Saturday’s scheduled Bruce Springsteen show at Camden Yards was one of eight postponed by the rock legend in a statement released this week, citing doctor’s orders to take September off to treat “symptoms of peptic ulcer disease.”

So what is peptic ulcer disease and under what circumstances would it cause someone to need a month off?

According to Joshua Forman, a gastroenterologist at the University of Maryland St. Joseph Medical Center, the extended respite could be a sign that the nearly 74-year-old musician has experienced a complication of preexisting ulcer disease. A person would be unlikely to need a month’s break for treatment in the absence of a red flag for worsening illness in the form of new or more severe symptoms, he said.

Forman is not involved in Springsteen’s care, but did have tickets to see the Saturday show and lamented his present “first-world problem” of not getting to go.

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What are possible complications of peptic ulcer disease that could’ve prompted the singer to lay down his guitar mid-tour? Forman explains the possible scenarios and gives the lowdown on peptic ulcer disease generally. The conversation has been edited for clarity and brevity.

Can you give me the skinny on what peptic ulcer disease is?

So first of all, peptic ulcer disease is one of the most common things that we see as GI doctors. It’s a breakdown in the lining of the stomach or the duodenum [the upper part of the small intestine that’s attached to the stomach]. Normally, there’s a very smooth layer of mucosa that covers the wall of the stomach and the intestine. When you have an ulcer, it’s just a breakdown or a defect in that lining. Most people who have this are actually asymptomatic; they don’t have any symptoms.

When people do have symptoms, the most common one is pain, usually in the top part of the abdomen, which can sometimes get worse or better with eating. We diagnose a peptic ulcer usually with an upper endoscopy, which is using a camera to look in the upper gastrointestinal tract. If you can picture a crater on the moon, that’s almost what these ulcers look like.

While this is obviously speculation because I don’t know any of the details of Springsteen’s case, usually when somebody’s missing work because of an ulcer, it’s because they’ve had a complication. And the complications are usually either bleeding — vomiting blood or seeing it in your stool — or perforation, when the ulcer eats a hole the wall of the stomach or the intestine.

A perforation requires emergency surgery and can cause death, but that’s really rare in this era of medicine. There are also situations where you can have an ulcer that’s not benign; they can be malignant.

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Seventy percent of people with peptic ulcers are asymptomatic until they have a complication.

What causes peptic ulcer disease, and how is it treated?

The gold standard treatment for ulcers is a class of medications called proton pump inhibitors, or PPIs, which basically shut off the pumps in the stomach that produce acid — omeprazole is a common example of one of these meds. When you cut off acid production, the body heals itself, which can take as long as eight to 12 weeks, depending on how big or how deep the ulcer is. With treatment, the pain goes away within days to weeks.

The most common cause of ulcers is the use of nonsteroidal anti inflammatory medications, or NSAIDs, like ibuprofen. A colleague of mine just had a dental issue and was taking a lot of ibuprofen, and he had a perforated gastric ulcer and had to have surgery. So it’s something that can happen if you’re taking a lot of ibuprofen because it blocks a pathway that creates a protective lining in the stomach, so you don’t produce that lining as effectively and the acid in your stomach can cause this breakdown.

The other common cause of ulcers is a bacteria called Helicobacter pylori or H. pylori, that’s pretty much all around in the environment and it’s just something you can pick up, if you’re exposed to a form of it that is compatible with the lining of your stomach and takes up residence. Sometimes H. pylori can cause pain or inflammation, or sometimes it causes no symptoms at all. In other parts of the world — Asian countries, in particular — H. pylori is actually the leading cause of stomach cancer. It’s a risk factor for that. If H pylori is detected, it’s treated with antibiotics.

People commonly think of ulcers as caused by stress. Is that true?

A lot of people will say, ‘I’m under so much stress, I’m gonna have an ulcer.’ But ulcers are not caused by stress, though it was previously thought to play a role.

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Two physicians in Perth, Australia actually discovered the link between H. pylori and ulcers in 1982, and won a Nobel Prize for it. One of them, Barry Marshall, discovered this bacteria, thought it caused ulcers, and basically proved it by infecting himself with H. pylori, developing an ulcer and then treating the bacteria [with antibiotics]. It’s an unbelievable story and a landmark moment in understanding what causes ulcers.

Are certain people more at risk for developing ulcers?

Older patients are more at risk due to several factors. When you’re not as young as you used to be, your body may not do as good of a job keeping up all its defenses, and you’re more likely to be on a medication that, when combined with an NSAID, will increase your risk of developing an ulcer. They could be less active or have a change in dietary patterns that may increase their risk when lumped in with the main risk factors.

Drinking too much alcohol, cigarette smoking, and using chewing tobacco also increase the risk of getting an ulcer.

People will want to know — how much ibuprofen can they use without increasing their risk of getting an ulcer?

It’s a really good question and the answer is different for everyone. It’s not genetic, per se; people are just different and some may take Ibuprofen two or three times a week for a migraine and have a bad ulcer and somebody may take it every day and not have a problem. But certainly taking it on a daily basis for a prolonged period of time is going to increase your risk of ulcer disease or other complications of using an NSAID.

What symptoms of an ulcer would warrant a doctor visit or a trip to the ER?

If you’re taking an NSAID and you’re experiencing upper abdominal pain at rest or after eating, you should discuss it with your health care provider. If you have severe pain or pain that doesn’t go away, you should absolutely get evaluated in the ER, and certainly if there’s any evidence of bleeding, vomiting blood, blood in the stool, or black stool you should have somebody drive you to the ER or call 911.

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A previous version of this article misstated the affiliation of Barry Marshall, one of the physicians who discovered the bacteria causing ulcers. Dr. Miller was not affiliated with Johns Hopkins University.

Sarah True was a public health reporter for the Baltimore Banner. She previously worked as a freelance journalist covering healthcare and health policy, and has been both a medical social worker and a health policy analyst in a past life. She holds dual Master’s degrees in public health and social work.

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