Changing trends in the epidemiology and clinical outcome of acute upper gastrointestinal bleeding in a defined geographical area in Greece

AIM: Acute upper gastrointestinal bleeding (AUGIB) remains a common medical emergency and an important cause of morbidity and mortality. The aim of this study was to evaluate changes in clinico-epidemiologic characteristics of patients who presented with AUGIB during the last 10 years. METHODS: Data from all patients admitted with AUGIB in a defined geographical area in Greece from January 1 to December 31, 2005 (period B) were compared with retrospectively collected data from all patients admitted with AUGIB in the same area 10 years ago, from January 1 to December 31, 1995 (period A). The estimated incidence of AUGIB and peptic ulcer bleeding (PUB) in both periods was calculated using data from the population of this area according to the National Statistical Service. RESULTS: A reduction in the incidence of AUGIB from 162.9/100,000 population in 1995, to 108.3/100,000 population (rate ratio=0.49, confidence interval 95%=0.37-0.63) in 2005 and in the incidence of PUB from 104.8/100,000 population to 72.5/100,000 (rate ratio=0.49, confidence interval 95%=0.35-0.68) were, respectively, observed. This reduction was mainly due to the reduction in the incidence of duodenal ulcer bleeding (from 66.7 cases/100,000 to 35.5/100,000 population), whereas gastric ulcer bleeding incidence remained unchanged (33.1/100,000 vs. 34.4/100,000 cases). Mean age of patients increased from 59.4+/-17.1 years to 66.1+/-16.1, P<0.0001, and the patients' comorbidity. The percentage of NSAIDs' use remained stable (49.3% vs. 48.2%), whereas the use of oral anticoagulants and antiplatelets drugs increased significantly (from 2.2% to 6.8%, P=0.001 and from 1.2% to 10.8%, P<0.0001, respectively). Blood transfusion requirements per patient significantly decreased (from 2.5+/-2 to 2+/-2.4, P=0.009). The rate of rebleeding in PUB patients and emergency surgical hemostasis statistically decreased (from 12% to 5.9%, P=0.02 and from 5.9% to 3.1%, P=0.009, respectively). No significant difference in the overall mortality was observed (3.9% in 1995 vs. 6.5% in 2005). CONCLUSIONS: The incidence of AUGIB during the past 10 years significantly decreased, mainly due to the decline in the incidence of bleeding duodenal ulcers. Nowadays, patients are older with more comorbidities, but mortality remains unchanged.     

Etiology and Outcome of Patients with Upper Gastrointestinal Bleeding: A Study from South of Iran

Background/Aim:

The prevalence of acute upper gastrointestinal bleeding (AUGIB) has undergone a change after implementation of eradication therapy for Helicobacter pylori in peptic ulcers effective prevention of esophageal variceal bleeding and eventually, progressive use of low dose aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs). To evaluate this subject, we performed a prospective study in two main University Hospitals of Shiraz (the largest city of southern Iran).

Materials and Methods:

All adults who were admitted in emergency room with impression of AUGIB and existing patients who developed AUGIB were included in the study. Gastroscopy was done with a follow-up for the next 15 days.

Results:

572 patients (mean age: 54.9 years) entered in the study. The most common presenting symptom was hematemesis or coffee-ground vomits (68%). 75% of patients gave history of consumption of low dose aspirin or other NSAIDs regularly. Gastric and/or duodenal ulcers were the most common causes (252/572, 44%) of AUGIB (Gastric ulcer: 173/572, 30% and duodenal ulcer: 93/572, 16%, respectively). Esophageal varices were the third common cause (64/572, 11%). 36 (6%) of the patients died. Mean age of these patients was higher than the patients who were alive (64.8 vs. 54.2 years, P = 0.001). Other than age, orthostatic hypotension on arrival (267/536 vs. 24/36, P = 0.018) and consumption of steroids (43/536 vs. 10/36, P = 0.001) were significant factors for increasing mortality.

Conclusions:

The most common cause of AUGIB, secondary only to NSAIDs consumption, is gastric ulcer. Mortality of older patients, patients who consumed NSAIDs and steroids concomitantly, and patients with hemodynamic instability on arrival were higher.     

Factors associated with failure of endoscopic injection haemostasis in bleeding peptic ulcers.

BACKGROUND: The effectiveness of a submucosal injection of adrenaline solution in endoscopic haemostasis is well documented in patients suffering from peptic ulcer bleeding. After treatment, however, a significant number of patients continue to bleed or rebleed, and require emergency surgical intervention. The aim of this study was to define factors associated with the failure of endoscopic injection haemostatic therapy in peptic ulcer bleeding. METHODS: In the period 1992 to 1998, we prospectively studied all patients suffering from peptic ulcer bleeding and identified endoscopically as being either bleeding actively or carrying a visible vessel. A total of 427 patients (343 men and 84 women; mean age 58.6 +/- 16.6 years) were all subjected to endoscopic injection with adrenaline solution on an emergency basis. Patients who eventually required surgical intervention for permanent haemostasis were considered as endoscopic haemostasis failures, whereas those who did not were considered as endoscopic treatment successes. We evaluated all clinical and endoscopic parameters that might have been related to failure of endoscopic injection therapy. RESULTS: Endoscopic injection haemostasis was successful in 341 patients (79.9%) and a failure in 86 (20.1%) who finally underwent emergency surgical haemostasis. On analysing the examined parameters, failure was significantly related to shock on admission (OR 2.31, 95% CI 1.33, 6.97), spurt bleeding at endoscopy (OR 2.45, 95% CI 1.51, 3.98), posteriorly located duodenal ulcer (OR 2.48, 95% CI 1.37, 7.01) and anastomotic ulcer (OR 3.39, 95% CI 1.37, 7.29). Endoscopic injection haemostasis therapy was less effective in patients with chronic ulcers compared to those who had acute NSAID-related ulcers. A history of peptic ulcer (OR 1.57, 95% CI 1.14, 3.05), previous peptic ulcer bleeding (OR 2.45, 95% CI 1.51, 3.98) or non-use of NSAIDs (OR 2.81, 95% CI 1.33, 4.62) were negative predictors for the outcome of endoscopic haemostasis. CONCLUSION: With the use of specific clinical and endoscopic characteristics it is possible to define a subgroup of high-risk patients for continued bleeding or rebleeding despite endoscopic injection therapy. These patients may be candidates for intensive monitoring, early surgical intervention or possibly complementary endoscopic haemostatic methods.     

Acute upper gastrointestinal bleeding in patients on long-term oral anticoagulation therapy： Endoscopic findings, clinical management and outcome

AIM: Acute gastrointestinal bleeding is a severe complication in patients receiving long-term oral anticoagulant therapy. The purpose of this study was to describe the causes and clinical outcome of these patients. METHODS: From January 1999 to October 2003, 111 patients with acute upper gastrointestinal bleeding (AUGIB) were hospitalized while on oral anticoagulants. The causes and clinical outcome of these patients were compared with those of 604 patients hospitalized during 2000-2001 with AUGIB who were not taking warfarin. RESULTS: The most common cause of bleeding was peptic ulcer in 51 patients (45%) receiving anticoagulants compared to 359/604 (59.4%) patients not receiving warfarin (P<0.05). No identifiable source of bleeding could be found in 33 patients (29.7%) compared to 31/604 (5.1%) patients not receiving anticoagulants (P=0.0001). The majority of patients with concurrent use of non-steroidal anti-inflammatory drugs (NSAIDs) (26/35, 74.3%) had a peptic ulcer as a cause of bleeding while 32/76 (40.8%) patients not taking a great dose of NSAIDs had a negative upper and lower gastrointestinal endoscopy. Endoscopic hemostasis was applied and no complication was reported. Six patients (5.4%) were operated due to continuing or recurrent hemorrhage, compared to 23/604 (3.8%) patients not receiving anticoagulants. Four patients died, the overall mortality was 3.6% in patients with AUGIB due to anticoagulants, which was not different from that in patients not receiving anticoagulant therapy. CONCLUSION: Patients with AUGIB while on long-term anticoagulant therapy had a clinical outcome, which is not different from that of patients not taking anticoagulants. Early endoscopy is important for the management of these patients and endoscopic hemostasis can be safely applied.     

Helicobacter pylori and risk of ulcer bleeding among users of nonsteroidal anti-inflammatory drugs: a case-control study.

BACKGROUND & AIMS: Peptic ulcer complications related to use of nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most common serious adverse drug reactions. Whether Helicobacter pylori infection potentiates this gastrointestinal toxicity of NSAIDs is still unresolved. In this study, we investigated the role of H. pylori as a cause of bleeding peptic ulcer among NSAID users. METHODS: A case-control study of current users (n = 132) of NSAIDs (including acetylsalicylic acid), admitted because of bleeding peptic ulcer, was performed. Controls were 136 NSAID users without gastrointestinal complications. H. pylori was diagnosed by either increased levels of serum immunoglobulin G or by 13C-urea breath test. RESULTS: Fifty-eight (44%) case subjects had a bleeding gastric ulcer, 54 (41%) had a bleeding duodenal ulcer, 12 (9%) had both gastric and duodenal ulcers, and 8 (6%) had hemorrhagic gastritis. H. pylori was present in 75 (57%) cases compared with 59 (43%) controls. The adjusted odds ratio of bleeding peptic ulcer among NSAID users associated with H. pylori infection was 1.81 (95% confidence interval, 1.02-3.21). H. pylori accounted for approximately 24% of bleeding peptic ulcers among elderly NSAID users. CONCLUSIONS: NSAID users infected with H. pylori have an almost twofold increased risk of bleeding peptic ulcer compared with NSAID users without H. pylori.     

L’ulcère bulbaire hémorragique et les anti-inflammatoires non stéro?diens : quelle gravité de l’accident hémorragique ?

Introduction

Non steroidal anti inflammatory drugs (NSAIDs) are among the most prescribed and used drugs, because of their therapeutic efficacy in multiple epidemiological indication. Severity of the bleeding in the case of duodenal ulcer would be different between the group of patients taking NSAIDs and those not taking NSAIDs before bleeding complication.

Materials and methods

We propose to study the group of patients admitted for bleeding peptic ulcer (BPU) with NSAIDs and to compare it to the group without NSAIDs. Four hundred and twenty eight patients were admitted during this period for bleeding duodenal ulcer.

Results

The NSAID previous hemorrha 29.5% of patients (n=126). There was no statistically significant difference between the group taking NSAID (n=126) and NSAIDs negative (n=302) in terms of average age (45.4 vs 45 respectively). There is a clear male predominance compared in the 2 groups. There was no statistically significant difference in terms of average rate of Hte, endoscopic data (seat of the ulcer, stage Forrest, endoscopic hemostasis). The surgery was no more frequent in cases of BPU associated with NSAID Furthermore, patients who used NSAIDs had more frequent initial hemodynamic instability (4 patients vs 1, p=0.01), recurred more frequently (8.7% vs 4%, p=0.04) and there was trend to more death in the group with NSAID.

Conclusion

The episode of bleeding from peptic ulcer associated with NSAID use was more severe     

Limitations of endoscopic haemostasis by ethanol injection and surgical management for bleeding peptic ulcer

Abstract Two hundred and fifty-three patients with bleeding peptic ulcer underwent therapeutic endoscopy using local ethanol injection and were evaluated to determine the need for surgery and outcome. Permanent endoscopic haemostasis was achieved in 178 (70.4%) cases. Pulsatile arterial bleeding in ulcers and shock on admission (respectively, P < 0.01, P < 0.05) were significantly more frequent in patients with unsuccessful endoscopic treatment. Postoperative stay was significantly longer ( P < 0.05) for patients with bleeding peptic ulcer than for patients requiring surgery for intractable ulcer without bleeding. Surgery was recommended if three attempts at endoscopic treatment did not achieve permanent haemostasis. The need for more than three such treatment sessions and the presence of a large excavated ulcer with an exposed vessel in an elderly patient were considered to indicate the necessity for surgery. Surgical procedures to which the operator is accustomed and intensive management were recommended for emergency cases to optimize the likelihood of survival.     

非甾体消炎药及阿司匹林相关消化性溃疡出血住院患者的实时调查

目的 分析非甾体消炎药(NSAIDs)及阿司匹林相关消化性溃疡出血患者的临床特点及其预后.方法 由同一调查者对2004年8月至2005年12月在北京大学第三医院消化科住院的所有消化性溃疡出血患者进行实时问卷调查.问卷内容包括人口学资料、NSAIDs及阿司匹林用药情况、临床表现、实验室及内镜检查、治疗、费用及预后等.通过单因素及多因素loistic回归分析确定与止血治疗无效相关的危险因素.结果 有NSAIDs及阿司匹林服药史的消化性溃疡出血患者共51例(设为NSAIDs组),占同期147例住院的消化性溃疡出血患者的34.7%,其余为非NSAIDs组.与非NSAIDs组比较,NSAIDs组平均年龄较大、急性起病者多见(P=0.014),腹痛症状少(61.5%比27.5%,P＜0.001),患冠心病(10.4%比17.6%,P＜0.001)、高血压(10.4%比39.2%,P＜0.001)及糖尿病(4.2%比19.6%,P=0.005)者多见,重度贫血多见(7.3%比23.5%,P=0.008),接受输血治疗者多见(24.0%比41.2%,P=0.025),再出血者多见(9.4%比15.7%,P=0.034);住院总费用及治疗费高于非NSAIDs组(P=0.089及P=0.063).既往溃疡病史为NSAIDs组止血治疗失败的危险因素(P＜0.05).结论 与非NSAIDs组相比,NSAIDs及阿司匹林相关消化性溃疡出血患者较少有腹痛症状,起病急,出血重,止血治疗效果差,治疗所需费用较高,特别是既往有溃疡病史的患者.临床医生在应用NSAIDs及阿司匹林前应注意相关高危因素.

Abstract：

Objective To investigate the clinical characteristic and prognosis of nonsteroidal antiinflammatory drugs( NSAIDs)and aspirin associated peptic ulcer bleeding. Method All patients with peptic ulcer bleeding were studied by the same researcher after admission and discharge. Results Fifty-one cases with NSAIDs and aspirin medication of the total peptic ulcer bleeding patients ( 147 cases) were included (34. 7% ). Compared with patients not associated with NSAIDs and aspirin medication, they are older [(41.2 ± 1. 9 ) years vs ( 59.4 ± 2. 2 ) years, P ＜ 0. 001], more commonly associated with hypertension ( 10. 4% vs 39. 2% ,P ＜0. 001 ), coronary heart disease ( 10. 4% vs 17.6% ,P ＜0. 001 ) ,diabetes (4. 2%vs 19. 6%, P = 0. 005 ); and had more severe anemia (7. 3% vs 23. 5%, P = 0. 008 ). Fewer patients in NSAIDs group had epigastric pain (61.5% vs 27.5%, P ＜ 0. 001 ), while there was more re-bleeding (9.4% vs 15.7%, P = 0.034). In all bleeding patients, factors associated with re-bleeding, surgical intervention and death included NSAIDs and aspirin medication, and low platelet count. In patients with NSAIDs and aspirin medication, re-bleeding was associated with previous ulcer history ( P ＜ 0. 05 ).Conclusion Peptic ulcer bleeding patients with NSAIDs and aspirin medication were more severe ill, and less likely to present with epigastric pain.     

非甾体抗炎药相关性溃疡并出血的临床特点

目的 研究非甾体抗炎药(NSAIDs)相关性胃十二指肠溃疡并出血的临床特点。方法 调查我院1997年1月-2001年12月间因胃十二指肠溃疡并出血收住院治疗患者的临床资料,根据人院前1周内有无服用NSAIDs史将患者分为2组,对2组病人的临床资料进行分析比较。结果 本研究共纳入446例患者,其中服药组86例,未服药组360例。2组病人在性别、出血方式、既往消化性溃疡史、胃及十二指肠溃疡的具体部位、糜烂,以及是否需要内镜治疗等方面的差异无显著性。但是服药组患者的年龄较未服药组更高,血红蛋白在服药组下降更明显(P＝0.004);胃溃疡和复合溃疡、多发溃疡在服药组更多见(P＜0．001),而未服药组幽门螺杆菌(Hp)的感染率较服药组更高,分别为72．5％和53.4％(P＝0.001)。进一步的研究发现,患者年龄和Hp感染状态对NSAIDs相关溃疡并出血的临床特点无明显影响。结论 应加强对NSAIDs相关性胃十二指肠溃疡并出血临床特点的认识,尽量减少NSAIDs的不良反应。     

Interaction between Helicobacter pylori and non-steroidal anti-inflammatory drugs in peptic ulcer bleeding

BACKGROUND: Helicobacter pylori and non-steroidal anti-inflammatory drugs (NSAIDs) are the two primary causes of peptic ulcer disease. How H. pylori and NSAIDs interact and influence the development of ulcer bleeding is still not clear. METHODS: A hospital-based, age- and sex-matched case-control study was conducted. Multivariate and stratified analyses were performed for further evaluation of the interaction between H. pylori and NSAIDs. RESULTS: Ninety-seven patients (52 gastric ulcers, 45 duodenal ulcers) and 97 non-ulcer controls were enrolled in the study. H. pylori and NSAIDs were both found to be independent risk factors for ulcer bleeding (H. pylori odds ratio, 2.22; 95% confidence interval (CI), 1.23-4.01; NSAIDs odds ratio, 4.57; 95% CI, 2.50-8.35). There was no synergistic effect. In contrast, a negative interaction was observed in the logistic regression and stratified analysis, although the difference was not significant (H. pylori adjusted odds ratio, 3.47; 95% CI, 1.73-6.95; NSAID adjusted odds ratio, 6.16; 95% CI, 3.14-12.09). CONCLUSION: H. pylori increases the risk of peptic ulcer bleeding but may play a protective role in NSAID users.     

消化性溃疡患者非甾体类抗炎药服用史和幽门螺杆菌感染的协同致病性分析

目的了解服用非甾体类抗炎药(NSAIDs)和幽门螺杆菌(H.pylori)感染在消化性溃疡及合并上消化道出血发病中是否具有协同作用。方法应用病例对照研究,于1999年7月至2004年12月选取吉林大学中日联谊医院的803例消化性溃疡患者(其中208例溃疡合并上消化道出血者)与同一时期就诊的2061例非胃十二指肠疾病患者,进行NSAIDs服用史的调查和H.pylori感染的检测。结果服用NSAIDs合并H.pylori感染者患胃溃疡的OR值明显高于单纯服用NSAIDs者和单纯H.pylori感染者患胃溃疡的OR值之和;服用NSAIDs合并H.pylori感染的胃溃疡及十二指肠溃疡患者发生上消化道出血的OR值均低于单纯服用NSAIDs和单纯H.pylori感染的胃溃疡患者和十二指肠溃疡患者发生上消化道出血的OR值之和;与无溃疡未服NSAIDs者比较,偶尔服药者溃疡出血与短期服药者及长期服药者比较,差异无统计学意义。结论NSAIDs和H.pylori感染在胃溃疡的形成中具有协同作用;在溃疡合并上消化道出血的发病中无协同作用;溃疡合并上消化道出血与服用NSAIDs的时间长短无关。     

Genotypes of Helicobacter pylori in patients with peptic ulcer bleeding

AIM: Helicobacter pylori causes chronic gastritis, peptic ulcer, gastric cancer and MALT-lymphoma. Different genotypes of Helicobacter pylori are confirmed from diverse geographic areas. Its association with bleeding peptic ulcer remains controversial. The aim of this study was to investigate the Helicobacter pylori vacA alleles, cagA and iceA in patients with bleeding peptic ulcer. METHODS: We enrolled patients with bleeding, non-bleeding peptic ulcers and chronic gastritis. Biopsy specimens were obtained from the antrum of the stomach for rapid urease test, bacterial culture and PCR assay. DNA extraction and polymerase chain reaction were used to detect the presence or absence of cagA and to assess the polymorphism of vacA and iceA. RESULTS: A total of 168 patients (60.4%) (25 patients with chronic gastritis, 26 patients with bleeding gastric ulcer, 51 patients with non-bleeding gastric ulcer, 26 patients with bleeding duodenal ulcer, and 40 patients with non-bleeding duodenal ulcer) were found to have positive PCR results between January 2001 and December 2002. Concerning genotypes, we found cagA (139/278, 50%), vacA s1a (127/278, 45.7%), and ice A1 (125/278, 45%) predominated in all studied patients. In patients with bleeding peptic ulcers, vacA s1a and m1T were fewer than those in patients with non-bleeding peptic ulcers (37/106 vs 69/135, P=0.017, and 4/106 vs 21/135, P =0.002). CONCLUSION: In patients with peptic ulcers, H pylori vacA s1a and m1T prevent bleeding complication.     

Predictors of hemostatic failure after adrenaline injection in patients with peptic ulcers with non-bleeding visible vessel

BACKGROUND: Non-bleeding visible vessel (NBVV) in patients with bleeding peptic ulcer is associated with a high risk of rebleeding. The aim of this study was to define factors associated with failure of endoscopic hemostasis and rebleeding in patients with NBVV. METHODS: Clinical and endoscopic parameters related to failure of endoscopic hemostasis with adrenaline in 191 bleeding peptic ulcer patients with NBVV were evaluated. RESULTS: Endoscopic hemostasis was permanently successful in 154 patients (80.6%). Emergency surgical hemostasis for rebleeding was required in 37 patients (19.4%). Univariate analysis showed that therapeutic failure was significantly related to the presence of shock on admission (P=0.003), posterior duodenal ulcers (P=0.001), peptic ulcer history (P=0.001), previous peptic ulcer bleeding (P=0.002), or lack of history of non-steroidal anti-inflammatory drugs consumption, when compared to use of such drugs (P=0.04). Patients where therapy failed had lower hemoglobin levels at admission (7.8+/-1.9 g/dL versus 10+/-2.4 g/dL, P=0.005). In a multivariate analysis low hemoglobin (P<0.001) as well as history of previous peptic ulcer bleeding (P=0.002) and posterior duodenal ulcers (P=0.001) were negative predictors. Using the mean value of hemoglobin as the cut-off point, it is noteworthy that only 2 out of 81 patients (2.5%) who had none of these predictive factors required emergency surgical hemostasis, whereas 34 out of 110 patients (30.9%) with at least one predictive factor required emergency surgery. CONCLUSION: It is possible, by employing specific characteristics, to define a subgroup of high-risk patients for rebleeding in patients with NBVV despite therapeutic endoscopy and thus candidates for a complementary endoscopic method of hemostasis or emergency surgical intervention.     

Acute upper gastrointestinal bleeding in octogenarians： Clinical outcome and factors related to mortality

AIM： To evaluate the aetiology, clinical outcome and factors related to mortality of acute upper gastrointestinal bleeding （AUGIB） in octogenarians.
METHODS： We reviewed the records of all patients over 65 years old who were hospitalised with AUGIB in two hospitals from January 2006 to December of 2006. Patients were divided into two groups： Group A （65-80 years old） and Group B （〉 80 years old）. RESULTS： Four hundred and sixteen patients over 65 years of age were hospitalized because of AUGIB. Group A included 269 patients and Group B 147 patients. Co-morbidity was more common in octogenarians （P = 0.04）. The main cause of bleeding was peptic ulcer in both groups. Rebleeding and emergency surgery were uncommon in octogenarians and not different from those in younger patients. In-hospital complications were more common in octogenarians （P = 0.05） and more patients died in the group of octogenarians compared to the younger age group （P = 0.02）. Inability to perform endoscopic examination （P = 0.002）, presence of high risk for rebleeding stigmata （P = 0.004）, urea on admission （P = 0.036）, rebleeding （P = 0.004） and presence of severe co-morbidity （P 〈 0.0001） were related to mortality. In multivariate analysis, only the presence of severe co-morbidity was independently related to mortality （P = 0.032）.
CONCLUSION： While rebleeding and emergency surgery rates are relatively low in octogenarians with AUGIB, the presence of severe co-morbidity is the main factor of adverse outcome.     

Factors influencing mortality from bleeding peptic ulcers

The mortality, causes of death, and the factors that are influencing deaths from bleeding acute and chronic peptic ulcers were evaluated retrospectively. During a 2-year period (1986-87) 272 patients were endoscoped for acute gastrointestinal hemorrhage and were found to have bled from a peptic ulcer (chronic gastric ulcers, 90; chronic duodenal ulcers, 114; acute gastroduodenal ulcers, 66; stomal ulcers, 2). The overall mortality was 9.6% (n = 26) (gastric ulcers, 6.7%; duodenal ulcers, 11.4%; acute ulcers, 10.6%). Statistically significant factors adversely affecting prognosis for gastric ulcer were re-bleeding, need for operation and serious intercurrent illness; for duodenal ulcer were units of transfused blood, re-bleeding, signs of recent hemorrhage at endoscopy, need for operation, and serious intercurrent illness; and for acute ulcer were increasing age, shock, units of transfused blood, re-bleeding, and serious intercurrent illness. Multivariate analysis was only attempted for duodenal ulcers because of sample sizes; it suggested that active bleeding or visible vessel at endoscopy, re-bleeding, and serious intercurrent illness were independent factors for mortality. From this study it is apparent that the major determinants of a fatal outcome in bleeding peptic ulcer diseases were serious intercurrent illness and rebleeding. As it must be anticipated that patients with these particular problems are at high risk of a poor outcome, it follows that it is important they have access to skilled treatment as provided by a specialist team in an intensive care ward. It also follows that every effort should be made to keep ulcers in remission to free the ulcer patient of potentially lethal complications.     

Small bowel ulcerative lesions are common in elderly NSAIDs users with peptic ulcer bleeding

AIM: To determine the frequency of small bowel ulcerative lesions in patients with peptic ulcer and define the significance of those lesions.METHODS: In our prospective study, 60 consecutive elderly patients with upper gastrointestinal bleeding from a peptic ulceration (cases) and 60 matched patients with a non-bleeding peptic ulcer (controls) underwent small bowel capsule endoscopy, after a negative colonoscopy (compulsory in our institution). Controls were evaluated for non-bleeding indications. Known or suspected chronic inflammatory conditions and medication that could harm the gut were excluded. During capsule endoscopy, small bowel ulcerative lesions were counted thoroughly and classified according to Graham classification. Other small bowel lesions were also recorded. Peptic ulcer bleeding was controlled endoscopically, when adequate, proton pump inhibitors were started in both cases and controls, and Helicobacter pylori eradicated whenever present. Both cases and controls were followed up for a year. In case of bleeding recurrence upper gastrointestinal endoscopy was repeated and whenever it remained unexplained it was followed by repeat colonoscopy and capsule endoscopy.RESULTS: Forty (67%) cases and 18 (30%) controls presented small bowel erosions (P = 0.0001), while 22 (37%) cases and 4 (8%) controls presented small bowel ulcers (P < 0.0001). Among non-steroidal anti-inflammatory drug (NSAID) consumers, 39 (95%) cases and 17 (33%) controls presented small bowel erosions (P < 0.0001), while 22 (55%) cases and 4 (10%) controls presented small bowel ulcers (P < 0.0001). Small bowel ulcerative lesions were infrequent among patients not consuming NSAIDs. Mean entry hemoglobin was 9.3 (SD = 1.4) g/dL in cases with small bowel ulcerative lesions and 10.5 (SD = 1.3) g/dL in those without (P = 0.002). Cases with small bowel ulcers necessitate more units of packed red blood cells. During their hospitalization, 6 (27%) cases with small bowel ulcers presented bleeding recurrence most possibly attributed to small bowel ulcers, nevertheless 30-d mortality was zero. Presence of chronic obstructive lung disease and diabetes was related with unexplained recurrence of hemorrhage in logistic regression analysis, while absence of small bowel ulcers was protective (relative risk 0.13, P = 0.05).CONCLUSION: Among NSAID consumers, more bleeders than non-bleeders with peptic ulcers present small bowel ulcers; lesions related to more severe bleeding and unexplained episodes of bleeding recurrence.     

Bleeding peptic ulcer: characteristics and outcomes in Newcastle, NSW

Background: Peptic ulcer disease risk factors have changed, as has the impact of treatment on morbidity and mortality. Recent data on clinical presentation and outcome are sparse in Australia. Aim: To determine the characteristics and outcome of patients presenting with a bleeding peptic ulcer to a tertiary referral centre. Methods: We evaluated patients diagnosed with peptic ulcer bleeding between 2004 and 2008 at a tertiary referral hospital. Variables assessed included demographic data, comorbidities, medication use and Rockall score. Outcomes of interest were the time to endoscopy, peptic ulcer treatment, transfusion requirements, urgent surgery and survival. Results: Peptic ulcers were confirmed in 265 patients (55% male), of which 145 were gastric and 119 duodenal. The mean age was 71 years. On admission 38% of patients had haemodynamic instability and 92% had one or more comorbidity. Consumption of ulcerogenic medications at the time of admission was frequent (non‐steroidal anti‐inflammatory drugs (NSAIDs) 22%, aspirin 41%, clopidogrel or warfarin 10%) and proton pump inhibitors infrequent (15%). A gastroenterologist managed all patients according to their usual practice. Only a minority of patients received over three units of packed red cells. Few patients were referred for surgery (3%) or died (3%), but both events were significantly higher for the duodenal ulcer group. Conclusion: The characteristics and outcomes in patients with peptic ulcer bleeding have changed. Peptic ulcer disease remains a public health problem with modifiable risk factors, such as Helicobacter pylori infection and NSAIDs, which should be targeted to reduce the burden of illness.     

On the Natural History of Peptic Ulcer

Lindell G, Celebioglu F, Staël von Holstein C, Graffner H. On the natural history of peptic ulcer. Scand J Gastroenterol 1994;29:979-982.

Background: Three out of 1000 individuals have peptic ulcer every year, and 20% of the ulcer episodes are associated with bleeding. Whether major innovations such as endoscopy and strong acid-suppressing drugs have had any impact on the natural course of peptic ulcer disease is largely unknown.

Methods: Three hundred and fifty-one patients (median age, 63 years) with endoscopically proven peptic ulcer during 1979-1984 were included in the study and retrospectively followed up via medical records. The total population is based on two different groups of patients, the first comprising 229 consecutively diagnosed ulcer patients during 1979-81 and, to increase the number of bleeders, a second group including 122 bleeding ulcer patients consecutively diagnosed during 1981-84. At the end of the follow-up period all non-ulcer-operated patients were asked to answer a questionnaire on symptoms, investigations, and medication.

Results: The male to female ratio was 2.4:1 in duodenal ulcer patients, but a 1:1 ratio was shown both in gastric and prepyloric/pyloric ulcer patients (p < 0.001). Patients with bleeding ulcers were significantly older than non-bleeders (68 years versus 58 years; p < 0001), as were patients with gastric ulcers compared with prepyloric/pyloric or duodenal ulcer patients (68 years versus 63 and 61 years, respectively; p < 0.01). The 10-year cumulative mortality in the unselected group (median age, 62 years) was 43%, and the annual risk of dying of peptic ulcer disease was 0.6%. No difference in 10-year recurrence rate was seen between patients with bleeding ulcer at inclusion and non-bleeders (46.2% versus 44.3%; p = NS), but the annual risk of bleeding was 5.3% and 0.8%, respectively (p< 0.0001). In the group of patients answering the questionnaire 51% reported upper abdominal pain during the last year of follow-up.

Conclusions: In spite of today's treatment regimens almost half of the patients with peptic ulcer disease experienced recurrence during a 10-year period, and more than half had ulcer symptoms after 10 years. Most probably, maintenance treatment with H₂-receptor antagonists should have been offered more liberally during the 1980s.