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EDITORIAL COMMENT |
Connecticut Gastroenterology Consultants 40 Temple Street New Haven, CT 06510
In her state of the art review in this issue of Psychosomatic Medicine (1), Susan Levenstein, whose research on the biopsychosocial implications of peptic ulcer bestrides the Atlantic, provides an elegant evaluation of the current status of psychosomatic research in the field. This critical review, which finds stress an underestimated factor in peptic ulcer, disdains anecdotes and prefers numbers, although anecdotes provide the real test of numbers that so often merge individual observations in large and sometimes less precise collections. Anecdotes in a sense supply the categorical imperative of medicine: if something happens once or twice, then it can happen again and we should look to the reasons why, rather than discarding the observation as an outlier. Indeed, as I review the very numerate presentation of Levenstein and colleagues, I see that the variations in percentages are sometimes so large (17% to 50% for socioeconomic status, for example) that the numbers provide only a rough guide to thinking about peptic ulcer. This wide range is important in an era when Helicobacter pylori has turned into the "Great Satan" of gastroenterology.
To deviate for a moment, I want to emphasize that the term "peptic ulcer disease " has supplanted the less assertive "peptic ulcer," as if somehow "disease" added luster to the common place (2). Philosophers call that sort of thing reification, turning an abstract idea into a thing. A good example is the current popularity of GERD (gastroesophageal reflux disease), known in Britain as GORD thanks to their attachment to archaic diphthongs. In my old medical-student days, heartburn was heartburn, hiatus hernia had come into the literature only in the 1930s; people still took baking soda for what was not yet renamed "reflux esophagitis;" the belch that followed relieving their distress. Folks in the 1940s with heartburn did not think that they were victims of some dire disease and would have been astonished to learn that they were at risk for Barrett’s esophagus and such an increased chance of esophageal cancer that they should undergo regular endoscopies.
Strictly speaking, of course, the very term peptic ulcer has already reified dyspepsia and wrongly gives precedence to the ulcer crater rather than to the symptoms. After all, an ulcer is the final product of many different events, and its very discovery depends on the technology available. X-ray studies of the barium-filled stomach proved not very good at detecting peptic ulcer, as fiberoptic endoscopy quickly showed; the side-viewing scope was even more helpful than its end-viewing predecessor. That leads us to ask what is important? If a patient has symptoms of a peptic ulcer, are those complaints unimportant until a crater is found? Is stress more important in the one than the other? Physicians who rely solely on technology for diagnosis may find themselves at a loss when endoscopic scanning electron microscopes display minute erosions irritating gastric nerves and accounting for dyspepsia. That is why I have long urged that an eponym such as "Moynihan’s disease," (3) which requires no crater and accounts ulcer-like dyspepsia as important as an ulcer crater is preferable to the term peptic ulcer and certainly I am convinced that the eponym is far more preferable to peptic ulcer disease, which is only a signpost pointing to many different causes.
Levenstein and colleagues review the multifactorial origins of peptic ulcer, concluding, entirely plausibly, that stress increases vulnerability to other ulcerogenic agents like H. pylori, an assertion that makes good intuitive sense. The authors carefully buttress their review by pointing out the confounding factors that account for misreporting, overdiagnosis, or underreporting of the problem. The very estimates of prevalence or incidence are equally muddled by now current availability of over-the-counter H-2 blockers, the intensive advertising to the public of proton pump inhibitors, and other events which have made it likely that typical peptic ulcer symptoms are likely to be treated by those outside the profession and by the patients themselves, and which go uncounted by physicians who require a crater for their diagnosis.
The patient unlucky enough to have no visible ulcer crater at endoscopy is labeled "nonulcer dyspepsia," a term long derided by some as logically faulty for defining a disease by the absence of another disease. After all, nonulcer dyspepsia might, with equal justice, have been called "non-gallbladder dyspepsia," if the gastroenterologists were doing ultrasound and not endoscopy.
Similar problems arise, as this excellent review suggests, in considerations of stress, where the very human propensity to try to make sense of mysterious events, denominated "effort after meaning," has enlarged the importance of sometimes random preceding events. In other fields, that search for logic in a world that is not always logical has lead to acceptance of grief and loss as partly responsible form of stress in the genesis of cancer, an idea that arose first in Rochester, New York, in the 1940s and 1950s and has flourished ever since. Thus, stress is more like a steamer trunk, crammed full of all kinds of items, rather than a carry-on bag with one suit carefully pressed in it; what to one person comes as distress, to another will be an exhilarating challenge. Stress means so many different things to so many different people.
Physicians educated in the 1940s cannot forget the valiant contributions of Franz Alexander (4), that impressive Berliner transplanted to Chicago, and the less well-known Flanders Dunbar (5), another proponent of psychosomatic medicine, a rich one-time medical student at Yale who sent her secretary in her place to take notes in class so often that Dean Milton Winternitz of that medical school is said to have suggested that the secretary might also deserve the MD degree. These two giants of psychosomatic medicine popularized the idea that specific psychological stances led to specific gastrointestinal diseases, the "holy psychosomatic seven." The idea that physical stress also led to peptic ulcer was enhanced in the late 1940s by the work of Hans Selye in a Canadian laboratory far away from his home in the old Austro-Hungarian empire, who demonstrated how adrenal steroids produced ulcers in rats.
I conclude from the paper by Levenstein and her colleagues that peptic ulcer has many origins and that one of them is "stress," which plays an important, if yet undefined, role in its genesis. The point is that peptic ulcer is not one disease; however, in many people H. pylori lies in the background, whereas in others it may be aspirin or nonsteroidal anti-inflammatory agents, or even emotional or physical stress that is the driving force. The ulcer crater is the least important of the manifestations, and in a more holistic culture where what the patients report is relied on as much as what the physicians uncover, symptoms might gain equality with visible signs. Then physicians might recognize that H. pylori is important as a permissive factor, but that many other agencies all contribute to the genesis of what could just as well (or perhaps better) be called Moynihan’s disease.
REFERENCES
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