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Psychological stress increases peptic ulcer risk irrespective of H. pylori infection, NSAID use
Psychological stress increased risk for peptic ulcer regardless of Helicobacter pylori infection status or use of nonsteroidal anti-inflammatory drugs, according to data from a prospective study of a population-based cohort in Denmark.
“Peptic ulcer has always been considered a classic example of psychosomatic interactions, but the literature finding ulcer to be caused by life stress is plagued with methodological limitations: inadequately documented diagnoses, cross-sectional methodology, and/or lack of information about major known ulcer risk factors,” Susan Levenstein, MD, from the Aventino Medical Group in Rome, Italy, told Healio Gastroenterology. “Doubt therefore remains as to whether the detected association might be due to confounding, diagnostic bias, or the stressful effect of ulcer symptoms.”
Susan Levenstein
Aiming to resolve the controversy surrounding whether psychological stress contributes to developing peptic ulcers, Levenstein and colleagues obtained blood samples to test for H. pylori antibodies in addition to psychological, social, behavioral and medical data from a population-based sample of 3,379 Danish adults without a history of ulcer who participated in a 1982 World Health Organization study on the risk and development of cardiovascular diseases (MONICA study).
They measured stress based on concrete life stressors and perceived distress using a 10-point stress index. From 1987 to 1988 and from 1993 to 1994, surviving participants were reinterviewed (2,809 and 2,410, respectively). Ulcer diagnoses were confirmed by reviewing radiologic and endoscopic reports and by searching all participants in the Danish National Patient Register.
Overall there were 76 confirmed incident ulcers throughout the study period. Risk for ulcer was higher in the highest tertile of stress index scores (3.5%) vs. the lowest tertile (1.6%; adjusted OR = 2.2; 95% CI, 1.09-1.31). Adjusting for H. pylori-positivity, alcohol consumption or inadequate sleep did not affect the per-point OR for the stress index (OR = 1.19; 95% CI, 1.09-1.31); however, it fell after adjusting for socioeconomic status (OR = 1.17; 95% CI, 1.07-1.29) and fell further after adjusting for smoking, NSAID use and lack of exercise (OR = 1.11; 95% CI, 1.01-1.23). Multivariable analysis showed stress, socioeconomic status, smoking, H. pylori infection and NSAID use were all independent predictors of ulcer.
Stress increased risk for both gastric (OR = 1.19; 95% CI, 1.03-1.37) and duodenal ulcers (OR = 1.11; 95% CI, 0.98-1.27). Risk for stress-related ulcer was statistically comparable irrespective of H. pylori status or NSAID drug use.
“Our analyses provide the best evidence to date that psychological distress and concrete life stressors increase the risk of subsequent ulcer development, in both H. pylori-positive and H. pylori-negative individuals, even when socioeconomic status, non-steroidal anti-inflammatory drugs, and smoking are taken into account,” Levenstein said. “Behavioral mediators account for part, but not all, of this association. Clinicians treating ulcer patients should investigate potential psychological stress among other risk factors.” – by Adam Leitenberger
Disclosure: The researchers report no relevant financial disclosures.