Obesity is Associated With High Risk Stigmata of Peptic Ulcer Disease

Abstract

Obesity is a worsening epidemic in the United States (US). National Health and Nutrition Examination Survey (NHANES) data shows that one third of the US population is obese (BMI >30). Patients with obesity are at increased risk for a variety of GI conditions including GERD symptoms, erosive esophagitis, Barrett's esophagus, esophageal adenocarcinoma, gallstones, colonic adenomas, colon cancer, non-alcoholic fatty liver disease, and liver cirrhosis. Population studies suggest that obesity is a risk factor for peptic ulcer disease (PUD). The endoscopic appearance or stigmata of bleeding on initial esophagogastroduodenoscopy (EGD) predicts recurrent bleeding. AIM: To evaluate if obesity is a risk factor for high risk endoscopic stigmata of PUD. METHODS: This study was an IRB-approved protocol. 8050 EGD between 11/17/05 and 2/28/10 were reviewed for the finding of ulcer. Inclusion criteria: 1) Initial EGD with the finding of gastric or duodenal ulcer. Exclusion criteria: 1) malignant ulcer, 2) esophageal ulcer, and 3) incomplete documentation. Data collected: age, sex, BMI, ulcer stigmata, location, size, inpatient/outpatient status, NSAID and aspirin status, and H. pylori status. Ulcer appearance was documented by the Forrest classification. High risk stigmata: active spurting of blood (IA) or oozing blood (IB), a nonbleeding visible vessel or pigmented protuberance (IIA), and an adherent clot (IIB). Low risk stigmata: flat, pigmented spot (IIC), and clean-based ulcer (III). Statistical analysis: Chi square, logistic regression. RESULTS: 350 patients (mean age 64.8) with PUD were included. The mean BMI was 27.8. There were 95.7% males, 32.6% of the patients were obese (BMI >30), 30.3% were positive for H. pylori, and 68.9% were taking NSAIDS. 42% were inpatients and 58% were outpatients. Of all ulcers, the mean size was 8.6 mm, 58.0% were located in the stomach, 87.1% were low risk, and 12.9% were high risk. The distribution of stigmata by the Forrest classification: IA 2.9%(n=10), IB 2.6%(n=9), IIA 5.7%(n=20), IIB 1.7%(n=6), IIC 11.7%(n=41), and III 75.4%(n=264). High risk stigmata was not associated with age, sex, H. pylori status, or use of NSAIDS. However, it was significantly associated with BMI category (BMI ≥35: high risk stigmata 23.3%; BMI < 35: high risk stigmata 11.4% (p = 0.03)) and location (duodenum: high risk stigmata 17.7% vs. stomach: high risk stigmata 9.4% (p = 0.02)). Both BMI category (p=0.03) and PUD location (p=0.02) were significant independent predictors of high risk stigmata. CONCLUSION: A BMI ≥ 35 was associated with a significantly higher risk of stigmata on initial EGD in patients with PUD. A BMI≥ 35 may be helpful in risk stratification of patients with suspected PUD bleeding.