no way bacteria could survive in the stomach’s extremely acidic environment - like battery acid right? So they noted it, but they just moved on.

M: You know a student the other day actually asked about this when we were talking about ulcers in class. Like wait a minute…how - you’ve just described how acidic and harsh the conditions of the stomach is - how can, how could a bacteria live? And so that’s really what everyone was thinking.

S: It’s an excellent question.

M: Yeah. But those Australian doctors did not move on. They figured out how to grow H. pylori in a highly acidic culture…by accident. 

S: Right. They left a gut culture growing over a long Easter holiday, and when they came back the following week they found the bacteria.

M: Most bacteria grow rapidly in the right culture conditions. But H. pylori is slow growing – which is why it took several days over a long weekend to show up. 

S: You know it’s really amazing how many scientific discoveries occur by accident!! Like discovering aspartame was so sweet by licking your finger

M: ugh…

S:  I know, yuck…

M: If you haven’t heard that story, definitely take a listen to our aspartame episode!

S: So, Warren and Marshall theorized that the inflammation in the gut walls was caused by this bacteria. They tried to get lab animals to develop ulcers by injecting them with H. pylori but couldn’t get that to work. 

M: But they still believed. So to test it, Dr. Marshall underwent an endoscopy and we’ll explain more about endoscopies in a little bit, he underwent this endoscopy to make sure he didn’t have H. pylori. Three weeks later he drank a dish of H. pylori – without telling his wife…I’d be so mad, or the hospital’s ethics board…

S: Ewwww that’s so groww….but definitely not the first time a doctor used themselves as a “guinea pig” right? Remember Dr. Goldberg and the filth parties...

M: Ugh.

S:  for the true cause of pellagra? 

M: Yeah those were terrible.

S: Yikes.

M: But seriously, true dedication!! 

S: I don’t think I’m that dedicated. 

M: I don’t think so either! All right, well after a few days Dr Marshall started to experience bloating and fullness after eating and his appetite was decreased. He started to feel sick with headaches, developed bad breath, and started to have bouts of retching or dry heaving.

S: So he underwent another endoscopy. This time they could see that his stomach wall was inflamed and damaged. And they confirmed that swarms of H. pylori were in the inflamed tissue. So this proved that H. pylori was infectious. 

M: And how do you treat a bacterial infection? Antibiotics. Marshall’s wife insisted he take an antibiotic and the symptoms of the H. pylori infection went away. Another endoscopy proved it. An experimental success! They published their paper in 1982. 

S: But the medical community did not believe them. They said there was no way bacteria could live in this acidic environment – and who was going to believe these random doctors from nowhere with no research credentials?! Most doctors still believed ulcers were caused by stress, spicy food, coffee, alcohol intake….not bacteria. 

M: But the Australians persisted with their research. They figured out that the spiral shape of the bacterium allows it to penetrate the stomach’s mucus lining kind of like a corkscrew, where it then secretes an enzyme that generates substances to neutralize the stomach’s acidity. 

S: This weakens the stomach’s protective mucus, making the tissue more susceptible to the damaging effects of the acid, and this leads to the development of sores and ulcers. 

M: Because of the neutralization of the stomach acid, the stomach responds by producing even more acid, which causes further damage to the stomach lining. 

S: Vicious cycle.

M: Yeah. 

S: It took several more years before the medical community finally accepted their results – that the cause of the majority of peptic ulcers was a bacterial infection by H. pylori. 

M: And Warren and Marshall were given the Nobel Prize in Medicine in 2005 for this discovery. So, vindication!

S: Woohoo! Good for them! Although scientists still don’t know for sure, H. pylori seems to be spread from person to person through contact, or we may get it from contaminated food or water. It’s thought that as much as 2/3 of the world’s population have H. pylori in their bodies. And rates vary by geography or ethnicity. But only 10-15% of those who are infected with H. pylori will actually develop ulcers. 

M: And H. pylori has also been linked to cancers of the stomach which is the 14th most common cause of death worldwide. 

S: So the main cause of ulcers is not stress or anxiety, not spicy food, but a bacterial infection. But that’s not the only thing that makes you more susceptible to ulcers.

M: Nope. Anything that weakens the mucus lining of the stomach can cause sores and inflammation. Infection with H. pylori is the most common reason. The second most common culprit is long term use of medications called NSAIDS – non steroidal anti-inflammatory drugs. 

These drugs are used to treat pain – drugs like aspirin, ibuprofen like Advil or Motrin, naproxen sold as Aleve, these NSAIDS work to reduce inflammation like steroids, but without the steroid side effects. 

S: Yeah they are really common. 

M: Yes. 

S: Many people take them for things like arthritis, or back pain, or headaches, or soreness. Taking NSAIDS once in a while is probably OK for most people, but chronic use – longer than 2 weeks or so – seems to also cause the mucus lining to thin, allowing stomach acid to damage the stomach lining. 

M: So the two most common things that can cause ulcers are an H. pylori infection or chronic NSAID use. But other things that increase your risk for developing peptic ulcers include drinking too much alcohol, smoking cigarettes or using chewing tobacco, radiation treatments,  anything that reduces the robustness of your immune system – including stress

S: So stress doesn’t CAUSE ulcers, but it may indirectly make you more susceptible to them if you are infected with H. pylori, or you take NSAIDS, or both. 

M: Right. There is also a rare condition called Zollinger-Ellison Syndrome that causes the stomach to produce too much acid – and this is a very rare cause of peptic ulcers. 

S: And you have an increased risk of developing an ulcer if ulcers or cancer of the gastrointestinal tract run in your family, or if you’ve previously had an ulcer.

M: So if you are experiencing symptoms like bloating, nausea or vomiting, frequent belching, abdominal pain – 

S: Especially when the stomach is empty like at night – 

M: Or feel uncomfortably full after eating, have frequent heartburn, or dark, bloody stools that may look like coffee grounds….see your healthcare provider. 

S: For sure. They’ll want to know your family history of GI issues. They’ll take blood, listen to your abdomen with a stethoscope, and they’ll palpate or tap your abdomen to check for tenderness or pain. 

M: If they suspect you do have an ulcer they will probably take blood to check to see if you are anemic because you may actually be bleeding and not know it. 

S: Yes that’s common. To check for a H. pylori infection specifically they may take blood, a stool sample, or they might do what’s called a urea breath test.

M: The doctor will usually also recommend that you have an upper endoscopy test – which is the super sciency word esophagogastroduodenoscopy or EGD.

S: That was amazing! That is a REALLY sciency word! I’m not sure I could do that - and there will be a spelling test later!! And that’s the test that Dr. Marshall had.

M: Multiple times. 

S: Right.

M: Yes. During an EGD, you’ll be sedated and the doctor will send a flexible tube with a camera down your throat, through the esophagus, stomach and even the first part of the intestine - remember that’s called the duodenum. They’ll look for inflamed areas, ulcers, and they can take biopsies as well. 

S: I’d definitely want to be sedated for that!

M: Yes, I’ve had an EGD. And it was surprisingly quick and painless but I’m glad I was out for it. 

S: Right. Well I have never had one but I did watch one during my dietetic internship and it was really interesting. 

M: That’s awesome. I wish I had had that opportunity. 

S: In some cases they may also recommend that you have an upper GI series and this is where they take x-rays after you drink thick barium. This allows them to look at your digestive system while you’re swallowing and digesting something. And you don’t need sedation for this test.

M: If these tests determine that you have a peptic ulcer, the treatment will depend on the cause. If you have one because of an H. pylori infection the standard treatment is to use a combo of two different antibiotics plus bismuth subsalicylate which is the main ingredient in Pepto-Bismol. These are going to kill the bacteria. They’re also going to want you to take a PPI like Prilosec or Prevacid to reduce stomach acid production. 

S: You’d take these for at least 7-14 days. And it’s really important to take all of the doses exactly as prescribed. If you stop taking your antibiotics early some bacteria may survive and persist in your stomach and those could develop antibiotic resistance.

M: Then you’re more likely to develop another ulcer that will be even harder to treat. 

S: And you don’t want that - right? Do not skip the meds!! Even if you’re feeling better. That’s true for all antibiotics. 

M: Definitely. 

S: If you have an ulcer without H. pylori infection and they suspect NSAIDs made you vulnerable to the stomach wall damage you’ll likely be prescribed a PPI for about 8 weeks or so along with changes in your NSAIDs.

 M: You may have to lower the dose or take a different pain reliever like acetaminophen or Tylenol which is not an NSAID. If you have to keep taking an NSAID they may also prescribe taking a PPI along with it. 

S: Sometimes they may not be able to determine the cause of your ulcer. So in that case they treat it like they do with H. pylori infection and they call it idiopathic peptic ulcer.

M: They always use that word “idiopathic” when they can’t determine the cause of the issue. 

S: Yeah. 

M: But I guess it sounds fancier than saying “We don’t know”!

S: I would agree with that. If your ulcer is bleeding and won’t stop with standard treatment, you may have to undergo another EGD so that they can treat the ulcer from the inside of the stomach, usually by cauterization. That's where bleeding vessels are sealed by controlled burning. 

M: And if that doesn’t sound extreme enough - in really severe cases an ulcer can cause a tear in the stomach or duodenal wall. 

S: Like our mummy!

M: Exactly. This is called a perforated peptic ulcer and it often requires surgical intervention.

S: The good news - this is pretty rare. It happens in only 1-3% of cases. But it is serious and can be deadly. 

M: So don’t ignore the symptoms we mentioned. 

S: Right. Ok what’s the bottom line on peptic ulcers?

M: Peptic ulcers are sores and inflammation occurring in the stomach or the first part of the small intestine. The #1 cause is an infection with a bacteria called H. pylori. The second most common cause is overuse of NSAIDs.

S: Ulcers usually won’t clear up on their own. So standard treatments includes antibiotics and proton pump inhibitors or PPIs that reduce stomach acid. 

M: They are NOT caused by stress or spicy food. Having an ulcer does not necessarily mean you have to change your diet or learn how to manage stress better.  

S: Researchers have mapped the entire genome of H. pylori so new and better treatments may be just around the corner.

M: The discovery that a bacterial infection is the primary culprit behind peptic ulcers is considered one of the most important medical discoveries of the late 20th century. But it took the overturning of old, traditional theories to change the course of treatment from antacids and stress management to antibiotics and PPIs. 

S: And it’s a good lesson right? Always check the science before believing anything but keep an open mind. Scientific discovery is a process.

M: And that’s it for our deep dive into ulcers. But before we go, we want to emphasize that the information shared on this episode about peptic ulcers is for educational purposes only and is not intended as medical advice. 

S: If you have any concern about your gastrointestinal health or are considering any changes to your medication regimen, please consult your healthcare provider. They can provide personalized guidance based on your individual health, needs, and circumstances. 

M: Remember, your health and well-being are of utmost importance, and seeking professional medical advice is always the best course of action for addressing any medical concerns. Thank you so much for joining us today!

S: Oh we so appreciate your listening to our podcast. And please remember to follow us on your preferred platform.

M: Join us next time when we will have a snack-i-sode about an ancient meat substitute – seitan. 

S: Oh -looking forward to it!

Both: Class Dismissed.

S: We hope you enjoyed this episode. You can find the show notes and a list of sources on our website, yournutritionprofs.com. 

M: Your homework is to follow us at your nutrition profs on Instagram and to listen to our next episode. You can listen on Amazon Prime, Apple Podcasts, Spotify, YouTube, or anywhere podcasts are found. We’d appreciate it if you’d “like” us, write a review, subscribe, and invite your family and friends to join us too. 

S: If you have a nutrition or health question you’d like answered, let us know! We may even do a show about it! Send an email to yournutritionprofs@gmail.com or click on the “Contact Us” page on our website.

M: Thanks to Brian Pittman for creating our artwork. You can find him on instagram @BrianPittman77

Both: See you next time!