How many times have people heard or uttered the words: “Calm down or you’ll give yourself an ulcer.” Well, the good news is that it is unlikely that someone is going to breed an ulcer simply because they’re stressed out. The bad news is that there are lots of other ways to develop ulcers. In fact, perhaps one in 10 Americans are likely to develop one in their lifetime; some won’t even realize there is an ulcer literally eating away their insides; and that if left untreated, ulcers can do the body all sorts of nasty harm. So, what are the related dangers and how are they recognized, avoided and treated? Relax. Dr. Nina Nandy of the American Gastroenterological Association met with WellWell recently to lay out everything you need to know about ulcers. Read on.
Tell us what a gastroenterologist does. Its focus is probably wider than what we’re assuming.
A gastroenterologist is a doctor of digestive diseases. We do our training in internal medicine, then we do a special fellowship and GI for three to four years. We focus on anything from acid reflux to ulcers to rectal bleeding, diarrhea and constipation, all that good stuff. Not only do we deal with all the digestive health issues, but we do procedures as well, like your regular routine screening colonoscopy and more advanced things like taking out gallstones or common bile duct stones.
Can you explain what an ulcer is and the different types?
An ulcer in the most basic sense of the word is a sore or a lesion that can form usually in the lining of the digestive tract, typically in the stomach. We call those gastric ulcers. When it forms in the upper part of the small intestine we call those duodenal ulcers. You’ve probably heard of people with diabetic foot ulcers and things like that. So, it’s really not limited to the GI tract. They usually happen when the protective lining of the GI tract is damaged in some way or eroded, which allows all the stomach acid and juice to irritate the sensitive tissues.
What causes an ulcer and is stress a contributor?
The most common causes of GI ulcers are H pylori or Helicobacter pylori. That’s a bacteria that infects the lining of the stomach and the small intestine and that causes weakening of the protective mucous layer. That’s something we always test for. The other more common cause of ulcers is NSAIDs or non-steroidal anti-inflammatory drugs and those are things like aspirin, ibuprofen and naproxen that can irritate the lining. There are other causes like smoking and lots of alcohol genetic factors. There are some medical conditions that also make you more prone to developing ulcers like Crohn’s disease, Zollinger, Ellison syndrome and other inflammatory bowel diseases. That brings us back to the very important and interesting concept of stress. So, stress doesn’t directly cause ulcers, but it makes behaviors in people who already have ulcers contribute to making them worse. It also contributes to unhealthy behaviors because when you’re stressed you might smoke or drink more or have poor eating habits. And that can certainly contribute to ulcer risk.
And what about uncontrolled acid reflux?
Reflux or GERD, as we call it, gastroesophageal reflux disease, is something to talk about every single day. It’s very common and it doesn’t directly lead to ulcers, but it can contribute to their development in a lot of important ways. So, what is GERD? The acid reflexes when the stomach acid flows back up into the esophagus, maybe because the lower esophageal sphincter muscle is loose, and that irritates the lining of the esophagus. Over time, any time you have chronic irritation that weakens the protective barrier of the esophagus and makes it more susceptible to damage. So sometimes chronic or severe cases can lead to ulceration in the esophagus. We call that erosive esophagitis. Sometimes it can lead to a condition called Barrett’s esophagus, which are some precancerous changes in the lining of the stomach. Basically, the cells change and they start to look more like stomach cells. They can protect themselves against acid, but the esophagus wasn’t meant to do that. And chronic exposure can sometimes cause these ulcerative changes. Acid reflux itself doesn’t directly cause ulcers, but it exacerbates and makes conditions worse leading to ulcer formation, especially in people who are susceptible.
Genetics can be a cause in addition to aspirin and ibuprofen. Beyond that, what are other causes of ulcers?
Certainly, anything that’s going to erode the protective lining of the stomach, any behavior that does that which would be using NSAID Drugs, excessive smoking, excessive drinking. Behavioral things like uncontrolled acid reflux by eating certain foods that are known to make the symptoms worse. Things like spicy, acidic, greasy food—that kind of thing. But that’s not the same for every person. But, certainly, some of these behaviors, especially smoking and drinking, can contribute.
Are there certain groups that are more at risk for developing ulcers?
Some studies show that men were maybe more at risk of developing ulcers than women. We thought that maybe estrogen was protective in some way in terms of inhibiting a chronic stress response. But there are new studies that came out where the incidence of ulcers in women to men was three to two and that risk goes up as we age because maybe we’re losing some of these protective barriers in the GI tract. Historically, I think they were more in men because there were higher rates of smoking and men were using anti-inflammatory drugs more for arthritis and joint pain. But I think that’s changed a lot.
And do we know roughly how many people are suffering from ulcers?
The prevalence is hard to say. In the United States, it’s estimated that about 10 percent of people will develop some kind of gastric peptic ulcer at some point in their lives, which is a lot. That figure depends on age, gender and other health conditions. And sometimes a lot of this is underreported.
Do you think the percentage is rising or lowering?
I think it’s increasing because we are better able to detect what’s going on. I think we’re seeing more of it because we have more advanced techniques to find them, whereas in the past people only went to the doctor if they had a complication of an ulcer like bleeding and other things. I think it may not be a true increased prevalence, but we’re seeing more and more of it because we know what to look for.
How does anyone know or suspect they have an ulcer? What are the symptoms?
Ulcers cause a variety of symptoms. It depends on the location and the severity, but the most common thing you’ll see with ulcers is abdominal pain. Usually, it’s like a burning or gnawing sensation that occurs between the breastbone and the navel. Sometimes it’s intermittent and sometimes it’s persistent. Depending on the location, it can be worse when you eat or sometimes people feel better when they eat. And then you get indigestion and bloating or belching. You may also feel a fullness in your upper stomach, nausea, vomiting, loss of appetite or unintentional weight loss. Those are the more common symptoms. Then there are less common symptoms that are important for us to check out like heartburn, black sticky poops and blood in your stool. You would need to get that checked out because a bleeding ulcer is a big deal. There can be chronic blood loss, which you may not see. You can get very tired. Then also there are some ulcers that don’t have symptoms.
How long would these symptoms last before you determine that you need to have this checked out?
In medicine, there are always so many different factors, right? So, I think for example, if a person has certain risk factors, they’re a young, healthy person, but they just had surgery and they’re on a bunch of Motrin and they have pain, but it might not be a long-term thing. But then some people have chronic issues that go on for months and they don’t get it checked out until there’s blood one day or they have really bad pain. So, it’s hard to say how long these have been going on. But when we actually take a look at the ulcers, we can get an idea of how chronic it’s been.
Is your primary care physician likely to investigate whether someone has an ulcer?
A lot of times, they’ll just send them to me if they suspect something. They’re trying their hardest. But they have a lot of factors that they have to deal with on their checklist like blood pressure and lipids and cholesterol, that kind of thing. But I do think they do a pretty good job of investigating if somebody has bad heartburn, bad reflux, GI pain or weight loss. If they are concerned, they will refer to a GI specialist or a lot of them might do a non-invasive test checking for that bacterium.
Do you suspect younger people are getting more ulcers?
The risk factors for developing ulcers generally come with age and when the protective lining of the stomach gets eroded. But I do see a lot of ulcers in younger people. I think with the appropriate risk factors, we see it more and more. But I don’t know if just a young person without any of those risk factors would be more at risk of developing ulcers.
What are the risks of an untreated ulcer leading to problems other than pain and bleeding?
Ulcers can pose a variety of risks if they’re not treated, which is why it’s important to get this looked at. One thing to consider is the cause of the ulcer. If the cause of the ulcer is H pylori, that bacteria we talked about which is very common, it is considered a carcinogen. It can cause a very rare type of lymphoma in the GI tract. Not only do you want to get that treated, but you have to check for eradication, meaning six to eight weeks after you’re done with antibiotics, get a test to make sure that bug is gone. We want to make sure you don’t have it, so it doesn’t lead to that risk. And then of course, bleeding is common with ulcers because the more erodes a blood vessel can poke through and some of those can be really bad. They require, clipping, banding, injecting and sometimes surgery. The other thing that’s really bad is a perforation or a tear. So, if it also gets deep enough, it can eat away and go through the lining of the stomach. And then that can cause stomach acid and digestive juice to spill into the abdominal cavity, and that can be life-threatening. Another bad thing ulcers can do is cause obstruction or blockage. Let’s say you’ve got a big ulcer in the stomach that’s located in the area where the stomach goes into the small intestine, that’s called the pylorus. You can get what’s called a gastric outlet obstruction. You’re going to get nauseous, feel bloated and you can have persistent vomiting due to that weight loss.
How do we begin to treat ulcers?
I’m assuming we took a scope because it’s important to know the location of the ulcer, how many and how big are the blood vessels. The treatment depends on what causes it. So, if H pylori bacteria causes it, you want to treat it with antibiotics. It’s usually a three or four-drug regimen for two weeks and then we test again in six to eight weeks to make sure the bug is gone. If the cause of the ulcer is taking medications like NSAIDs—and there are other medications that can cause ulcers—then you want to stop them if you can and treat them with medications that protect the lining of the stomach. Of course, if you have a bleeding ulcer, we go in there and put a clip on it or inject it. There are lots of other things we can do while we’re doing the procedure. So, the treatment depends on what causes it and whether there are complications.
How do you maintain a healthy stomach lining? Are there certain foods that promote better gut health?
It’s very simple. Eating whole grains, fruits, vegetables and lean proteins can promote good digestive health. You want to avoid eating heavy meals that are processed and can sit in the stomach for a long time. Fried stuff just makes it harder for the stomach to empty, so the longer it’s sitting in there, the more the stomach acids are trying to break it down. That can lead to the destruction of the lining. So, anything that’s processed, even nitrates. In certain countries, smoked fish, for example, is popular and smoked and cured meats have been known to destroy the lining of the stomach or promote stomach cancer in large amounts.
What are the biggest misconceptions people have about ulcers?
I think the biggest misconception is that, like your mom always says, you stress yourself out and you’re going to give yourself an ulcer. The biggest misconception is that it’s only caused by stress or spicy food. Yes, that can make ulcer symptoms worse but it’s not the primary cause. The primary cause is usually H pylori bacteria or drugs like NSAIDS. The other big misconception is that ulcers are always painful. That’s not true. You can have other symptoms. There can be silent ulcers depending on where they are located.
Then there was this whole thing about avoiding spicy foods or eating a lot of dairy will help you feel better like eating yogurt or drinking milk. Well, milk can also be irritating to the gut lining, so that’s not necessarily good. Also, sometimes people say, ulcers are always treated by surgery and that’s not true either. Usually, surgery is pretty rare to treat an ulcer unless it has torn, perforated or there’s a horrible bleed that we can’t control.
About Nina Nandy MD FACG
Nina Nandy MD FACG is a Gastroenterologist in Austin, TX. She received a BA in microbiology from Cornell University, an MS in molecular biology from New York University and graduated Cum Laude from the Boston University School of Medicine. She completed her internship and residency in internal medicine at Harvard University, Beth Israel Deaconess Medical Center and the University of Connecticut, respectfully before completing a fellowship in gastroenterology at the University of New Mexico. In addition to board certifications in Internal Medicine and Gastroenterology, she is board-certified in obesity medicine and in the practice of Ayurvedic medicine. She is a fellow of the American College of Gastroenterology and has been a podcast host for the American Gastroenterological Association’s Small Talks Big Topics since 2019. Please visit the American Gastroenterological Association to learn more.
