What is peptic ulcer disease, the condition that stopped Springsteen's tour?

When Bruce Springsteen delayed upcoming tour dates due to peptic ulcer disease, a lot of fans were left wondering what that meant. Gastroenterologist Ryan Beyer, M.D., of the MUSC Health Digestive Disease Center, explains in this Q&A.

Q: What is peptic ulcer disease? 

A: When we say peptic ulcer disease, we mean ulcers in the stomach or the first part of the small intestine. What do we mean by ulcer? It’s basically a caved-out area of the stomach lining or the lining of the small intestine. So instead of having a nice normal stomach lining, you have a little crater in there.

Some peptic ulcers are pretty superficial. They can even be asymptomatic – people don't even know they have them. We just find them, maybe, if we're scoping them for other reasons. (Scoping means using an endoscope, a long tube, to look at the digestive tract. A tiny camera on that tube sends images to the doctor.)

But other peptic ulcers are deadly and can cause significant bleeding. Sometimes they cause a perforation, or a hole through the stomach, which is dangerous. That doesn’t happen too often anymore, since we have good medication.

Q: How often do you see peptic ulcers?

A: It's pretty common in our practice. We certainly see them a lot in our clinics or the endoscopy suite – patients who are admitted for bleeding. We diagnose these pretty much every day here at MUSC Health. For the individual, it's not super common, but we see enough patients that we're seeing these very frequently.

Q: What are the most common symptoms of peptic ulcers?

A: The main thing is abdominal pain – specifically in the upper part of the abdomen just below the chest. Especially if it gets worse after eating, that's something to be concerned about. 

But it depends on where the ulcer is. Sometimes it might be worse, as I mentioned, immediately after eating. On the other hand, sometimes it might feel better after eating, but then get worse later, just depending on whether it's in the stomach or the small intestine. Certainly, throwing up blood is the most concerning symptom. And that's something that should bring someone to the emergency room. Another sign that there's significant bleeding, can be black tarry stool. That's something we call melena. It’s basically digested blood. That's a sign that you can have a quicker bleed going on and need to go to the emergency room.

Q: Can the ulcers that haven’t become that bad go away on their own?

A: Absolutely. A lot of times they're already healing by the time we see the patients. We just treat for a little bit longer to help them heal up and make sure they don't worsen. Most things that cause abdominal pain, ulcer or otherwise, will get better within a few days. 

So you could get in to see a primary care doctor, and they might just say, ‘Hey, take this acid medication and see.’ Even without an ulcer, stomach acid can be a cause of some of that discomfort. And if that makes it go away, then you don't need anything else. 

I would say if it lasts more than a week or so, it’s probably reasonable to talk to your primary care provider. They might decide whether or not to send you for an endoscopy or talk to a gastroenterologist or just try some medications first, before they send you our way.

Q: What causes peptic ulcers? 

A: The biggest causes are medications called nonsteroidal anti-inflammatory agents. So things like ibuprofen, Motrin, Aleve, even aspirin. They act in a way that makes our body less able to make mucus. That makes us more prone to getting ulcers. Not everyone who takes those medications will get ulcers, but that's probably the most common reason.

There's also a bacteria that can infect our stomachs called Helicobacter pylori, or H. pylori. And that's probably the second leading cause of ulcers. It's a bacteria that is specifically designed so it can survive in our stomachs where most bacteria cannot. It also affects our body's defenses and can cause a local inflammation, which can lead to ulcers. 

The two act synergistically, too. If someone has this H. pylori infection and they are taking those medications, they are more likely to get peptic ulcers.

Q: How do you treat peptic ulcers? 

A: It depends on the presentation. Usually, all it takes is medication to suppress acid – like Prilosec, Nexium, that class of medications. And that's enough to heal it. 

 

But if someone comes to the hospital and they're having significant bleeding from an ulcer, then we usually do an upper endoscopy. We go in, and we might have to do something to stop the bleeding. That can involve either putting a clip on the ulcer or cauterizing the vessel or the bleeding area. 

The nice thing about MUSC Health is that we have a good multidisciplinary options for peptic ulcers, especially the severe ones that come to the hospital that are bleeding acutely. On rare occasions, we GI doctors can’t stop the bleeding. Our interventional radiologist can go in through the veins, find the artery that's bleeding and embolize that to stop the bleeding. Surgery gets involved if that is also unsuccessful or the ulcer has perforated. 

If there's H. pylori bacteria involvement, then we'll treat that separately with antibiotics. But we keep you on acid medication for at least two months. And then we like to go in and look again to make sure they have healed, because rarely, ulcers can actually be a cancer. 

Q: Bruce Springsteen is taking the rest of the year off from touring while he undergoes treatment for peptic ulcer disease, according to his team’s Instagram post. Is that length of time for recovery common?

A: No. But I don't know the details of his case. 

If they're in the hospital bleeding, peptic ulcer patients will definitely require a little bit of time to recover, especially if the blood count drops to a significantly low amount that can really sap someone's energy. 

But the typical outpatient would come see me. We'd give them medications, and they'd be feeling better within a week or so. So it's not really clear why he's taking that much time off, but again, I don't know the details. 

It's possible he had severe anemia, and they want to give his body time to build his blood supply back up. So that might make the most sense. But again, without knowing the specifics of this case, I'm not really sure. It's certainly not typical, though. I mean, people are out there working with ulcers and might not even know it.

Q: Are there different types of ulcers?

A: When we say peptic ulcer, we are basically saying that it's due to stomach acid, not alone, but with something else. Specifically in the stomach and the first part of the small intestine. 

You can have a malignant ulcer if it was due to a cancer. You can have ulcers throughout the GI tract due to things like Crohn's disease or ulcerative colitis. 

You can have ulcers basically through your gut that are not acid-related. And you can have ulcers due to medications elsewhere, that are not caused directly in the same way. We don't classify those as peptic ulcers. So there are a lot of different reasons to have ulcers in the gut. But peptic ulcers are the most common.

Q: People used to talk about stress leading to ulcers. Is that a factor? 

A: Being stressed, feeling anxiety, can lead to a lot of gastrointestinal symptoms. It might cause abdominal pain. But that does not cause a stomach ulcer. 

Now when we as physicians say “stress ulcer,” we're talking about the patient who is sick in the intensive care unit on a breathing machine, or they had some head trauma or massive burns, that sort of thing. So being under that much stress on the body can cause ulcers. But not just some anxiety from work or something like that. That would not cause ulcers.”