EDITORIAL COMMENT Peptic Ulcer Is Not a Disease, Only a Sign!Stress Is a Factor in More Than a
Few Dyspeptics In her state of the art review in this issue of Psycho- somatic Medicine (1), Susan Levenstein, whose re-
search on the biopsychosocial implications of peptic
ulcer bestrides the Atlantic, provides an elegant eval-
uation of the current status of psychosomatic research
in the field. This critical review, which finds stress an
underestimated factor in peptic ulcer, disdains anec-
dotes and prefers numbers, although anecdotes pro-
vide the real test of numbers that so often merge indi-
vidual observations in large and sometimes less
precise collections. Anecdotes in a sense supply the
categorical imperative of medicine: if something hap-
pens 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 col-
leagues, 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 pop-
ularity 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 Barretts 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 symp-
toms. 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 pep-
tic 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 endo-
scopic scanning electron microscopes display minute
erosions irritating gastric nerves and accounting for
dyspepsia. That is why I have long urged that an ep-
onym such as Moynihans disease, (3) which re-
quires 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 underre-
porting of the problem. The very estimates of preva-
lence or incidence are equally muddled by now cur-
rent 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 phy-
sicians 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 de-
fining 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 en-
doscopy. Similar problems arise, as this excellent review sug- gests, in considerations of stress, where the very hu- 186 Psychosomatic Medicine 62:186 187 (2000) 0033-3174/00/6202-0186
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