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Stress-Related Gastrointestinal Problems


Introduction.
What is stress?
Stress and the gastrointestinal system (general view).
Stress ulcers.
Pathogenesis of stress ulcers.
Stress and the Irritable Bowel Syndrome.
Conclusion.
References.


Introduction:

No body of us has not got into a stressful event or get stressed from certain things in his or her life.  Many of us experience stress as a daily event.  Stress either has its usual effect, which is known to all medical professionals, the fight or flight response or it may lead to chronic effects due to which certain diseases may arise.  The main organ that control stress is the brain and specifically the hypothalamus part of it.  In usual stress, we experience a series of  events as follows.  Our heart pumps very fast, blood pressure rises, blood is shifted away from the intestinal tract to the muscular system, our hands get cold, our throat and mouth get dry and we tend to breath rapidly so that a general sense of anxiety or tension is established.  One can say that such reactions are good in order to face stressful conditions.  However, it has been found that long lasting stress may cause  serious illnesses.  The gastrointestinal system is one of the systems that can be affected negatively by stress.  In the following paragraphs, stress ulcers and irritable bowel syndrome in their relation to stress will be described.


What is Stress?

It is any stimulus or change that occurs in the external or internal environment of our bodies, and leads to disturbance in the homeostasis and  may result in illness under certain conditions. There are several types of stress: physical stress such as surgery, burns, trauma and emotional stress and  psychosocial stress (1). In general, stressors can be either short term or long term. Occasionally, with short term stressors there are no serious problems due to activation of the body adaptation syndrome (e.g.: fight or flight response), unless there are multiple short-term stressors and the individual is unable to cope well with them. Long term stressors are more likely to cause problems as they may lead to chronic anxiety which in turn may cause illnesses involving different organs in the body 2.


Stress and the gastrointestinal system (general view):

Many years ago, several researches and experiments have been carried out to understand the effect of stress on both healthy and diseased gastrointestinal systems. Many physiological and pathological changes have been found such as motility disorders and mucosal damage in response to different stressors. One famous experiment is the story of Tom. Tom had injured his esophagus completely when he was a child, and that ended him having a gastric fistula. He lived with this for 50 years before medical attention was given to him.  Scientists have taken the opportunity and studied the gut reactions to stress on Tom's gut.  They reported the following changes on his stomach while he was emotionally very stressed: 1- stomach membrane became deeply red due to rapid influx of blood, 2- small ulcers developed on the surface.
Major effects of stress have been noticed, in particular on stress ulcer and irritable bowel syndrome which will be described more in the next paragraphs.


Stress ulcers or stress related mucosal damage:

Stress ulcers is the term given to  mucosal damage or lesions of the esophagus, stomach or duodenum in critically ill or stressed otherwise healthy patients. Mucosal lesions range from small petechial hemorrhages and erosions to deep ulceration and occasional perforation (4).   Selye (1936) showed  one of the famous triad of stress as being an acute erosions and ulcers in the gastrointestinal tract.  Physical stress, prolonged and serious illness, hemorrhagic or septic shock, burns, head injuries…etc, have been considered as  causes of gastric mucosal susceptibility to damage by hydrochloric acid and pepsin 5.


Pathogenesis of stress ulcers:

 Stressors could be either physical or psychological with the ability of each one of them to stimulate the limbic system in the CNS (controls emotions) which in turn activates both the hypothalamic and the medullary systems.  Consequently, these systems lead to gastric acid hypersecretion, disturbances in gastrointestinal motility and increase in the production  of various endogenous substances such as the glucocorticoids, catecholamines and histamine.  However, it has been found recently that stress ulcers are not usually associated with acid hypersecretion since antisecretory drugs can prevent acid secretion but not the development of stress ulcers.  Eventually, these alterations may lead to local ischemia and anoxia due to systemic arterial hypotension and disturbed microcirulation in the gastric mucosa.  More recently, it has been shown that oxygen-derived free radicals may have a role in the ischemic mucosal injury.   Robert and Szabo have proposed a summarized mechanism as follows: severe stress---> vascular shock---> impairment of gastric circulation---> gastric anoxia---> focal autodigestion---> ulcers (5).   In general, the etiology of stress-related mucosal damage is multifacotrial and complex.  Patients with ulcers are of three types:

1- Psychologically balanced persons who can cope with their chronic illness and in whom psychological factors do not affect their disease.
2- People with personality disorders that result in emotional distress regardless of exposure to chronic stressors.
3- People with exposure and sensitivity to chronic stressors.

Emotional distress is produced only in the later two groups and it tends to increase behavioral risk factors (e.g. smoking or aspirin consumption), or cause psychophysiologic changes that may interact with environmental factors such as H. pylori.  Consequently, all these elements may contribute in altering the secretory functions and/or disrupt mucosal defense mechanisms leading to ulcers' formation or persistence (6).


Stress and the irritable bowel syndrome:

Several experiments have been carried out to show the effect of stress on IBS patients.  One interesting experiment was done with hypnosis on patients with IBS to understand the effects of different emotions (excitement, anger & happiness) on them.  The study sample consisted of 18 patients aged 20-48 years, having irritable bowel syndrome.  After the patients were hypnotized, they were instructed to feel angry, excited or happy.  At the same time colonic motility as well as  respiration rate were recorded. The experiment showed that emotions do have an effect on the large intestine as it was found out that both anger and excitement increased the colonic movement and respiration rate while happiness tended to reduce colonic motility.
 In general, physicians through their experiences believe that there is a close relationship between stress and bowel function.  These believes were confirmed through several studies. A recent one studied the relationship between daily stress and digestive symptoms on women with or without irritable bowel syndrome.  It has been found out that there is a significant and positive relationship between daily stresses and digestive symptoms such as bloating and diarrhea.  Without exception, both healthy and women with IBS were affected.   Moreover, another study was done to understand  the influence of fear and panic on bowel functions, showed a direct relationship between them.  Furthermore, some researchers found that there is a relationship between sexual abuse and irritable bowel syndrome (7).   An old experiment was done to understand the effect of stress on colonic motility.  Changes in colonic motility were recorded during stressful interviews.  Specifically, hostility showed an spastic effects on colonic motility while depression led to inhibition of motor activity (fig.3).  However, these findings were not specific for irritable bowel syndrome since they were also found in persons not suffering from this disorder.  Therefore, emotional stress is considered to be one factor contributing to the genesis of IBS but not the only one 6.


Conclusion:

In conclusion, stress related gastrointestinal problems are one of the various medical problems that have been confirmed by many researches and experiments.  Therefore, proper management can be carried out by certain ways.  Generally, people must be aware of the effect of stress on their bodies' functions both in health and disease. Consequently, they can control or handle their daily stresses in a less damaging way.  People can't live without stress but they can some times control their tension if they put in their minds its serious effects . As we have noticed that patients with gastrointestinal problems are more likely to be affected by stressful events.  Therefore, medical role must take place in advising such patients to decrease their tension as much as they can or even try to control it.  Furthermore, some patients may need psychiatric help to guided to them to the right way.


References:

1- Rees, Linford. A New short textbook of psychiatry. London: Edward Arnold, 1988.
2- Found@ http://well-net.com/prevent/well3.html
3- Found@http://www.ahfmr.ab.ca/May96/reactions.html
4- Found @http://gasbone.herston.uq.edu.au/teach/phvc_stul/stressul.htm
5- Stress-induced vascular damage and ulcer. Yabana, Tsuyoshi and Yachi, Akira. Dig Dis Sci 1988 Jun;33(6):751-759
6- Gastrointestinal Disease (pathology/diagnosis/management). 5th ed. Vol.1. Philadelphia: W.B. Saunders Company, 1993.
7- Found@ http://www.americanwholehealth.com/library/ibs/ibsstress.html