Does stress cause ulcers?

By Melinda Wenner Moyer

Q My family always says I’m going to give myself an ulcer if I don’t manage my stress. But is that really a thing?

A Although people have long believed — and doctors used to claim — that stress can cause stomach ulcers, the relationship between the two is not straightforward, experts say.

It’s true that some critically ill patients, like those admitted to intensive care units, can develop stress ulcers, which are sores in the lining of the gastrointestinal tract that quickly arise after extreme physical stress. But “there is simply no data” confirming that everyday psychological stress can directly cause ulcers, said Dr. Tonya Adams, a gastroenterologist at Gastro Health in Fairfax, Virginia.

That said, it’s possible that, among people who are at high risk for developing ulcers for other reasons, such as overusing specific medications or being infected with a certain type of bacteria, stress could tip them over the edge, said Dr. Neha Mathur, a gastroenterologist at Houston Methodist Hospital.

The complex role of stress

A common type of ulcer — called a peptic ulcer — forms when stomach acid erodes the protective lining of the stomach or the small intestine, causing sores to develop, said Dr. Carolyn Newberry, a gastroenterologist at New York Presbyterian. Another type, known as a gastric ulcer, forms when the sores develop in the stomach lining specifically.

Researchers estimate that about 5% to 10% of people worldwide will develop an ulcer.

Most people with peptic ulcers do not have symptoms, Mathur said. But some can have upper abdominal pain, upset stomach, heartburn, bloating or nausea. Some ulcers also bleed, causing dark, tar-like stools or stools tinged with bright red blood.

It’s not unreasonable to think that stress could cause ulcers, considering that “stress can definitely cause many gastrointestinal diseases,” Mathur said, including irritable bowel syndrome, severe acid reflux and inflammatory bowel disease.

But the role of stress in causing ulcers is less clear cut, with some studies suggesting a connection and others not. In a 2015 study of about 3,400 adults, researchers in Denmark found that those who reported the highest levels of stress, compared with those reporting the lowest stress, had 2.2 times higher odds of developing ulcers over the next 11 to 12 years. The researchers noted, however, that about one-third of this excess risk was likely not because of the direct effects of stress, but because of how people reacted to stress — perhaps through smoking or excessive drinking of alcohol, which can each increase ulcer risk.

On the other hand, when researchers analyzed the medical records of nearly 24,000 adults in South Korea who had undergone a procedure called an endoscopy to diagnose ulcers, and gave the patients a test to assess their stress levels, they found that stress was associated with an increased risk for several gastrointestinal conditions, but not ulcers.

Stress may, then, contribute to ulcer development, but a stressed-out person may not develop an ulcer without having other risk factors, Newberry said.

What does cause ulcers?

There are several known causes of ulcers. In a study published in 2020, researchers analyzed the medical records of about 1.3 million patients who had visited U.S. endoscopy centers between 2009 and 2018 and found that 17% of peptic ulcers were caused by infection with the bacteria called Helicobacter pylori. When people ingest the bacteria, their immune systems release inflammatory cells that can damage the lining of the gastrointestinal tract, Mathur explained.

People who regularly use steroids or nonsteroidal anti-inflammatory drugs (like ibuprofen or aspirin) can also develop ulcers, Mathur said. Taken continuously over a long period of time, and especially at high doses, these drugs can damage the gastrointestinal lining.

In a landmark 1987 study, researchers evaluated the gastrointestinal tracts of 63 men and two women who had continuously taken NSAIDs for at least six weeks to treat arthritis. They found that 68% of the patients showed evidence of gastrointestinal injury and 15% had developed ulcers.

Cigarette smoking and excessive alcohol use can also cause ulcers, Adams said, because they inflame and cause damage to the gastrointestinal tract. People with Zollinger-Ellison syndrome, a rare disorder that causes cells in the gastrointestinal tract to release too much acid, often get ulcers, too, Adams added.

Treatment for ulcers depends on their cause. If bacteria are involved — which doctors can determine by administering stool or breath tests or by performing an endoscopy — patients are typically prescribed antibiotics as well as prescription-strength antacids, Mathur said. If not, people are usually treated with prescription antacids and are counseled about potential lifestyle changes, such as to cut down on smoking, drinking or NSAID use.

Often, just to be sure, doctors will perform an endoscopy after six to eight weeks to check that the treatment has worked. “We want to go back in and make sure things have healed,” Mathur said.