Gastric and duodenal ulcers—collectively called “peptic ulcers”—are a sharply circumscribed loss of tissue, involving the mucosa, submucosa and muscular layer, occurring in areas of the stomach or duodenum exposed to acid-pepsin gastric juice. Peptic ulcer is a common cause of recurring or persistent upper abdominal distress, especially in young men. Duodenal ulcer comprises about 80% of all peptic ulcers, and is commoner in men than in women; in gastric ulcer the gender ratio is about one. It is important to distinguish between gastric ulcer and duodenal ulcer because of differences in diagnosis, treatment and prognosis. The causes of peptic ulcer have not been completely determined; many factors are believed to be involved, and in particular nervous tension, the ingestion of certain drugs (such as salicylates and corticoids) and hormonal factors may play roles.
Persons at Risk
Although peptic ulcer cannot be regarded as a specific occupational disease, it has a higher-than-average incidence among professional people and those working under stress. Stress, either physical or emotional, is believed to be an important factor in the aetiology of peptic ulcer; prolonged emotional stress in various occupations may increase the secretion of hydrochloric acid and the susceptibility of the gastroduodenal mucosa to injury.
The results of many investigations of the relationship between peptic ulcer and occupation clearly reveal substantial variations in the incidence of ulcers in different occupations. Numerous studies point to the likelihood of transport workers, such as drivers, motor mechanics, tramcar conductors and railway employees, contracting ulcers. Thus, in one survey covering over 3,000 railway workers, peptic ulcers were found to be more frequent in train crew, signal operators and inspectors than in maintenance and administrative staff; shift work, hazards and responsibility being noted as contributing factors. In another large-scale survey, however, transport workers evidenced “normal” ulcer rates, the incidence being highest in doctors and a group of unskilled workers. Fishers and sea pilots also tend to suffer from peptic ulcer, predominantly of the gastric type. In a study of coal miners, the incidence of peptic ulcers was found to be proportional to the arduousness of the work, being highest in miners employed at the coal face. Reports of cases of peptic ulcer in welders and in workers in a magnesium refining plant suggest that metal fumes are capable of inducing this condition (although here the cause would appear to be not stress, but a toxic mechanism). Elevated incidences have also been found among overseers and business executives, i.e., generally in persons holding responsible posts in industry or trade; it is noteworthy that duodenal ulcers account almost exclusively for the high incidence in these groups, the incidence of gastric ulcer being average.
On the other hand, low incidences of peptic ulcer have been found among agricultural workers, and apparently prevail among sedentary workers, students and draftsmen.
Thus, while the evidence regarding the occupational incidence of peptic ulcer appears to be contradictory to a degree, there is agreement at least on one point, namely that the higher the stresses of the occupation, the higher the ulcer rate. This general relationship can also be observed in the developing countries, where, during the process of industrialization and modernization, many workers are coming increasingly under the influence of stress and strain, caused by such factors as congested traffic and difficult commuting conditions, introduction of complex machinery, systems and technologies, heavier workloads and longer working hours, all of which are found to be conducive to the development of peptic ulcer.
The diagnosis of peptic ulcer depends upon obtaining a history of characteristic ulcer distress, with relief of distress on ingestion of food or alkali, or other manifestations such as gastro-intestinal bleeding; the most useful diagnostic technique is a thorough x-ray study of the upper gastro-intestinal tract.
Attempts to gather data on the prevalence of this condition have been seriously hampered by the fact that peptic ulcer is not a reportable disease, that workers with peptic ulcer frequently put off consulting a physician about their symptoms, and that when they do so, the criteria for diagnosis are not uniform. The detection of peptic ulcer in workers is, therefore, not simple. Some excellent researchers, indeed, have had to rely on attempts to gather data from necropsy records, questionnaires to physicians, and insurance company statistics.
From the viewpoint of occupational medicine, the prevention of peptic ulcer—seen as a psychosomatic ailment with occupational connotations—must be based primarily on the alleviation, wherever possible, of overstress and nervous tension due to directly or indirectly work-related factors. Within the broad framework of this general principle, there is room for a wide variety of measures, including, for example, action on the collective plane towards a reduction of working hours, the introduction or improvement of facilities for rest and relaxation, improvements in financial conditions and social security, and (hand in hand with local authorities) steps to improve commuting conditions and make suitable housing available within a reasonable distance of workplaces—not to mention direct action to pinpoint and eliminate particular stress-generating situations in the working environment.
At the personal level, successful prevention depends equally on proper medical guidance and on intelligent cooperation by the worker, who should have an opportunity of seeking advice on work-connected and other personal problems.
The liability of individuals to contract peptic ulcers is heightened by various occupational factors and personal attributes. If these factors can be recognized and understood, and above all, if the reasons for the apparent correlation between certain occupations and high ulcer rates can be clearly demonstrated, the chances of successful prevention, and treatment of relapses, will be greatly enhanced. A possible Helicobacter infection should also be eradicated. In the meantime, as a general precaution, the implications of a past history of peptic ulcer should be borne in mind by persons conducting pre-employment or periodic examinations, and efforts should be made not to place—or to leave—the workers concerned in jobs or situations where they will be exposed to severe stresses, particularly of a nervous or psychological nature.