Peptic ulcer at the end of the 20th century: biological and psychological risk factors

The prevailing concept of peptic ulcer etiology has swung over entirely in just a few years from the psychological to the infectious, yet the rich lit erature documenting an association between psychosocial factors and ulcer i s not invalidated by the discovery of Helicobacter pylori. Physical and psy chological stressors interact to induce ulcers in animal models, concrete l ife difficulties and subjective distress predict the development of ulcers in prospective cohorts, shared catastrophes such as war and earthquakes lea d to surges in hospitalizations for complicated ulcers, and stress or anxie ty can worsen ulcer course. Many known ulcer risk factors, including smokin g, nonsteroidal anti-inflammatory drug use, heavy drinking, loss of sleep a nd skipping breakfast, can increase under stress; the association of low so cioeconomic status with ulcer is also accounted for in part by psychosocial factors. Among possible physiological mechanisms, stress may induce gastri c hypersecretion, reduce acid buffering in the stomach and the duodenum, im pair gastroduodenal blood flow, and affect healing or inflammation through psychoneuroim-munological mechanisms. Psychosocial factors seem to be parti cularly prominent among idiopathic or complicated ulcers, but they are prob ably operative in run of the mill H pylori disease as well, either through additive effects or by facilitating the spread of the organism across the p ylorus, while gastrointestinal damage by nonsteroidal anti-inflammatory dru gs can also be potentiated by stress. Although the clinical importance of p eptic ulcer is fading along with the millenium, due to secular trends and n ew therapies, it remains worthy of study as a splendid example of the biops ychosocial model.