Is duodenal ulcer really a psychosomatic disease? A population-based case-control study

There is an association between selective serotonin reuptake inhibitor use and uncomplicated peptic ulcers: a population-based case-control study

BACKGROUND

Persons who use serotonin reuptake inhibitors (SSRIs) seem to be at increased risk of having serious upper gastrointestinal bleeding. In vitro studies have shown that SSRIs inhibit platelet aggregation. It remains unknown if SSRIs have a direct ulcerogenic effect.

AIM

To investigate if there is a possible association between use of SSRIs and uncomplicated peptic ulcers.

METHODS

A population-based case-control study was conducted in the county of Funen, Denmark, using local prescription database and patient register. The 4862 cases all had a first diagnosis of uncomplicated peptic ulcers from 1995 to 2009. Controls (n = 19 448), matched for age and gender, were selected by risk-set sampling.

RESULTS

The adjusted odds ratios (OR) of uncomplicated peptic ulcers among current, recent and past users of SSRIs were 1.50 (95% CI 1.18-1.90), 1.56 (95% CI 0.98-2.49) and 1.32 (95% CI 1.08-1.61). There was no association with tricyclic antidepressants [OR 0.94 (95% CI 0.65-1.35)]. The adjusted OR for the SSRI-uncomplicated peptic ulcers association was 0.76 (95% CI 0.46-1.25) among users of proton pump inhibitors.

CONCLUSIONS

Use of SSRI is associated with uncomplicated peptic ulcers, possibly by some effect on the healing process. We cannot exclude some effects of residual confounding or bias by frequent physician contact.

Efficiency of antianxiety preparation tenoten used in complex therapy of patients with Helycobacter pylory-associated ulcer disease of the duodenum

Tenoten reduces anxiety in patients with ulcer disease of the duodenum, promotes pain control, and induces no side effects. Tenoten can be recommended for active use in complex therapy of patients with ulcer disease.

The risk of pancreatic cancer in patients with gastric or duodenal ulcer disease

Although Helicobacter pylori (H. pylori) seropositivity is linked to an excess risk of pancreatic cancer, the biologic mechanism is unknown. Gastric ulcer is primarily associated with corpus colonization of H. pylori, atrophic gastritis and formation of N-nitrosamines. Duodenal ulcer is a marker of antral colonization, hyperacidity and uninhibited secretin release. We estimated relative risks for pancreatic cancer among patients with gastric or duodenal ulcer, based on a register-based retrospective cohort study with 88,338 patients hospitalized for gastric ulcer and 70,516 patients for duodenal ulcer recorded in the Swedish Inpatient Register between 1965 and 2003. Following operation, the 14,887 patients who underwent gastric resection and 8,205 with vagotomy were analyzed separately. Multiple record-linkages allowed complete follow-up and identification of all incident cases of pancreatic cancer until December 31, 2003. Standardized incidence ratios (SIRs) estimated relative risks. During years 3-38 of follow-up, we observed a 20% excess risk (95% confidence interval [CI] 10-40%) for pancreatic cancer among unoperated gastric ulcer patients. The excess increased to 50% (95% CI 10-110%) 15 years after first hospitalization (p for trend = 0.03). SIR was 2.1 (95% CI 1.4-3.1) 20 years after gastric resection. Unoperated duodenal ulcer was not associated with pancreatic cancer risk, nor was vagotomy. Our results lend indirect support to the nitrosamine hypothesis, but not to the hyperacidity hypothesis in the etiology of pancreatic cancer.

Personal history and family history as a predictor of gastric cardiac adenocarcinoma risk: a case-control study in Taiwan

OBJECTIVES

To clarify the risk of gastric cardiac adenocarcinoma for patients with a personal and/or family history of gastrointestinal diseases.

METHODS

The present study was a hospital-based case-control study conducted from 1992 to 1997 in Kaohsiung, Taiwan, consisting of 176 cases and 579 controls matched by age, sex, and time of hospitalization. With informed oral consent, each subject completed a structured questionnaire during hospitalization regarding sociodemographic status, lifestyle, and health history.

RESULTS

The response rate was 98%. Adjusting for age, sex, years of schooling, socioeconomic status, body mass index (BMI), and smoking. Multivariate logistic regression models indicated a reduced effect for patients with a personal history of duodenal ulcer (DU) (odds ratio (OR) = 0.8, 95% confidence interval (CI) 0.5-0.9). No association was observed between the risk of gastric cardiac cancer and other forms of gastric disease. Furthermore, we also demonstrated that individuals with a family history of gastric cancer had a higher risk than those who lacked a family history (OR = 2.5, 95% CI 1.3-4.8).

CONCLUSIONS

Our findings provide further evidence that individuals with DU history are less likely to have gastric cardiac cancer, and we infer that Helicobacter pylori (H. pylori) infection (85-95% DU patients infected with H. pylori) alone may not be sufficient to cause gastric cardiac adenocarcinoma. In addition, this study also suggests that a positive family history of gastric cancer may predict an increased risk for the disease.

Psychosocial factors in peptic ulcer and inflammatory bowel disease

Over the past decade, while gastroenterologists' interest in mind-body interactions in organic disorders dwindled, stronger evidence has linked psychosocial factors with the incidence and recurrence of peptic ulcer and with the course of inflammatory bowel disease. Psychological-behavioral approaches to treatment continue to be disappointing. Psychosocial factors may affect ulcer by increasing duodenal acid load, altering local circulation or motility, intensifying Helicobacter pylori infection, stimulating corticosteroid secretion, and affecting health risk behaviors; possible mechanisms for inflammatory bowel disease include immune deregulation, gut permeability changes, and poor medication adherence. Both belong to the growing category of diseases thought to have an infectious component: for peptic ulcer the bacterium Helicobacter pylori, for inflammatory bowel disease an exaggerated immune response to gut bacteria. Peptic ulcer and inflammatory bowel disease, which present unique interactions among psychological, immunologic, endocrine, infectious, and behavioral factors, are splendid paradigms of the biopsychosocial model.

Socioeconomic status and ulcer. A prospective study of contributory risk factors

Peptic ulcer is associated with low socioeconomic status. In this study we used longitudinal population-based data to investigate factors other than Helicobacter pylori that might contribute to this association. Of 4597 Alameda County Study participants, 104 developed ulcers between 1965 and 1974. We examined the impact of baseline risk factors on the association between education and incident ulcer. Among women, high school dropouts had a higher risk of incident ulcer than those who attended college (age-adjusted odds ratio [OR], 3.3; 95% confidence interval [CI], 1.5, 7.3). Adjustment for smoking, alcohol, lack of sleep, skipping breakfast, chronic pain, and liver disease eliminated 21.7% of this excess risk, whereas adjustment for psychological characteristics and life stress eliminated 56.5% of the risk; adjusted for all risk factors, the OR was 1.9. Among men, the risk associated with low education was weaker (OR, 1.9; 95% CI, 0.9, 3.9). Health risk behaviors and poor health had a greater impact (55.5% drop in excess risk with adjustment) and psychosocial factors a lesser impact (33.3% drop) in men than in women. Adjustment for heavy on-the-job labor decreased the risk by 77.8%, whereas the fully adjusted OR was 1.0. We conclude that psychological stress, health risk behaviors, analgesic use, and hard physical labor may contribute to the increased risk of ulcer in low socioeconomic populations.

Psychological predictors of peptic ulcer incidence in the Alameda County Study

It has often been suggested that mood and personality predispose to peptic ulcer, but little prospective evidence exists. We used longitudinal data from the Alameda County Study to seek associations of psychological characteristics with later ulcer development, taking into account the possible confounding or mediating, taking into account the possible confounding or mediating roles of nonpsychological factors. Among 4,595 Alameda County Study subjects ulcer-free in 1965, we studied five baseline psychological measures (depression, hostility, ego resiliency, social alienation or anomy, and personal uncertainty) with respect to reported ulcer in 1973-1974. All five measures had significant age-adjusted associations with incident ulcer [odds ratio (O.R.) 1.8-2.6]. After adjustment for smoking, drinking, skipping breakfast, lack of sleep, painful medical conditions, and liver disease, three measures remained significant: depression, anomy, and hostility. The age-adjusted O.R. of 2.8 [95% confidence interval (C.I.) 1.6, 4.8] for an upper versus a lower tertile index of independently predictive psychological factors fell to 2.1 with adjustment for health-related behaviors and medical conditions, and reached 1.7 (C.I. 1.0, 3.1) after addition of education to the model. We conclude that depression, maladjustment, and hostility are prospectively associated with peptic ulcer. These associations are partially accounted for by confounding or mediation by standard risk factors, and are to some extent related to socioeconomic status.

Socioeconomic factors in Helicobacter pylori infection among Danish adults

OBJECTIVES

This study examined the relationship between housing conditions, educational level, occupational factors, and serologically diagnosed acute and chronic Helicobacter pylori infection.

METHODS

Immunoglobulin G and immunoglobulin M serum antibodies against H. pylori were measured in 3589 Danish adults who participated in a population study.

RESULTS

Low socioeconomic status (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.7, 3.0), short duration of schooling (OR = 2.0, 95% CI = 1.3, 2.5), lack of training/education (OR = 1.4, 95% CI = 1.2, 1.7]), unskilled work (OR = 1.7, 95% CI = 1.2, 2.5), and high work-related energy expenditure (OR = 1.4, 95% CI = 1.1, 1.9) increased the likelihood of chronic H. pylori infection. Infection was frequent in people who had lived abroad. Increased levels solely of immunoglobulin M antibodies were found more often in people who were divorced (OR = 2.3, 95% CI = 1.2, 4.4) or unmarried (OR = 2.0, 95% CI = 1.1, 3.8) or who worked long hours (OR = 2.0, 95% CI = 1.1, 4.0).

CONCLUSIONS

Educational and occupational factors relate to the likelihood of chronic H. pylori infection in adults. The rate of acute infection is high in single individuals.

The risk of stomach cancer in patients with gastric or duodenal ulcer disease

BACKGROUND

Helicobacter pylori infection, now considered to be a cause of gastric cancer, is also strongly associated with gastric and duodenal ulcer disease. The discovery of these relations has brought the long-controversial connection between peptic ulcers and gastric cancer into focus.

METHODS

We estimated the risk of stomach cancer in a large cohort of hospitalized patients with gastric or duodenal ulcers, as recorded in the Swedish Inpatient Register between 1965 and 1983. Altogether, 57,936 patients were followed through 1989, for an average of 9.1 years. The standardized incidence ratio--the ratio of the observed number of cancers to the number expected on the basis of the incidence in the Swedish population at large--was used as a measure of relative risk.

RESULTS

After peaking in the first 3 years of follow-up, the standardized incidence ratio for gastric cancer among 29,287 patients with gastric ulcers leveled off at 1.8 (95 percent confidence interval, 1.6 to 2.0) and remained significantly increased throughout follow-up, which was as long as 24 years for some patients. Prepyloric ulcer, diagnosed in 8646 patients, was not associated with a significant excess risk (standardized incidence ratio, 1.2; 95 percent confidence interval, 0.8 to 1.6). In the cohort of patients with duodenal ulcers (24,456 patients), the incidence of gastric cancer was significantly lower than expected. After the second year of follow-up, the standardized incidence ratio was only 0.6 (95 percent confidence interval, 0.4 to 0.7) and remained stable thereafter.

CONCLUSIONS

Gastric ulcer disease and gastric cancer have etiologic factors in common. A likely cause of both is atrophic gastritis induced by H. pylori. By contrast, there appear to be factors associated with duodenal ulcer disease that protect against gastric cancer.

Non-ulcer dyspepsia and peptic ulcer: the distribution in a population and their relation to risk factors

BACKGROUND

The aetiology of non-ulcer dyspepsia and a possible connection to peptic ulcer disease is debated. This paper discusses this problem in a population based study.

AIMS

The relation between non-ulcer dyspepsia and peptic ulcer disease was explored by the distribution in the general population and their associations to demographic, lifestyle, and psychological factors.

METHODS

All inhabitants of a community aged 20-69 years received a questionnaire concerning abdominal complaints, health, lifestyle, diet, and social conditions. Reports on peptic ulcer were verified with medical records. Dyspeptic subjects and matched healthy, non-dyspeptic controls were endoscoped in a blinded procedure.

SUBJECTS

Of 2027 persons invited, 1802 (88.9%) returned the questionnaire from which dyspeptic subjects and controls were identified. Of 782 subjects invited to endoscopy, 309 dyspeptic and 310 control subjects (79.2%), participated.

RESULTS

Men reported dyspepsia (30.4%) and peptic ulcer (8.7%) more often than women (24.1% and 5.2%, respectively). Non-ulcer dyspepsia was frequent (between 10.6% and 17.2%) in both sexes and age groups up to 60 years, with a lower frequency in both men and women above this age (3.0% and 6.8%). Non-ulcer dyspepsia was associated with having a family history of dyspepsia and of peptic ulcer and the use of tranquillisers. Nearly one third of dyspeptic persons above the age of 40 years had peptic ulcer, but peptic ulcer prevalence was low under this age. Peptic ulcer was associated with a family history of peptic ulcer, smoking, and daily life stress, and also with poor living conditions during childhood, frequent recurrence of herpes labialis, conditions that were associated with Helicobacter pylori infection.

CONCLUSIONS

Non-ulcer dyspepsia and peptic ulcer have different patterns of relations to lifestyle, social, and psychological factors. The results perhaps support the hypothesis of peptic ulcer being an infectious disease in contrast with non-ulcer dyspepsia.

Psychologic predictors of duodenal ulcer healing

We investigated psychologic influences on duodenal ulcer by examining the effect of personality, stress, and mood, measured at diagnosis, on subsequent ulcer healing. Stressful life events, psychopathology (assessed using the Minnesota Multiphasic Personality Inventory), anxiety, depression, smoking, alcohol consumption, nonsteroidal antiinflammatory drug use, and serum pepsinogen I levels were determined immediately after endoscopy showed duodenal ulcer craters in 70 patients with recent onset of symptoms. Endoscopy was repeated following 6 weeks of ranitidine therapy. Six ulcers (8.6%) persisted, and the duodenum remained inflamed in an additional five cases, for a total of 16% with incomplete healing. The only baseline characteristic significantly associated with poor healing was anxiety (p = 0.03 for ulcer persistence, p = 0.02 for incomplete healing). Being in the highest anxiety tertile was associated with a more than fourfold elevation in the risk of incomplete healing (p = 0.02). The association between anxiety and poor healing was not changed by modification of the anxiety score to eliminate gastrointestinal symptom items or by adjustment for serum pepsinogen, sex, or cigarette smoking. Anxiety inhibits the healing of duodenal ulcers treated with adequate antisecretory therapy.

Quality of life and relapse of duodenal ulcer before and after eradication of Helicobacter pylori

BACKGROUND

The aim of the study was to compare relapse rates and quality of life before and after eradication of Helicobacter pylori in a group of patients with documented recurrent duodenal ulcer disease.

METHODS

Seventy-four patients with three endoscopically verified duodenal ulcers during the past 2 years received triple treatment consisting of bismuth subnitrate, oxytetracycline, and metronidazole for 14 days. Quality of life was measured with the Psychosocial Adjustment to Illness Scale (PAIS-SR) and H. pylori status with the 14C-urea breath test.

RESULTS

After triple treatment H. pylori was eradicated in 96%, and the ulcer was healed in all. Ulcer relapse was reduced from 100% before to 1.4% during a mean observation time of 111 weeks. The H. pylori reinfection rate was 2.4% during the 1st year. The patients were more satisfied with the health care system and had better sexual relationship and less psychologic distress 1 year after eradication of H. pylori than before.

CONCLUSIONS

For patients with recurrent duodenal ulcer, eradication of H. pylori with triple treatment leads to a significantly reduced ulcer relapse rate and improved quality of life.

Risk of cancer following partial gastrectomy for benign ulcer disease

The relative risk of developing cancer after partial gastrectomy for benign ulcer disease, expressed as the standardized incidence ratio, was examined in a population-based cohort comprising 6459 patients operated on between 1950 and 1958. Follow-up to 1983 revealed 1112 patients with cancer versus 1128 expected cases (relative risk 1.0 (95 per cent confidence interval (c.i.) 0.9-1.1)). The overall risk increased over time; it was higher in younger than in older patients but was not related to sex, surgical procedure (Billroth I or II gastrectomy) or diagnosis at operation (duodenal or stomach ulcer). There was an increased risk for lung cancer (relative risk 1.5 (95 per cent c.i. 1.2-1.7)), for oesophageal cancer in patients operated on for stomach ulcer (relative risk 2.2 (95 per cent c.i. 1.0-4.2)) and for cancer of the biliary tract in men (relative risk 1.9 (95 per cent c.i. 1.2-2.9)) and in those operated on for duodenal ulcer (relative risk 1.7 (95 per cent c.i. 1.0-2.8)). The overall risk for genital cancer in women was unchanged but decreased with increasing duration of follow-up and age. Cancers of the nervous system occurred less frequently than expected (relative risk 0.5 (95 per cent c.i. 0.3-0.8)), while the risk for cancer of the buccal cavity, lymphatic and haematopoietic systems, pancreas, breast, prostate, kidney and bladder was unchanged.

Psychological factors and somatic symptoms in functional dyspepsia. A comparison with duodenal ulcer and healthy controls

One hundred patients with functional dyspepsia, 100 patients with duodenal ulcer and 100 healthy controls were assessed on anamnestic factors, somatic symptoms and psychological measures. Patients with functional dyspepsia had significantly higher levels of state-trait anxiety, general psychopathology, depression, a lower general level of functioning and more somatic complaints from different organ systems, especially the musculo-skeletal system, compared to patients with duodenal ulcer and healthy controls. Patients with functional dyspepsia had more frequent dyspepsia symptoms and a longer disease history than duodenal ulcer patients. Discriminant analyses using a model of fifteen psychological and anamnestic variables, classified correctly 71.5% of the subjects due to diagnoses. The test for multiple somatic complaints (Giessener Beschwerdebogen) was the most important discriminating factor (Eigenvalue 0.78). Seventy-five per cent of the patients were correctly classified, 71% by diagnosis with respect to diagnoses of duodenal ulcer and functional dyspepsia using frequency of dyspeptic symptoms as discriminating factor (Eigenvalue 0.40). Functional dyspepsia seems to be a disease entity of its own, distinct from duodenal ulcer and strongly associated with psychological factors.

Mortality among patients with partial gastrectomy for benign ulcer disease

Partial gastrectomy for benign ulcer disease may influence future risk of death, eg, through changes in life-style or metabolism. To reveal such possible long-term effects, we analyzed a population-based cohort of 6459 patients operated on from 1950 through 1958 and followed through 1985. We found a lower overall mortality than in the general Swedish population (standardized mortality ratio = 0.94; 95% confidence interval 0.91-0.97). Mortality was decreased among those with duodenal ulcers, Billroth II operations, and older age at operation but increased as time passed after operation. Mortality was significantly (P < 0.05) increased from tuberculosis, alcoholism, emphysema, stomach ulcer, intestinal obstruction, gallbladder or biliary disease, suicide, and accidental falls but decreased from ischemic heart disease and cerebrovascular disease. Preoperative selection of healthy patients and the probable increased prevalence of risk factors for ulcer disease (smoking, alcoholism, and lower socioeconomic status) in this cohort explain most of these findings. Apart from intestinal obstruction, gallbladder or biliary tract diseases, and tuberculosis, the surgical procedure did not appear to increase mortality beyond one year after operation.

Psychologic factors associated with peptic ulcer disease

Peptic ulcer disease provides an excellent model for the study of mind-body interactions in the pathogenesis and course of an illness. Early psychodynamic explanations of the role of personality factors in the evolution of peptic ulcer disease have been supplemented in recent years by more scientifically based studies on the role of stress and coping ability. Multiple psychosocial variables have confounded the outcome of many of these studies. Yet, a clear need and guidelines exist for the comprehensive medical and psychosocial evaluation and treatment of patients with peptic ulcer disease. Concomitant psychiatric assessment and management, including psychotherapeutic and psychopharmacologic approaches, for those patients with refractory symptoms or ongoing psychiatric symptoms carried out in close collaboration with primary caregivers will significantly decrease overall morbidity and mortality.

Long-term survival in patients operated on for benign peptic ulcer disease

Survival rate was analysed in a cohort of 6459 patients who had undergone partial gastrectomy for benign ulcer disease and who had survived the first year after operation. The cohort was followed for 27-35 years. There was a slight but significant decrease in relative survival rate to 92 per cent (95 per cent confidence interval 87-97 per cent) 35 years after operation. No decrease in relative survival rate was observed during the first 20 years after operation. There was no difference by gender or surgical procedure, but patients operated on for gastric ulcer, compared with duodenal ulcer, and patients operated on at younger ages had a poorer relative survival rate. The effects of partial gastrectomy on survival, both overall and by diagnosis or age at operation, are probably attributable to confounding factors linked with the peptic ulcer disease rather than to the surgical procedure itself. We conclude that partial gastrectomy seems to have very little impact on survival once the patient has survived the first year after operation.

The risk of large bowel cancer after partial gastrectomy for benign ulcer disease

The relative risk (standardized incidence ratio [SIR] for colorectal cancer after partial gastrectomy for ulcer disease was examined in a population-based cohort comprising 6459 patients operated during 1950 to 1958. Follow-up through 1983 revealed 131 cases of colorectal cancer versus 150.3 expected cases (SIR = 0.87; 95% confidence limits 0.73, 1.03). The relative risk was decreased during the first 19 years of follow-up (SIR = 0.75; 0.58, 0.96) and close to equal thereafter (SIR = 1.02; 0.79, 1.29). Sex, age at operation, type of operation, and diagnosis at operation (stomach or duodenal ulcer) did not affect the relative risk significantly. Confounding by socioeconomic status is one conceivable explanation for the decreased relative risk during the first years of follow-up, whereas the increasing risk with longer duration of follow-up might be a consequence of the surgical procedure itself.

Peptic ulcer and non-ulcer dyspepsia--a disease and a disorder

In a cross-sectional survey for coronary risk factors, 14,390 middle-aged men and women answered a questionnaire concerning life-style, diet and disease, including peptic ulcer (PU) and dyspeptic symptoms. The overall lifetime prevalence of reported PU was 5.3% in men and 2.1% in women. The prevalence of reported dyspeptic symptoms, consistent with non-ulcer dyspepsia (NUD), was 22.6% in men and 18.1% in women. Reporting of both PU and NUD was significantly associated with sex and age, NUD less marked than PU. PU and NUD differed substantially with respect to associations with psychologic, social, life-style, and dietary variables. PU was strongly associated with age, a family history of peptic ulcer, body mass index, and smoking. NUD, on the other hand, showed closest association to psychological factors and social conditions. This difference between PU and NUD might be of aetiological and therefore clinical significance, and calls for therapeutic trials in NUD patients with interventions different from the traditional peptic ulcer treatments.

Stomach cancer after partial gastrectomy for benign ulcer disease

We followed for 25 to 33 years 6459 patients who had undergone partial gastrectomy for benign ulcer disease to determine the incidence of stomach cancer. The overall risk was no different from that among sex- and age-matched controls from the Swedish Cancer Registry (standardized incidence ratio = 0.96; 95 percent confidence limits, 0.78 and 1.16). However, when the patients were classified according to the duration of follow-up after operation, sex, surgical procedure, diagnosis at the time of operation, and age at operation, differences in risk were observed between the subgroups. After adjustment for potential confounding variables, the average adjusted risk increased 28 percent (adjusted standardized incidence ratio = 1.28; 95 percent confidence limits, 1.11 and 1.49) for each successive five-year interval after operation. The adjusted risk was greater among women than men (adjusted standardized incidence ratio = 1.96; 95 percent confidence limits, 1.18 and 3.24). Patients who had undergone a Billroth I anastomosis had a lower crude risk, both overall (standardized incidence ratio = 0.40; 95 percent confidence limits, 0.20 and 0.71) and after we controlled for other confounding variables (adjusted standardized incidence ratio = 0.27; 95 percent confidence limits, 0.12 and 0.62), than did those who had undergone a Billroth II procedure. The adjusted risk of stomach cancer was greater among patients operated on for gastric ulcer than among those operated on for duodenal ulcer (adjusted standardized incidence ratio = 2.21; 95 percent confidence limits, 1.45 and 3.35). Risk decreased with increased age at operation. Between successive strata of age at operation (less than 39, 40 to 49, 50 to 59, and greater than or equal to 60 years of age), the adjusted risk decreased on the average by about half (adjusted standardized incidence ratio = 0.52; 95 percent confidence limits, 0.41 and 0.66).