An ulcer is a lesion, which is an open sore accompanied by an infection and/or inflammation. Ulcers can happen anywhere in the body. This article will focus on stress-related stomach ulcers (gastric ulcers).
The following can either cause or worsen underlying stomach ulcers:
- Helicobacter pylori (H. pylori bacteria) infections
- NSAID Use (Non-Steroidal Antiinflammatory Drugs – eg., ibuprofen, naproxen sodium, etc.)
- Spicy Foods
- Emotional and Physical Stress
Ok, now that I have given you an overview of ulcers, let’s drill this down more to focus on the intent of this article – stress ulcers.
What are Stress Ulcers?
Stress ulcers tend to occur in the upper digestive tract, resulting in esophageal, stomach, and duodenal ulcers.
Also known as Stress-induced Gastritis, these ulcers tend to occur during times of great physical and psychological stress on the body.
Typically, this will happen with events that lead to hospitalization and during hospitalization, especially in the intensive care unit.
Any severe or extreme physical or emotional stress on the individual, such as extended anxiety, major invasive surgery (cardiac bypass, etc.), or severe injury, can precipitate the formation of stress ulcers and internal bleeding.
The relationship between stress levels and ulcer formation is well-established. However, this does NOT mean that stress is the sole cause of ulcers. There are other causes of ulcers in addition to stress.
We need to go a little deeper to understand the process.
Contrary to belief, stomach acid is not the main culprit. The primary cause of stress ulcers seems to be splanchnic hypoperfusion.
This refers to a markedly lower blood flow volume to the gut’s internal organs, leading to problems that I will discuss below.
When an individual undergoes stress, the sympathetic nervous system is activated (the commonly known “fight or flight” response).
The resulting release of adrenaline and noradrenaline constricts the blood vessels causing blood pressure to increase.
Additionally, the secretion of pro-inflammatory cytokines, regulators of the body’s responses to trauma, inflammation, infection, and immune responses, is increased.
The stress also triggers an increase in the amount of acid being produced.
In the short term, these responses benefit the body as they shift blood flow away from the gastrointestinal tract to critical organs such as the brain.
However, when they persist for longer, the constant lack of blood supply to the gut causes a breakdown of stomach mucosal defenses and structural integrity. In this vulnerable state, the gastric acid then worsens the ulceration in the lining of the stomach – kind of like rubbing salt into an open wound. This is what leads to the development of ulcers.
What does a stress ulcer feel like? (Symptoms of Ulcers)
Stress ulcer symptoms overlap with other stomach conditions, making diagnosis difficult. These are the main symptoms:
- Abdominal pain (with or without bloating)
- Feeling full in your stomach more than usual
- Loss of appetite
- Nausea or vomiting
- Fatigue, becoming short of breath quickly, pale skin (signs and symptoms of blood-loss-associated anemia)
If you see the following, blood loss from your ulcers may be severe or indicate that they are rapidly bleeding, and you should go to the emergency room immediately:
- Dark stools that appear tarry (indicative of a bleed in your stomach)
- Fainting or feeling light-headed
- Vomiting up large quantities of blood or contents that look like coffee grounds
Are stress ulcers life-threatening?
Worst-case scenario, yes. If you are consistently experiencing a GI bleed, it is a medical emergency, and you need to be seen by a doctor and treated immediately.
Sustained blood loss is never good, and your condition may lead to serious complications depending on the severity of the gastrointestinal bleeding.
The other cause for concern is that you are at risk for getting a severe bacterial infection due to the open sore in your stomach lining. This can lead to sepsis and shock, quickly resulting in death if the infection is not treated emergently.
Also, your doctor must rule out other causes of the bleeding, such as colon or stomach cancer.
How are stress ulcers diagnosed?
Your doctor will want to determine if you are having peptic ulcers caused by an H. pylori infection (see my article here, where I go in-depth into diagnosing and treating H. pylori infections) or other medical causes.
To be certain, your doctor will want to inspect your stomach visually, typically done during an upper GI endoscopy.
During this procedure, a flexible tube with a camera at the end is inserted into your esophagus and an empty stomach. The doctor then carefully looks at the lining of your stomach.
Your healthcare provider can visualize ulceration or bleeding inside your stomach through this process.
Once your physician confirms a diagnosis of stress gastritis, then an evidence-based, clinically sound treatment plan can begin.
How are stress ulcers treated?
Think about this – you have open sores inside your stomach, which are constantly bathed in the hydrochloric acid in your gastric juices.
This is NOT the ideal environment for those sores to begin to heal!
So, the first step to begin the healing process is reducing stomach acidity.
The acidity or alkalinity of any solution is measured on the pH scale.
The scale reads from 0 to 14, 7 being neutral. Anything below seven is considered acidic, and anything above seven is considered alkaline.
For a visual representation of where common items fall within this scale, I have included the image below for reference:
As you can see from the infographic, the pH value of stomach acid is around 1.
So, going back to my earlier statement about reducing stomach acidity to facilitate ulcer healing, clinicians and scientists have found that the ideal pH is around 4.
The stomach lining can repair itself at this pH level without dealing with the annoying stomach acid irritating the delicate tissue.
How do we reduce the acidity? By taking histamine blockers such as famotidine or proton pump inhibitors (PPIs) like esomeprazole or omeprazole.
Taking over-the-counter antacids such as calcium carbonate is discouraged because they don’t provide a sustained level of protection against stomach acid.
Prescribing PPIs to hospitalized patients, especially in the burn, surgical, or critical care units, is standard practice.
This prescribing convention is called Stress Ulcer Prophylaxis (SUP). Here is an example of a SUP protocol that is standard across many medical institutions.
- Critical and acute care hospitalization, chronic emotional or physiological stress, and prolonged anxiety can cause stomach ulcers to form
- NSAID use can also lead to stomach ulcers
- Feeling of fullness, lack of appetite, stomach pain, nausea, vomiting, and fatigue may indicate the presence of stomach ulcers
- If you are having dark, tarry bowel movements, see blood in your stools, or are vomiting up blood, especially with coffee ground particles, see your doctor immediately
- Stress ulcers can be treated with common prescription and OTC medications
- Moody FG, Cheung LY. Stress ulcers: their pathogenesis, diagnosis, and treatment. Surg Clin North Am. 1976 Dec;56(6):1469-78. doi: 10.1016/s0039-6109(16)41099-6. PMID: 793064.
- Megha R, Farooq U, Lopez PP. Stress-Induced Gastritis. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499926/