Incidence Of Peptic Ulcer Bleeding Research Articles

Impact of Helicobacter pylori Eradication on Incidence of Peptic Ulcer Bleeding in Patients Taking Regular Aspirin

Hawkey C, Avery A, Coupland CAC, et al; HEAT Trialists. Helicobacter pylori eradication for primary prevention of peptic ulcer bleeding in older patients prescribed aspirin in primary care (HEAT): a randomised, double-blind, placebo-controlled trial. Lancet 2022; 400(10363):1597–1606.

Current Status and Future Perspective of Artificial Intelligence in the Management of Peptic Ulcer Bleeding: A Review of Recent Literature.

With the decreasing incidence of peptic ulcer bleeding (PUB) over the past two decades, the clinician experience of managing patients with PUB has also declined, especially for young endoscopists. A patient with PUB management requires collaborative care involving the emergency department, gastroenterologist, radiologist, and surgeon, from initial assessment to hospital discharge. The application of artificial intelligence (AI) methods has remarkably improved people’s lives. In particular, AI systems have shown great potential in many areas of gastroenterology to increase human performance. Colonoscopy polyp detection or diagnosis by an AI system was recently introduced for commercial use to improve endoscopist performance. Although PUB is a longstanding health problem, these newly introduced AI technologies may soon impact endoscopists’ clinical practice by improving the quality of care for these patients. To update the current status of AI application in PUB, we reviewed recent relevant literature and provided future perspectives that are required to integrate such AI tools into real-world practice.

A Nationwide Cohort Study Shows a Sex-Dependent Change in the Trend of Peptic Ulcer Bleeding Incidence in Korea between 2006 and 2015.

Background/AimsThe incidence of peptic ulcer disease has decreased in past decades; however, the trends in peptic ulcer bleeding (PUB) are inconsistent among regions. This study aimed to investigate the trends in PUB incidence and the effect of risk factors on PUB in Korea.MethodsThe records of patients hospitalized with PUB from 2006 to 2015 were retrieved from the Korean National Health Insurance Service Database. Standardized incidences of PUB were calculated, and the clinical characteristics such as age, sex, Helicobacter pylori infection, drug exposure, comorbidities, and mortality were obtained.ResultsIn total, 151,507 hospitalizations with PUB were identified. The overall annual hospitalization rate was 34.98 per 100,000 person-years. The incidence of PUB showed no significant change from 2006 to 2008 and decreased from 2008 to 2015, with an annual change of –2.7% (p<0.05); however, this change was only significant in men. The incidence of PUB was higher in men than in women between 40 and 70 years old and higher in women than in men older than 80 years. From 2006 to 2015, the H. pylori infection rate increased significantly in patients with PUB; however, there was no significant change in exposure to nonsteroidal anti-inflammatory drugs or other drugs that increase the risk of PUB.ConclusionsOver the past decade, the incidence of PUB has decreased in a sex-specific manner. There has been a decreasing trend in the H. pylori infection rate and no change in exposure to drugs that increase the risk of PUB in Korea.

Role of Sex and Socioeconomic Status in the Peptic Ulcer Bleeding Hospitalization: A Nationwide Cohort Study Between 2006 and 2015 in Korea

Background: Gastrointestinal peptic ulcer disease has been decreased during the last decades; however, the recent trend of peptic ulcer bleeding (PUB) incidence has not been reported. Besides traditional risk factors such as H. pylori and NSAIDs, sex has gained attention as a potential risk factor, and socioeconomic status (SES) was suggested as a critical factor in PUB. We investigated the effect of sex and SES as well as other risk factors on PUB in Korea using nationwide cohort data. Method: The records of patients hospitalized with PUB from 2006-2015 were retrieved from the Korean National Health Insurance Service-Database. SES was categorized into four classes by health insurance premiums, and clinical characteristics such as H. pylori infection, drug exposure, comorbidities, and mortality were compared according to sex and SES. Findings: In total, 151,507 hospitalizations with PUB were identified. The overall annual hospitalization rate was 34.98 per 100,000 population. The incidence of PUB from 2008 to 2015 decreased by an annual change of -2.7% (p < 0.05), but this was only significant in males. Although the incidence of PUB was increased with age, it was higher in males than in women aged between 40–70 years old and higher in women than in males aged over 80 years old. The lowest economic class had a 2.6-fold higher hospitalization rate than the other economic classes. Furthermore, compared to the upper economic classes, the lowest economic class was older and showed higher exposure to risk drugs, a higher transfusion rate and 30-day mortality, and lower H. pylori eradication. This discrepancy associated with SES has not improved in the last decade. Interpretation: The incidence of PUB is different according to sex and age. Economic deprivation also appears to be an important determinant for the development of PUB. Funding Statement: This research was supported by Support Program for Women in Science, Engineering and Technology through the National Research Foundation of Korea (NRF) funded by the Ministry of Science and ICT. (No. 2019H1C3A1032224). Declaration of Interests: The authors stated: None declared. Ethics Approval Statement: Ethical approval of this study protocol was obtained through the Wonkwang University Sanbon Hospital IRB. (No. 7302-201649).

Seasonal changes in gastric mucosal factors associated with peptic ulcer bleeding.

A close association has been established between climate and peptic ulcer bleeding (PUB). The incidence of PUB in cold climates is significantly higher than that in hot climates. In this study, gastric mucosal damage and its barrier function (through associated barrier factors) in extreme climate conditions were examined to investigate the pathogenesis of PUB in extreme cold climates. Gastric juice and biopsy specimens were collected from 176 patients with peptic ulcer. Conventional hematoxylin and eosin staining was used to exclude malignant ulcers. Helicobacter pylori infections were detected by modified Giemsa staining. pH values of the gastric juice samples were obtained on-site by precise pH dipstick readings. The protein expression levels of heat shock protein (HSP) 70, occludin, nitric oxide synthase (NOS), epidermal growth factor (EGF) and EGF receptor (EGFR) in the gastric mucosa were detected by immunohistochemistry. No significant differences were identified between the high and low bleeding risk groups in the rates of H. pylori infection and the pH values of the gastric juices in the extreme hot or cold climates. Furthermore, no statistically significant differences were identified in the protein expression levels of occludin, NOS, EGF and EGFR between the high and low bleeding risk groups. In the extreme cold climate, the expression of HSP70 and the mucus thickness of the gastric antrum in the high bleeding risk group were significantly lower than those in the low bleeding risk group. The protein expression levels of occludin, HSP70, NOS and EGFR in the extreme cold climate were significantly lower than those in the extreme hot climate, whereas the gastric acid secretion was significantly higher in the extreme cold climate than that in the extreme hot climate. In conclusion, low expression of HSP70 in the gastric mucosa and reduced gastric mucus thickness may play key roles in the mechanism of PUB in extreme cold climates. The significant decrease in barrier factors and increase in damage in extreme cold climates may be associated with the seasonal pattern of peptic ulcers.

Does H. pylori Affect Ulcer Bleeding in Aspirin Users

Low-dose aspirin (ASA) and Helicobacter pylori infection can cause peptic ulcer bleeding (PUB) by different mechanisms. But is the incidence of PUB in ASA users affected by presence of H. pylori ? To find out, investigators in Hong Kong prospectively followed three cohorts of ASA users every 3 to 6 months for up to 10 years:

The Influence of Etiologic Factors on Clinical Outcome in Patients with Peptic Ulcer Bleeding

Peptic ulcer bleeding remains an important cause of morbidity and mortality. The aim of this study was to evaluate the prevalence of non-steroidal anti-inflammatory drugs (NSAID) use, Helicobacter pylori infection and non-H. pylori-non-NSAIDs causes of peptic ulcer bleeding and to identify the predictive factors influencing the rebleeding rate and in-hospital mortality in patients with bleeding peptic ulcer. A total of 1,530 patients with endoscopically confirmed peptic ulcer bleeding were evaluated consecutively between January 2005 and December 2009. The 30-day mortality and clinical outcome were related to patient's demographic data, endoscopic and clinical characteristics. The age-standardized 1-year cumulative incidence for peptic ulcer bleeding was 40.4 cases/100,000 people. The proportion of patients over 65 years increased from 45.7 % in 2005 to 61.4 % in 2009 (p = 0.007). Overall 30-day mortality rate was 4.6 %, not significantly different for conservatively and surgically treated patients (4.9 vs. 4.1 %, p = 0.87). Mortality was significantly higher in patients over 65 years of age and those with in-hospital bleeding recurrence. Patients with non-H. pylori-non-NSAID idiopathic ulcers had significantly higher 30-day mortality rate than those with H. pylori ulcers and NSAID-H. pylori ulcers (7.1 vs. 0 vs. 0.8 %, p = 0.001 and p = 0.007, respectively). There was no statistically significant difference between patients with NSAID ulcers and non-H. pylori-non-NSAID idiopathic ulcers in terms of 30-day mortality rate (5.3 vs. 7.1 %, p = 0.445). The incidence of peptic ulcer bleeding has not changed over a 5-year observational period. The overall 30-day mortality was positively correlated to older age, underlying comorbid illnesses, in-hospital bleeding recurrence and the absence of H. pylori infection.

Incidence of Peptic Ulcer Bleeding in the US Pediatric Population

The aim of the present study was to determine the incidence of peptic ulcer bleeding (PUB) in pediatric patients. A hospital inpatient database, Premier Perspective, and an insurance claims database, MarketScan, were analyzed to estimate upper and lower limits for the annual incidence of PUB in the US pediatric population. Using data from the Premier Perspective database and database-specific projection methodology, the total number of cases of hospitalization of pediatric patients for PUB in the United States in 2008 was estimated to be between 378 and 652. This translated to an incidence of 0.5 to 0.9/100,000 individuals in the pediatric population. Using data from the MarketScan database, the incidence of PUB in the insured pediatric population was estimated to be 4.4/100,000 individuals. Overall, 17.4% of insured pediatric patients diagnosed as having any upper gastrointestinal ulcer in 2008 were reported to have developed PUB. The estimated incidence of PUB in the US pediatric population in 2008 ranged from 0.5 to 4.4/100,000 individuals. The total number of cases of PUB in pediatric patients in the United States each year was thus estimated to be between 378 and 3250. Such estimates provide a likely lower and upper limit for the total number of cases of the condition annually.

Esomeprazole for the treatment of peptic ulcer bleeding

Peptic ulcer bleeding is the most common cause of acute bleeding in the upper GI tract. The incidence of peptic ulcer bleeding has slowly decreased and endoscopic treatment options have improved; nevertheless, it remains a very common condition with a 7–15% mortality. Acidic environments have a negative effect on hemostasis. Therefore, acid inhibitors have been applied in the adjuvant treatment of peptic ulcer bleeding, both in preventing rebleeding and in treating the underlying cause. This requires profound acid suppressive therapy aiming for a rapid onset of effect and a persistent intragastric pH above 6. This can only be achieved by proton pump inhibitors (PPIs). Esomeprazole is the S-isomer of omeprazole, and the first PPI to consist of only the active isomer. A number of studies have compared esomeprazole with other PPIs, demonstrating a faster and more persistent increase in intragastric pH with the use of esomeprazole than with other agents. Continuous high-dose intravenous treatment with esomeprazole decreases rebleeding, surgery, transfusion rates and hospital days in peptic ulcer bleeding.

Time trends in incidence of peptic ulcer bleeding and associated risk factors in Norway 1985&amp;ndash;2008

The aim of this study was to examine time trends in the incidence of peptic ulcer bleeding and risk factors in a defined geographical area in Norway. Retrospective data were collected for 306 patients with bleeding peptic ulcers admitted to one hospital during the 1985-1986, 1995-1996, and 2007-2008 periods. The incidence in 1985-1986 was 52/100,000 and in 2007-2008 was 45/100,000. In the group aged 20-75 years, the incidence decreased by 54% from 54/100000 in 1985-1986 to 25/100000 in 2007-2008 (P = 0.001) and increased by 49% in the group aged >75 years from 272/100000 to 406/100000 (P = 0.0001). The use of aspirin or nonsteroidal anti-inflammatory steroid drugs (NSAIDs) was 31% in 1985-1986 and increased to 67% in 2007-2008 (P = 0.004). In patients using aspirin or NSAIDs, Helicobacter pylori was present in 73% in 1995-1996 and in 51% in 2007-2008. H. pylori infection declined from 84% to 52% between 1995-1996 and 2007-2008. The incidence rate of peptic ulcer bleeding did not change between 1985-1986 and 2007-2008, but decreased in the age group ≤75 years and increased in the age group >75 years. The use of low-dose aspirin and NSAIDs increased substantially over time, and H. pylori infection was still present in 51% of these patients in 2007-2008.

Upper GI Bleeding–Associated Mortality: Challenges To Improving A Resistant Outcome

Although the incidence of peptic ulcer bleeding (PUB) has decreased, mortality has remained constant despite the advances in endoscopic and pharmacological therapies. Recent data indicate that most PUB-linked deaths are not direct sequelae of the bleeding ulcer itself. Instead, mortality derives from multi-organ failure, cardiopulmonary conditions, or terminal malignancy, suggesting that improving treatments for the bleeding ulcer may impact mortality by very little. Recognizing this possibility is paramount for the implementation of strategies that provide supportive care and prevent complications and key-organ failure, as well as treat the ulcer. Identifying non-gastrointestinal (GI) risk factors for poor outcomes and a multidisciplinary approach for high-risk patients should help to affect this hard outcome.

Hospitalization for peptic ulcer and bleeding in users of selective COX‐2 inhibitors and nonselective NSAIDs with special reference to celecoxib

To assess the relative incidence of peptic ulcer bleeding and perforation (PUBP) in users of selective cyclooxygenase-2 (COX-2) inhibitors and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). This was a retrospective case-control study based on insurance claims, with chart review to confirm cases. The base population consisted of 2.2 million adult users of celecoxib, diclofenac, ibuprofen, naproxen, rofecoxib, or valdecoxib who were covered by commercial health insurance in the United States from 1999-2003. For 790 persons hospitalized for PUBP and 7887 controls, most recent NSAID/COX-2 use and a variety of medical and pharmacy risk factors were ascertained from the insurance files and analyzed by conditional logistic regression. The main outcome measure was the odds ratio (OR) associated with use of each drug by comparison to naproxen, and in successive intervals after last dispensing. Hospitalization for PUBP was highest from the date of NSAID/COX-2 dispensing through the end of an exposure period that corresponded to the days supply; the rate dropped steadily thereafter. The covariate-adjusted ORs by comparison to naproxen were: ibuprofen 0.86 (95% confidence interval (CI) 0.68, 1.09), rofecoxib 0.79 (0.62, 1.02), diclofenac 0.66 (0.47, 0.94), valdecoxib 0.50 (0.26, 0.97), and celecoxib 0.45 (0.35, 0.58). The nonselective NSAIDs had an OR for PUBP of 1.51 (1.26, 1.98) compared to the selective COX-2 inhibitors. Nonselective NSAIDs convey half again as much risk of hospitalization for PUBP as do COX-2 inhibitors. Celecoxib users had about half the hospitalization rate of users of naproxen.

Epidemiology of acute upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding is an important emergency situation. Population-based epidemiology data are important to get insight in the actual healthcare problem. There are only few recent epidemiological surveys regarding acute upper gastrointestinal bleeding. Several surveys focusing on peptic ulcer disease showed a significant decrease in admission and mortality of peptic ulcer disease. Several more recent epidemiological surveys show a decrease in incidence of all cause upper gastrointestinal bleeding. The incidence of peptic ulcer bleeding remained stable. Peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, responsible for about 50% of all cases, followed by oesophagitis and erosive disease. Variceal bleeding is the cause of bleeding in cirrhotic patients in 50-60%. Rebleeding in upper gastrointestinal bleeding occurs in 7-16%, despite endoscopic therapy. Rebleeding is especially high in variceal bleeding and peptic ulcer bleeding. Mortality ranges between 3 and 14% and did not change in the past 10 years. Mortality is increasing with increasing age and is significantly higher in patients who are already admitted in hospital for co-morbidity. Risk factors for peptic ulcer bleeding are NSAIDs use and H. pylori infection. In patients at risk for gastrointestinal bleeding and using NSAIDs, a protective drug was only used in 10%. COX-2 selective inhibitors do cause less gastroduodenal ulcers compared to non-selective NSAIDs, however, more cardiovascular adverse events are reported. H. pylori infection is found in about 50% of peptic ulcer bleeding patients. H. pylori should be tested for in all ulcer patients and eradication should be given.

Changing Trends in the Epidemiology and Clinical Outcome of Acute Upper Gastrointestinal Bleeding in a Defined Geographical Area in Greece

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. 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. 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). 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.

Outcome of Upper GI Bleeding in NSAID Users

Nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with increased incidence of peptic-ulcer bleeding, whereas selective

Nonvariceal Upper Gastrointestinal Bleeding

This topic was elegantly reviewed a year ago by Rollhauser and Fleischer [1]. The conclusions at the time are largely echoed this year, with no major changes in either treatment algorithms or outcomes. The incidence of peptic ulcer bleeding appears to be declining slowly, more so in the duodenum, with a slight rise in the incidence of gastric ulcer. The value of early endoscopy appears to be clear, while second-look endoscopy remains controversial. Intensive-care monitoring appears to be of value, as well as proton-pump inhibitor (PPI) treatment, although protection against stress ulcers is still inadequate.

NSAIDs: high estimated incidence of peptic ulcer bleeding

NSAIDs: high estimated incidence of peptic ulcer bleeding

Ulcers and nonvariceal bleeding.

Peptic ulcer remains the commonest and most significant cause of nonvariceal upper gastrointestinal bleeding. The incidence of peptic ulcer bleeding is rising in elderly patients, particularly for duodenal ulcer. Patients presenting with upper gastrointestinal bleeding who have low Rockall scores are at low risk of rebleeding and death. These patients currently utilize considerable health-care resources, but could safely be managed at home. The Rockall score can be used to predict the risk of rebleeding and death following variceal bleeding, but for patients with ulcer bleeding, its ability to predict death is questioned. Acid suppression is effective in preventing rebleeding from peptic ulcer. Standard doses of intravenous omeprazole may be as effective as high-dose regimens. Oral omeprazole also reduces rebleeding following endoscopic therapy for peptic ulcer. Mallory-Weiss tears result in significant bleeding in 23 % of cases. Endoscopic therapy may only be required in cases in which active bleeding is present. Endoscopic therapy is effective and safe in patients with major peptic ulcer bleeding who are over 80 years old. For peptic ulcer, injection of larger volumes of epinephrine (adrenaline; mean 16.5 ml) are more effective than small volumes (mean 8 ml). Injection of normal saline alone is less effective than bipolar electrocoagulation. The addition of fibrin glue to epinephrine injection does not confer an additional benefit over epinephrine alone. Argon plasma coagulation can be used to treat a range of lesions in the gastrointestinal tract. It is also effective for treatment of bleeding ulcer, but is no better than established methods. Haemoclips may be useful in bleeding Mallory-Weiss tears, but their use is difficult in patients bleeding from peptic ulcer. The presence of a large ulcer and active bleeding at the time of endoscopy are independent predictors of failure of endoscopic therapy.