Systematic review of the symptom burden, quality of life impairment and costs associated with peptic ulcer disease

Peptic Ulcer Disease: A Review

Importance

In the US, peptic ulcer disease affects 1% of the population and approximately 54 000 patients are admitted to the hospital annually for bleeding peptic ulcers.

Observations

Approximately 10% of patients presenting with upper abdominal pain in a primary care setting have a peptic ulcer as the cause of their symptoms. The principal causes of peptic ulcer disease are Helicobacter pylori infection, which affects approximately 42% of patients with peptic ulcer disease, and aspirin or nonsteroidal anti-inflammatory drug (NSAID) use, which are etiologic factors in approximately 36% of people with peptic ulcer disease. Complications of peptic ulcer include bleeding (73% of patients), perforation (9% of patients), and pyloric obstruction (3% of patients). Annually, 10 000 people die of peptic ulcer disease in the US. Endoscopy definitively diagnoses peptic ulcer disease. Acid blockers, such as omeprazole, can heal peptic ulcers in approximately 80% to 100% of patients within 4 weeks, but gastric ulcers larger than 2 cm may require 8 weeks of treatment. Eradication of H pylori decreases peptic ulcer recurrence rates from approximately 50% to 60% to 0% to 2%. Discontinuing NSAIDs heals 95% of ulcers identified on endoscopy and reduces recurrence from 40% to 9%. When discontinuing an NSAID is not desirable, changing the NSAID (eg, from ketorolac to ibuprofen), adding a proton pump inhibitor such as omeprazole or lansoprazole, and eradicating H pylori with treatment such as bismuth, metronidazole, and tetracycline combined with omeprazole can reduce recurrence rates.

Conclusions and Relevance

Peptic ulcer disease is associated with increased hospitalization rates and mortality. Acid blocking with proton pump inhibitors, such as omeprazole or lansoprazole, is the primary treatment. Recurrence of ulcers can be prevented by eradicating H pylori if present and discontinuing aspirin or NSAIDs if applicable.

Peptic ulcer disease

Annual prevalence estimates of peptic ulcer disease range between 0·12% and 1·5%. Peptic ulcer disease is usually attributable to Helicobacter pylori infection, intake of some medications (such as aspirin and non-steroidal anti-inflammatory medications), or being critically ill (stress-related), or it can be idiopathic. The clinical presentation is usually uncomplicated, with peptic ulcer disease management based on eradicating H pylori if present, the use of acid-suppressing medications-most often proton pump inhibitors (PPIs)-or addressing complications, such as with early endoscopy and high-dose PPIs for peptic ulcer bleeding. Special considerations apply to patients on antiplatelet and antithrombotic agents. H pylori treatment has evolved, with the choice of regimen dictated by local antibiotic resistance patterns. Indications for primary and secondary prophylaxis vary across societies; most suggest PPIs for patients at highest risk of developing a peptic ulcer, its complications, or its recurrence. Additional research areas include the use of potassium-competitive acid blockers and H pylori vaccination; the optimal approach for patients at risk of stress ulcer bleeding requires more robust determinations of optimal patient selection and treatment selection, if any. Appropriate continuation of PPI use outweighs most possible side-effects if given for approved indications, while de-prescribing should be trialled when a definitive indication is no longer present.

Implementing pharmacogenetic testing to optimize proton-pump inhibitors use among Indian population based on CPIC-CYP2C19-PPI dosing guidelines: The need of the hour

ABSTRACT

Proton-pump inhibitors (PPIs) are widely prescribed to decrease stomach acid and treat various acid-related Gastrointestinal tract (GIT) diseases. However, genetic variations, particularly in the CYP2C19 gene, affect PPIs metabolism and efficacy. Variants in CYP2C19 can result in different rates of PPI metabolism, influencing their effectiveness. Personalized medicine strategies, such as genotyping for CYP2C19, have the potential to enhance the effectiveness of PPI therapy and patient safety. This review aims to describe the relevance of CYP2C19 genetic profiling in the indian population, including normal function (e.g. CYP2C19*1, *11, *13, *15, *18, *28, and 38), decreased function (e.g., CYP2C19*9, *10, *16, *19, *25, and 26), loss of function (e.g., CYP2C19*2, *3, *4, *5, *6, *7, *8, *22, *24, *35, *36, and *37), and increased function (e.g., CYP2C19*17) variants. This review also examines the clinical pharmacogenomics implementation consortium (CPIC)-CYP2C19-PPI guidelines to highlight the importance of pharmacogenomics (PGx)-informed personalized PPI therapy for gastroesophageal reflux disease and peptic ulcer disease treatment. On average, each person in India possesses eight pharmacogenetic (PGx) variants that can be clinically significant, underscoring the need for preemptive testing. Implementing CYP2C19 genetic testing in India requires expanding laboratory capacity, increasing accessibility in primary care, increasing public awareness, collaboration between pharmacovigilance and PGx programs, investing in advanced sequencing technologies, data management systems, and integration with electronic health records and clinical decision support systems. Addressing challenges such as genetic diversity, socioeconomic factors, health-care access issues, and shortage of trained professionals is essential for implementation. Due to the lack of definitive country-specific policies and PGx guidelines from Indian drug regulatory agencies, guidelines from international consortia such as the Clinical Pharmacogenetics Implementation Consortium and drug labeling offer crucial foundational evidence. This evidence can be used to enhance patient outcomes and ensure the safe and effective use of PPIs in India.

Cholinesterase inhibitors and non-steroidal anti-inflammatory drugs and the risk of peptic ulcers: A self-controlled study

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution in adults aged 65 years and older. Their gastrointestinal adverse event risk might be further reinforced when using concomitant cholinesterase inhibitors (ChEIs). We aimed to investigate the association between NSAIDs and ChEI use and the risk of peptic ulcers in adults aged 65 years and older.

METHODS

Register-based self-controlled case series study including adults ≥65 years with a new prescription of ChEIs and NSAIDs, diagnosed with incident peptic ulcer in Sweden, 2007-2020. We identified persons from the Total Population Register individually linked to several nationwide registers. We estimated the incidence rate ratio (IRR) of peptic ulcer with a conditional Poisson regression model for four mutually exclusive risk periods: use of ChEIs, NSAIDs, and the combination of ChEIs and NSAIDs, compared with the non-treatment in the same individual. Risk periods were identified based on the prescribed daily dose, extracted via a text-parsing algorithm, and a 30-day grace period.

RESULTS

Of 70,060 individuals initiating both ChEIs and NSAIDs, we identified 1500 persons with peptic ulcer (median age at peptic ulcer 80 years), of whom 58% were females. Compared with the non-treatment periods, the risk of peptic ulcer substantially increased for the combination of ChEIs and NSAIDs (IRR: 9.0, [6.8-11.8]), more than for NSAIDs alone (5.2, [4.4-6.0]). No increased risks were found for the use of ChEIs alone (1.0, [0.9-1.2]).

DISCUSSION

We found that the risk of peptic ulcer associated with the concomitant use of NSAIDs and ChEIs was over and beyond the risk associated with NSAIDs alone. Our results underscore the importance of carefully considering the risk of peptic ulcers when co-prescribing NSAIDs and ChEIs to adults aged 65 years and older.

Gastric acid-responsive deformable sodium alginate/Bletilla striata polysaccharide in situ gel for the protection and treatment of alcohol-induced peptic ulcers

First-line drugs for peptic ulcer (PU) treatment are typically limited by poor targeting and adverse effects associated with long-term use. Despite recent advancements in novel therapeutic approaches for PU, the development of sustained-release delivery systems tailored to specific pathological characteristics remains challenging. Persistent inflammation, particularly gastric inflammatory microenvironment imbalance, characterizes the PU. In this study, we prepared an in situ gel composed of sodium alginate, deacetylated gellan gum, calcium citrate, and Bletilla striata polysaccharide (BSP) to achieve sustained release of BSP. The BSP in situ gel demonstrated favorable fluidity in vitro and completed self-assembly in vivo in response to the acidic milieu at a pH of 1.5. Furthermore, the shear, extrusion, and deformation properties increased by 26.4 %, 103.7 %, and 46.3 %, respectively, with long-term gastric retention (4 h) and mucosal adaptation. Animal experiments confirmed that the BSP in situ gel could attenuate necrotic injury and inflammatory cell infiltration, maintain mucosal barrier integrity, regulate cytokine imbalance and inflammation-associated hyperapoptosis, thus effectively alleviate the inflammatory microenvironmental imbalance in PU without significant side effects. Overall, our findings demonstrated that the BSP in situ gel is a promising therapeutic strategy for PU and opens avenues for developing self-assembled formulations targeting the pathological features of PUs.

Depression during the COVID-19 pandemic among older Canadians with peptic ulcer disease: Analysis of the Canadian Longitudinal Study on Aging

The COVID-19 pandemic and associated public health measures have exacerbated many known risk factors for depression that may be particularly concerning for individuals with chronic health conditions, such as peptic ulcer disease (PUD). In a large longitudinal sample of older adults with PUD, the current study examined the incidence of depression during the pandemic among those without a pre-pandemic history of depression (n = 689) and the recurrence of depression among those with a history of depression (n = 451). Data came from four waves of the Canadian Longitudinal Study on Aging (CLSA). Multivariate logistic regression analyses were conducted to identify factors associated with incident and recurrent depression. Among older adults with PUD and without a history of depression, approximately 1 in 8 (13.0%) developed depression for the first time during the COVID-19 pandemic. Among those with a history of depression, approximately 1 in 2 (46.6%) experienced depression during the pandemic. The risk of incident depression and recurrent depression was higher among those who were lonely, those with functional limitations, and those who experienced an increase in family conflict during the pandemic. The risk of incident depression only was higher among women, individuals whose income did not satisfy their basic needs, those who were themselves ill and/or those whose loved ones were ill or died during the pandemic, and those who had disruptions to healthcare access during the pandemic. The risk of recurrent depression only was higher among those with chronic pain and those who had difficulty accessing medication during the pandemic. Implications for interventions are discussed.

Xiangshao Decoction alleviates gastric mucosal injury through NRF2 signaling pathway and reduces neuroinflammation in gastric ulcer rats

BACKGROUND

A type of gastric mucosal injury disease known as gastric ulcer (GU) is clearly connected to the aberrant release of gastric acid. Traditional botanicals have the potential for anti-inflammation, anti-oxidation, and other multitarget therapies, as well as being safe.

PURPOSE

The purpose of this study was to investigate the potential effects of Xiangshao Decoction (XST) on gastric mucosal injury in GU rats and to explore the possible molecular mechanisms.

METHODS

After identifying XST and its components, we established GU rats and cell models by acetic acid and H₂O₂ induction, respectively. SOD and MDA indexes in gastric tissues and GES-1 cells, and the serum levels of BDNF, ALT, and AST were detected with relevant kits, changes of the gastric mucosa were observed and recorded, and gastric tissue pathology was observed by H&E staining. The production of ROS in GES-1 cells was detected by fluorescent probes. Cell transfection techniques were used to silence or overexpress NRF2. The mRNA or protein expressions of NRF2, KEAP1, NQO1, HO-1, SOD2, IL-1β, IL-6, TNF-α, IBA1, GFAP, or γ-H2AX in the gastric tissue, hippocampus, or GES-1 cells were measured via qPCR, Western blot, immunofluorescence staining, or immunohistochemical staining.

RESULTS

The pH of gastric acid, ulcer score, and pathological damage score in GU rats could be reversed by XST administration. Expressions of IL-1β, IL-6, and TNF-α in the gastric mucosal tissues and the hippocampus of GU rats after administration of XST were down. Expressions of NRF2, NQO1, HO-1, SOD2, etc. in the gastric mucosal tissues and BDNF in the hippocampus were up-regulated. The production of ROS and MDA and the expressions of IL-1β, IL-6, TNF-α, and KEAP1 in H₂O₂-induced GES-1 cells were significantly reduced after XST intervention, while the activities of SOD and the expression of NRF2, NQO1, HO-1, and SOD2 were significantly increased, and these could be blocked by silencing NRF2 expression.

CONCLUSIONS

XST can improve oxidative stress injury and inflammatory response in GU rats and cell models, and its mechanism is mediated by the NRF2 signaling pathway.

The global epidemiology of upper and lower gastrointestinal bleeding in general population: A systematic review

BACKGROUND

Gastrointestinal bleeding (GIB) is a common and potentially life-threatening clinical event. To date, the literature on the long-term global epidemiology of GIB has not been systematically reviewed.

AIM

To systematically review the published literature on the worldwide epidemiology of upper and lower GIB.

METHODS

EMBASE^® and MEDLINE were queried from 01 January 1965 to September 17, 2019 to identify population-based studies reporting incidence, mortality, or case-fatality rates of upper GIB (UGIB) or lower GIB (LGIB) in the general adult population, worldwide. Relevant outcome data were extracted and summarized (including data on rebleeding following initial occurrence of GIB when available). All included studies were assessed for risk of bias based upon reporting guidelines.

RESULTS

Of 4203 retrieved database hits, 41 studies were included, comprising a total of around 4.1 million patients with GIB worldwide from 1980–2012. Thirty-three studies reported rates for UGIB, four for LGIB, and four presented data on both. Incidence rates ranged from 15.0 to 172.0/100000 person-years for UGIB, and from 20.5 to 87.0/100000 person-years for LGIB. Thirteen studies reported on temporal trends, generally showing an overall decline in UGIB incidence over time, although a slight increase between 2003 and 2005 followed by a decline was shown in 5/13 studies. GIB-related mortality data were available from six studies for UGIB, with rates ranging from 0.9 to 9.8/100000 person-years, and from three studies for LGIB, with rates ranging from 0.8 to 3.5/100000 person-years. Case-fatality rate ranged from 0.7% to 4.8% for UGIB and 0.5% to 8.0% for LGIB. Rates of rebleeding ranged from 7.3% to 32.5% for UGIB and from 6.7% to 13.5% for LGIB. Two main areas of potential bias were the differences in the operational GIB definition used and inadequate information on how missing data were handled.

CONCLUSION

Wide variation was seen in estimates of GIB epidemiology, likely due to high heterogeneity between studies however, UGIB showed a decreasing trend over the years. Epidemiological data were more widely available for UGIB than for LGIB.

Upper and Lower Gastrointestinal Bleeding: A Retrospective Study on 10 Years Experiences in Southeastern Iran

Background: Gastrointestinal bleeding (GIB) is an emergency medical situation that is very common, although often benign but can cause considerable morbidity and mortality and health care costs. The aim of this study was to analyze the endoscopic evaluation of upper GIB (UGIB) and lower GIB (LGIB) in Sistan and Balouchestan, southeast Iran. Methods: Data from patients with GIB in a referral university-affiliated hospital in Zahedan, Southeastern Iran during a 10-year period, were obtained. A total of 21884 reports of adult patients' endoscopy and colonoscopy from 2011 to 2020 who were admitted to Ali-Ibn-Abitaleb hospital were studied of which 5862 reports were related to GIB. Incomplete files were excluded. Information on age, sex, and endoscopic diagnosis of the 5053 reports was analyzed and compared using chi-square statistical test. Results: There were 3310 men (65.6%) and 1743 women (34.4%) with a mean (±SD) of age 48.4 (±19.83) years. 3079 patients had UGIB (60.8%) and 1974 patients had LGIB (39.2%). Peptic ulcer (72.8% duodenal ulcer and 27.2% gastric ulcer) was seen as the main reason for UGIB (29.7%) and hemorrhoids were the main reason for LGIB (44.2%). Mallory-Weiss syndrome was significantly common in the age<40 years old, and the incidence rate of malignancy was significantly higher in those aged>40 years old than in the younger age group (P<0.001). Conclusion: Peptic ulcer was the most common etiological factor and it was more common in men than in women. Gastroesophageal varices were the second most common cause of UGIB. Hemorrhoids and anal fissures were observed as the most common colonoscopic findings of LGIB. The prevalences of UGIB and LGIB are more common in men than women and increase with age. It is important for physicians to constantly update their information about the spectrum of diseases in their region and their changing over time to provide accurate diagnosis and management timely.

[Internal differential diagnoses in acute back pain : An internal perspective on the possible causes of acute back pain]

The majority of patients with acute back pain have no serious underlying disease; however, many internal diseases can be manifested as acute or chronic back pain. Therefore, in the assessment of patients with back pain the clinical history and clinical examination are important in order to detect indications for a possible underlying disease. Particularly red flags that indicate an acute or life-threatening disease should not be missed. In most cases where such red flags, risk factors or clinical indications are not present, no systematic search for internal underlying diseases is necessary. This article summarizes the most relevant differential diagnoses and clinical indications as well as warning symptoms.

A Comparative Analysis of Bleeding Peptic Ulcers in Hospitalizations With and Without End-Stage Renal Disease

Background

End-stage renal disease (ESRD) patients are highly susceptible to peptic ulcer bleeding (PUB). We aimed to assess the influence of ESRD status on PUB hospitalizations in the United States (USA).

Methods

We analyzed the National Inpatient Sample to identify all adult PUB hospitalizations in the USA from 2007 to 2014, which were divided into two subgroups based on the presence or absence of ESRD. Hospitalization characteristics and clinical outcomes were compared. Furthermore, predictors of inpatient mortality for PUB hospitalizations with ESRD were identified.

Results

Between 2007 and 2014, there were 351,965 PUB hospitalizations with ESRD compared to 2,037,037 non-ESRD PUB hospitalizations. PUB ESRD hospitalizations had a higher mean age (71.6 vs. 63.6 years, P < 0.001), and proportion of ethnic minorities i.e., Blacks, Hispanics, and Asians compared to the non-ESRD cohort. We also noted higher all-cause inpatient mortality (5.4% vs. 2.6%, P < 0.001), rates of esophagogastroduodenoscopy (EGD) (20.7% vs. 19.1%, P < 0.001), and mean length of stay (LOS) (8.2 vs. 6 days, P < 0.001) for PUB ESRD hospitalizations compared to the non-ESRD cohort. After multivariate logistic regression analysis, Whites with ESRD had higher odds of mortality from PUB compared to Blacks. Furthermore, the odds of inpatient mortality from PUB decreased by 0.6% for every 1-year increase in age for hospitalizations with ESRD. Compared to the 2011 - 2014 study period, the 2007 - 2010 period had 43.7% higher odds (odds ratio (OR): 0.696, 95% confidence interval (CI): 0.645 - 0.751) of inpatient mortality for PUB hospitalizations with ESRD.

Conclusions

PUB hospitalizations with ESRD had higher inpatient mortality, EGD utilization, and mean LOS compared to non-ESRD PUB hospitalizations.

Gut Health and Its Association with Wellbeing and Nutrient Intake in Community-Dwelling Older Adults

Many of the increasing number of community-dwelling older adults will need increased healthcare in the future. By characterising gut health and its association with wellbeing and nutrient intake in this population, we aim to recognise areas along the gut–brain axis through which the health of community-dwelling older adults might be promoted. In this cross-sectional observational study, validated questionnaires were used to assess gut health, nutrient intake, and wellbeing in 241 community-dwelling older adults (≥65 years old). In total, 65% of the participants experienced at least one gastrointestinal symptom, of which females had more abdominal pain and constipation, while the oldest old (i.e., ≥80 years old) had more diarrhoea. Increased gastrointestinal symptoms correlated with more stress, anxiety, depression, and a decreased quality of life, in addition to dyspepsia which correlated with a lower E% of protein. Most of the participants did not reach the recommended intake for protein, fibre and polyunsaturated fats. Males had a lower intake of protein (E%) and fibre (g/MJ) than females, and the oldest old had a lower E% of protein than younger older adults. In conclusion, our results demonstrate that gastrointestinal symptoms are common, and most of the study participants had an imbalanced macronutrient intake, which could be a target for future possible dietary interventions to improve overall health.

Helicobacter pylori infection treatment in the United States: clinical consequences and costs of eradication treatment failure

INTRODUCTION

Helicobacter pylori (Hp) is causal in benign and malignant gastrointestinal diseases. Accordingly, current guidelines recommend Hp eradication in patients with active infection. Unfortunately, treatment failure is common, exposing patients to complications associated with persistent Hp infection and consequences of repeated treatment, including promotion of antibiotic resistance. In the United States (US), data regarding eradication rates with available therapies are limited. Moreover, the clinical and economic burden of eradication treatment failure have not been thoroughly described.

AREAS COVERED

We aimed to characterize Hp eradication rates and the clinical consequences and associated costs of persistent Hp infection among US adults. We conducted focused literature reviews using initial searches in Embase, MEDLINE, and Cochrane Database of Systematic Reviews via Ovid followed by manual searches to identify relevant publications.

EXPERT OPINION

Hp eradication rates were suboptimal, with most studies reporting rates ≤80% with clarithromycin-based triple therapy and bismuth quadruple therapy. There was direct evidence supporting numerous benefits of successful Hp eradication, including decreased risk of recurrent or complicated peptic disease and non-cardia gastric cancer. Cost benefits of eradication were related to mitigation of conditions associated with persistent Hp infection, (e.g. complicated peptic ulcer disease, and gastric cancer) which altogether exceed US$5.3 billion.

Risk Factors of Mortality in Patients Hospitalized With Chronic Duodenal Ulcers

Background

We aimed to identify risk factors of mortality in patients hospitalized with duodenal ulcers (DUs).

Methods

A National Inpatient Sample–based retrospective cohort study from 2005 to 2014 was conducted on patients undergoing emergency admission for chronic DUs. Demographics, clinical data, and outcomes were collected. Multivariable logistic regression model was applied to find the risk factors of mortality.

Results

70 641 patients were included in this study, of which 30 525 (43%) were non-elderly (< 65 years) and 40 116 (57%) were elderly (65+ years) patients. 72% of non-elderly and 57% of elderly patients were males. Mortality rate of men vs women was similar in non-elderly group (1.9% vs 2%, respectively), whereas it significantly differed in elderly patients (4.5% vs 5.3%, respectively, P<.0001). Time to operation was 1.15 (1.83) days in survived vs 1.55 (3.86) days in deceased non-elderly patients ( P < .001). Time to operation was .85 (1.73) days in survived vs 1.79 (7.28) days in deceased elderly patients ( P < .001). In patients with operation, age, delayed operation, frailty, and presence of perforation were the main risk factors of mortality in both elderly and non-elderly patients. Invasive diagnostic procedure was shown as a protective factor in elderly patients. In the final model for patients with no operation, age, hospital length of stay, and frailty were the main risk factors of mortality in both elderly and non-elderly patients. Invasive diagnostic procedure was revealed as a protective factor in all patients as well.

Conclusion

Early operation in patients with DU requiring surgical intervention is essential to improve the outcomes.

Clinical manifestations of gastrointestinal diseases in the oral cavity

Aim

In this review, several gastrointestinal diseases that dentists may encounter in practice are highlighted and discussed.

Materials and methods

Using MEDLINE (PubMed), a comprehensive review of gastrointestinal diseases and their oral cavity manifestations was performed.

Results

Many gastrointestinal diseases present with oral symptoms that are detectable by dentists and dental hygienists. Often, oral manifestations of the disease may appear before systemic signs and symptoms. Managing patients with these conditions requires dentists to adjust their treatment and/or involve other health professionals.

Conclusion

Care must be taken when providing periodontal therapy or dental implants to patients suffering gastrointestinal diseases who are at high risk of bleeding, infection, or malnutrition, for example. Also, pharmacological therapy for these patients may need to be customized.

Chronic Abdominal Pain: Gastroenterologist Approach

BACKGROUND

Abdominal pain is a common symptom of gastroenterology examination. Chronic abdominal pain is present for >3 months.

SUMMARY

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal diseases encountered by both gastroenterologists and general practitioners. GERD is usually a chronic disease presented with a set of symptoms including heartburn and/or regurgitation, and less commonly epigastric pain. Epigastric pain syndrome is characterized by the following symptoms: epigastric pain and/or burning. It does not necessarily occur after meal ingestion, may occur during fasting, and can be even improved by meal ingestion. Duodenal ulcers tend to cause abdominal pain that is localized in the epigastric region and commence several hours after eating, often at night. Hunger provokes pain in most of the cases and decreases after meal. Gastric ulcer pain occurs immediately after eating, and consuming food increases pain. Pain is localized in the epigastrium and can radiate to the back. Abdominal pain in irritable bowel syndrome is related to defecation. A typical symptom of chronic pancreatitis is pain that radiates to the back. In Crohn's disease, inflammation causes pain. Key Messages: Pain can occur at different locations with diverse intensity and propagation and is often associated with other symptoms. For any gastroenterologist, abdominal pain is a big challenge.

Upper Gastrointestinal Bleeding

Upper gastrointestinal (GI) bleeding is a common reason for hospital admission in older adult patients and carries a high morbidity and mortality if not properly managed. Risk factors include advanced age, Helicobacter pylori infection, medication use, smoking, and history of liver disease. Patients with known or suspected liver disease and suspected variceal bleeding should also receive antibiotics and somatostatin analogues. Risk stratification scores should be used to determine patients at highest risk for further decompensation. Upper endoscopy is both a diagnostic and therapeutic tool used in the management of upper GI bleeding. Endoscopy should be performed within 24 hours of presentation after appropriate resuscitation. Management of anticoagulation in upper GI bleeding largely depends on the indication for anticoagulation, the risk of continued bleeding with continuing the medication, and the risk of thrombosis with discontinuing the medication. A multidisciplinary approach to the decision of anticoagulation continuation is preferred when possible.

Development and validation of the peptic ulcer scale under the system of quality of life instruments for chronic diseases based on classical test theory and generalizability theory

BACKGROUND

Quality of life (QOL) for patients with Peptic ulcer disease (PUD) is of interest worldwide and disease-specific instruments are needed for clinical research and practice. This paper focus on the development and validation of the PUD scale under the system of quality of life instruments for chronic diseases (QLICD-PU) by the modular approach and both classical test theory and Generalizability Theory.

METHODS

The QLICD-PU is developed based on programmatic decision-making procedures, including multiple nominal and focus group discussions, in-depth interviews, and quantitative statistical procedures. Based on the data of 153 PUD inpatients, correlation analysis, factor analysis, t-test, and Generalizability Theory analysis (including generalizability study and decision study, ie. G-study and D-study) were used to assess the validity, reliability, and responsiveness of the scale.

RESULTS

When the popular scale health survey short form (SF-36) was used as the standard, correlation and factor analysis confirmed good construct validity and criterion-related validity of QLICD-PU. Except for the social domain (0.62), the internal consistency α of all domains is higher than 0.70. The overall score and the test-retest reliability coefficients (Pearson r and intra-class correlation ICC) in all domains are higher than 0.80 (0.77 in the social domain). After treatments, the overall score and scores of all domains have statistically significant changes (P < 0.01), except for social impact and sexual function scores. The SRM (Standardized response mean) of domain-level scores ranges from 0.34 to 1.03. The G coefficient and reliability index (Ф coefficient) further confirm the reliability of the scale through more accurate variance components and decision-making information about changes in the number of items.

CONCLUSIONS

The QLICD-PU can be used as a useful measurement to assess the quality of life of PUD patients with good psychometric characteristics and multiple advantages.

Gastroprotective and Healing Effects of Polygonum cuspidatum Root on Experimentally Induced Gastric Ulcers in Rats

Polygonum cuspidatum is widely used as food and medicine in Korea, China, and Japan. Its major bioactive components, resveratrol and emodin, reportedly protect against gastric lesions. We therefore aimed to investigate: (1) the gastroprotective effects of P. cuspidatum roots in hydrochloric acid/ethanol (HCl/EtOH)- and indomethacin-induced acute gastric ulcer rat models; (2) the healing effects in an acetic acid-induced ulcer model; and (3) potential mechanisms by measuring gastric acid secretion-related parameters in a pyloric ligation-induced ulcer model, and by measuring antioxidant enzyme and prostaglandin E₂ levels in the gastric tissue of HCl/EtOH-treated rats. Oral administration of P. cuspidatum extract (PCE) at doses of 100 and 300 mg/kg significantly decreased HCl/EtOH- and indomethacin-induced gastric lesions. PCE at 300 mg/kg significantly reduced gastric lesions in acetic acid-induced ulcers. PCE increased superoxide dismutase (SOD)activity and glutathione(GSH) and prostaglandin E₂ levels in gastric tissue, whereas it did not alter gastric acid secretion-related parameters. Our findings indicate that PCE has gastroprotective effects against HCl/EtOH and non-steroidal anti-inflammatory drugs(NSAIDs) and promotes healing of acetic acid-induced ulcers. These gastric mucosal protection and ulcer healing effects are associated with antioxidant effects and the augmentation of prostaglandin E₂ and suggest that P. cuspidatum might be a promising preventive and therapeutic agent for treating gastric ulcers.

The global, regional, and national burden of gastro-oesophageal reflux disease in 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Gastro-oesophageal reflux disease is a common chronic ailment that causes uncomfortable symptoms and increases the risk of oesophageal adenocarcinoma. We aimed to report the burden of gastro-oesophageal reflux disease in 195 countries and territories between 1990 and 2017, using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017.

METHODS

We did a systematic review to identify measurements of the prevalence of gastro-oesophageal reflux disease in geographically defined populations worldwide between 1990 and 2017. These estimates were analysed with DisMod-MR, a Bayesian mixed-effects meta-regression tool that incorporates predictive covariates and adjustments for differences in study design in a geographical cascade of models. Fitted values for broader geographical units inform prior distributions for finer geographical units. Prevalence was estimated for 195 countries and territories. Reports of the frequency and severity of symptoms among individuals with gastro-oesophageal reflux disease were used to estimate the prevalence of cases with no, mild to moderate, or severe to very severe symptoms at a given time; these estimates were multiplied by disability weights to estimate years lived with disability (YLD).

FINDINGS

Data to estimate gastro-oesophageal reflux disease burden were scant, totalling 144 location-years (unique measurements from a year and location, regardless of whether a study reported them alongside measurements for other locations or years) of prevalence data. These came from six (86%) of seven GBD super-regions, 11 (52%) of 21 GBD regions, and 39 (20%) of 195 countries and territories. Mean estimates of age-standardised prevalence for all locations in 2017 ranged from 4408 cases per 100 000 population to 14 035 cases per 100 000 population. Age-standardised prevalence was highest (>11 000 cases per 100 000 population) in the USA, Italy, Greece, New Zealand, and several countries in Latin America and the Caribbean, north Africa and the Middle East, and eastern Europe; it was lowest (<7000 cases per 100 000 population) in the high-income Asia Pacific, east Asia, Iceland, France, Denmark, and Switzerland. Global prevalence peaked at ages 75-79 years, at 18 820 (95% uncertainty interval [95% UI] 13 770-24 000) cases per 100 000 population. Global age-standardised prevalence was stable between 1990 and 2017 (8791 [95% UI 7772-9834] cases per 100 000 population in 1990 and 8819 [7781-9863] cases per 100 000 population in 2017, percentage change 0·3% [-0·3 to 0·9]), but all-age prevalence increased by 18·1% (15·6-20·4) between 1990 and 2017, from 7859 (6905-8851) cases per 100  000 population in 1990 to 9283 (8189-10 400) cases per 100  000 population in 2017. YLDs increased by 67·1% (95% UI 63·5-70·3) between 1990 and 2017, from 3·60 million (1·93-6·12) in 1990 to 6·01 million (3·22-10·19) in 2017.

INTERPRETATION

Gastro-oesophageal reflux disease is common worldwide, although less so in much of eastern Asia. The stability of our global age-standardised prevalence estimates over time suggests that the epidemiology of the disease has not changed, but the estimates of all-age prevalence and YLDs, which increased between 1990 and 2017, suggest that the burden of gastro-oesophageal reflux disease is nonetheless increasing as a result of ageing and population growth.

FUNDING

Bill & Melinda Gates Foundation.

Pregnancy outcomes among women with peptic ulcer disease

Background Little is known about the impact of peptic ulcer disease (PUD) on pregnancy. Our objective was to evaluate the effect of PUD on pregnancy and newborn outcomes. Methods A retrospective cohort study was carried out using the Healthcare Cost and Utilization Project (HCUP)-National Inpatient Sample (NIS) from the United States. The cohort consisted of all births that took place from 1999 to 2015. PUD was classified on the basis of the International Classification of Diseases-Ninth Revision (ICD-9) coding. Multivariate logistic regression was used to evaluate the adjusted effect of PUD on maternal and neonatal outcomes. Results Of the 13,792,544 births in this cohort, 1005 were to women with PUD (7/100,000 births). Between 1999 and 2015, prevalence of PUD in pregnancy increased from 4/100,000 to 11/100,000, respectively. Women with PUD were more commonly older and more likely to have comorbid illnesses. Women with PUD were at greater risk of preeclampsia [odds ratio (OR) 2.11, 95% confidence interval (CI) 1.67-2.66], preterm premature rupture of membranes (PPROM; OR 2.16, 95% CI 1.30-3.59), cesarean delivery (OR 1.60, 95% CI 1.40-1.82), venous thromboembolism (OR 3.77, 95% CI 2.08-6.85) and maternal death (OR 24.50, 95% CI 10.12-59.32). Births to women with PUD were at increased risk of intrauterine growth restriction (IUGR; OR 1.54, 95% CI 1.11-2.14), preterm birth (OR 1.84, 95% CI 1.54-2.21), intrauterine fetal death (OR 2.18, 95% CI 1.35-3.52) and congenital anomalies (OR 2.69, 95% CI 1.59-4.56). Conclusion The prevalence of PUD in pregnancy has risen over the last several years. PUD in pregnancy should be considered a high-risk condition associated with important adverse maternal and neonatal outcomes.

Sarcopenia is Independently Associated with an Increased Risk of Peptic Ulcer Disease: A Nationwide Population-Based Study

Background and objective: Although obesity is associated with an increased risk of peptic ulcer disease (PUD), no study has evaluated the association of PUD with sarcopenia. The aim of this study was to evaluate the association of sarcopenia and obesity with PUD. Material and Methods: Data from the Korean National Health and Nutrition Examination Survey (KNHANES) IV and V for 2007–2012 were used. PUD history, dietary, alcohol consumption, smoking, physical activity patterns, and other socioeconomic factors were analyzed. Sarcopenia index (appendicular skeletal muscle mass (kg) ÷ body mass index (kg/m2)) and body fat mass were determined by dual-energy X-ray absorptiometry. Univariate and multivariate analyses were performed to evaluate the association of sarcopenia with the prevalence of PUD. Results: The 7092 patients were divided into the sarcopenic obesity (SO, n = 870), sarcopenic non-obesity (n = 2676), non-sarcopenic obesity (NSO, n = 2698), and non-sarcopenic non-obesity (NSNO, n = 848) groups. The prevalence of PUD in these groups was 70 (7.9%), 170 (7.4%), 169 (6.3%), and 47 (3.8%), respectively (p < 0.001). A crude analysis revealed that the prevalence of PUD was 2.2-fold higher in the SO group than in the NSNO group (odds ratio (OR), 2.2; 95% confidence interval (CI), 1.5–3.2), the significance of which remained after adjustment for age, sex, body mass index, and HOMA-IR (homeostatic model assessment insulin resistance) score (OR, 1.9; 95% CI, 1.3–2.7). Conclusion: In conclusion, in this nationally representative cohort, the combination of muscle and fat mass, as well as obesity, was associated with an increased risk of PUD.

Ilaprazole Compared With Rabeprazole in the Treatment of Duodenal Ulcer: A Randomized, Double-blind, Active-controlled, Multicenter Study

GOALS

The main goal of this study was to explore the dose-effect relationship of ilaprazole.

BACKGROUND

Ilaprazole is a kind of benzimidazole proton-pump inhibitor, which was confirmed efficacious and safe in treatment of duodenal ulcer (DU). However, the dose-effect relationship of ilaprazole was not clear.

STUDY

This was a double-blind, parallel, randomized study. Patients aged above 18 years with at least one endoscopically confirmed active nonmalignant DU were treated with rabeprazole 10 mg or ilaprazole 10 mg/5 mg for 4 weeks. Healing of ulcer was determined by its resolution from active to scarring stage. Symptoms relief was evaluated using a graded score. Safety and tolerability were evaluated on basis of clinical assessments.

RESULTS

A total of 390 patients completed the study finally. Ulcers were successfully healed in 75.38%, 77.86%, and 83.72% of patients after 4-week treatment with rabeprazole 10 mg, ilaprazole 5 mg, and ilaprazole 10 mg, respectively. The 4-week healing rate difference between rabeprazole 10 mg and ilaprazole 5 mg was 2.48% (95% confidence interval: -7.79% to 12.74%) leading to accept the noninferiority hypothesis. Logistic regression model suggested that ilaprazole 10 mg was superior to ilaprazole 5 mg at week 2 (odds ratio, 1.92; 95% confidence interval: 1.02, 3.59; P=0.04). Most patients (80%) became asymptomatic after treatment. At the dosages administered, the 3 drug groups exhibited similar efficacy and a similar safety profile.

CONCLUSIONS

Ilaprazole 5 mg is not inferior to rabeprazole 10 mg in treating DU, and a dose-effect relationship have been revealed between 5 mg and 10 mg of ilaprazole.

Efficacy and safety of Hou Gu Mi Xi for peptic ulcer diseases: Study protocol for a randomized controlled trial

BACKGROUND

Peptic ulcer disease (PUD) is a major burden worldwide. Several challenges remain with standard Western treatment of PUD, such as persistent weakness, fatigue, and relapse. A dietary traditional Chinese medicine (TCM) formula, Hou Gu Mi Xi (HGMX), has been developed as a complementary treatment for PUD.

AIMS

This multicenter, double-blind, randomized controlled trial will assess efficacy and safety of HGMX in patients with PUD.

METHODS

Three hundred sixty eligible patients will be assigned to receive HGMX, placebo, HGMX + rabeprazole or placebo + rabeprazole for 4 weeks after 2 weeks of standard Western treatment. This first step, with a 2 × 2 factorial design, will focus on assessing the main and interaction effects of HGMX and rabeprazole on ulcer healing. Then, rabeprazole will be stopped, and HGMX will be continued for up to 1 year. The second step, with a placebo-controlled design, will compare the long-term effects of HGMX and placebo. Extended follow-up with no treatment will continue for up to 2 years. Independent and paired t tests, Pearson χ test and the rank-sum test will be used to compare between-group differences. The P value will be adjusted using the O'Brien & Fleming method for multiple comparisons.

EXPECTED OUTCOMES

The primary outcomes are total efficacy rate of PUD treatment, quality of ulcer healing, and changes in spleen qi deficiency symptoms. The secondary outcomes include ulcer area, PUD recurrence, Helicobacter pylori eradication rate, gastric function, body weight, and body mass index. Adverse events (AEs), severe AEs, treatment-related AEs, and withdrawal owing to AEs will be recorded to assess treatment safety.

DISCUSSION

The trial results will provide high-quality evidence for HGMX, as a complementary therapy, for the long-term management of PUD and will be valuable for the development of related guidelines and regulations.

TRIAL REGISTRATION

The protocol of this trial was approved in all research hospitals and was registered in ClinicalTrials.gov at October 25, 2017(No. NCT03320538).

Evaluation of upper gastrointestinal system in acromegaly

PURPOSE

Acromegaly causes multiple comorbidities, including gastrointestinal disorders. The present study evaluated the frequency of hiatal hernia and other upper gastrointestinal pathologies in patients with acromegaly, given that visceromegaly and reduced nitric oxide levels in acromegaly may impact diaphragm and lower esophageal sphincter function and thus possibly the development of hiatal hernia.

METHODS

Thirty-nine acromegaly patients followed our center for the previous 6months were recruited. Upper gastrointestinal endoscopy was performed once in all patients to evaluate hiatal hernia, esophagitis, gastroduodenitis and ulcer.

RESULTS

Twenty-three patients were male and 16 female. Upper gastrointestinal endoscopy found hiatal hernia, esophagitis and gastroduodenitis or gastric ulcer in 3 (7.6%), 2 (1.7%) and 31 (79.4%) patients, respectively. Pathologic examination of gastric antrum biopsy found intestinal metaplasia in 12 (30.7%) patients, and Helicobacter pylori was positive in 13 (33.3%). There were no significant correlations between age, gender, disease duration or preoperative adenoma size on the one hand and hiatal hernia or other endoscopic findings on the other. Similarly, neither surgical success nor recurrence was associated with endoscopic findings.

CONCLUSIONS

The study showed that prevalence of gastritis, duodenitis, peptic ulcer and intestinal metaplasia is higher and prevalence of hiatal hernia lower in acromegaly patients than in the healthy population. Various unknown disease-related pathophysiological conditions may play a role; there is a need for further studies.

Is tramadol associated to bleeding peptic ulcer? A nationwide case-control study in hospitalized Swedish patients

AIMS

Tramadol, a widely used analgesic drug, inhibits the reuptake of noradrenaline and serotonin impairing the aggregation function of thrombocytes. However, the risk for severe bleeding has previously not been studied. The aim of the present study is to investigate the association between tramadol and bleeding peptic ulcer in the Swedish population.

METHODS

In this register based case-control study based on the Swedish national patient registry and prescription drug registry, we included 18 306 patients hospitalized with a first-time diagnosis of bleeding peptic ulcer. For every case, 4 matched controls were included. To investigate the temporal aspects of tramadol induced bleeding ulcer, exposure was divided into patients with newly initiated and ongoing treatment. To explore a possible confounding by indication, the effect of codeine, a drug also prescribed for the treatment of moderate pain, but not known to affect thrombocyte function, was investigated. Univariable and multivariable logistic regression was used to analyse the association between tramadol use and bleeding ulcer.

RESULTS

Tramadol was associated with an increased risk of bleeding ulcer (adjusted odds ratio (aOR) 2.1, 95% confidence interval: (2.0-2.3). The association was stronger for newly initiated treatment with tramadol 2.8 (2.5-3.2) and weaker for ongoing treatment 1.7 (1.6-1.9). Codeine was also associated with an increased risk of bleeding ulcer 1.9 (1.7-2.1) and this association was also stronger for newly initiated treatment with codeine 2.3 (2.0-2.6) and weaker for ongoing treatment 1.7 (1.5-1.9).

CONCLUSION

Treatment with tramadol was associated with an increased risk of bleeding peptic ulcer. Most of this association may be mediated by factors related to the pain condition rather than the pharmacologic effect per se.

Increased risk of peptic ulcer in patients with early-onset cataracts: A nationwide population-based study

Early-onset cataracts (EOC) are associated with an increased inflammatory response; therefore, a potential risk of other inflammatory diseases, like peptic ulcer, may be related. This study investigated the risk of peptic ulcer after being diagnosed with EOC. Retrospective claims data from the Taiwan National Health Insurance Research Database were analyzed. Study subjects comprised patients with EOC (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9- CM] codes 366.00, 366.01, 366.02, 366.03, 366.04, 366.09, 366.17 and 366.18), aged 20–55 years and newly diagnosed between 2000 and 2010 (n = 1910), and a comparison cohort without the disease (n = 7515). Both cohorts were followed up until 2010 to estimate the incidences of peptic ulcer. We used the Poisson regression model to compare incidence rate ratios and the 95% confidence interval (CI). Cox proportional hazards regression was used to assess the hazard ratio (HR) of peptic ulcer associated with EOC. The overall incidence rate of peptic ulcer was higher in the EOC cohort than in the comparison cohort (10.3 vs 7.68 per 1000 person-years) with an adjusted HR of 1.33 (95% CI = 1.05, 1.69). The present study suggests that patients with EOC are at an increased risk of being diagnosed with peptic ulcer in subsequent years.

ANTI-ULCEROGENIC EFFICACY AND MECHANISMS OF EDIBLE AND NATURAL INGREDIENTS IN NSAID-INDUCED ANIMAL MODELS

Background:

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a class of the most commonly used medicines and proven to be effective for certain disorders. Some people use NSAIDs on daily basis for preventive purpose. But a variety of severe side effects can be induced by NSAIDs. Studies have shown that edible natural ingredients exhibit preventive benefit of gastric ulcer. This paper reviews the efficacy and safety of edible natural ingredients in preventing the development of gastric ulcer induced by NSAIDs in animal models.

Methods:

A systematic literature search was conducted on PubMed, using the terms “herbal medicines” and “gastric ulcer”, “herbal medicines” and “peptic ulcer”, “food” and “peptic ulcer”, “food” and “gastric ulcer”, “natural ingredient” and “peptic ulcer”, “natural ingredient” and “gastric ulcer”, “alternative medicine” and “peptic ulcer”, “alternative medicine” and “gastric ulcer”, “complementary medicine” and “peptic ulcer”, “complementary medicine” and “gastric ulcer” in papers published in English between January 1, 1960 and January 31, 2016, resulting in a total of 6146 articles containing these terms. After exclusion of studies not related prevention, not in NSAID model or using non-edible natural ingredients, 54 articles were included in this review.

Results:

Numerous studies have demonstrated that edible natural ingredients exhibit antiulcerogenic benefit in NSAID-induced animal models. The mechanisms by which edible, ingredient-induced anti-ulcerogenic effects include stimulation of mucous cell proliferation, antioxidation, inhibition of gastric acid secretion, as well as inhibition of H (+), K (+)- ATPase activities. Utilization of edible, natural ingredients could be a safe, valuable alternative to prevent the development of NSAID-induced gastric ulcer, particularly for the subjects who are long-term users of NSAIDs.

Upper Gastrointestinal Toxicity Associated With Long-Term Aspirin Therapy: Consequences and Prevention

Antiplatelet therapy represents a fundamental part of preventive management for patients who are at risk of a secondary cardiovascular disease (CVD) event. In most cases, the antiplatelet regimen is based on low-dose aspirin, a drug that is highly effective in reducing the incidence of CVD events, but is associated with a substantial risk of gastrointestinal (GI) toxicity. The dyspeptic symptoms, which can result from aspirin administration, and which may occur with or without associated ulceration and bleeding, may lead patients to discontinue therapy, thus increasing their CVD risk. For patients in whom aspirin is indicated and who are deemed to be at increased risk of upper GI events, concomitant therapy with a proton pump inhibitor (PPI) is currently recommended. These agents are highly effective in reducing the upper GI lesions associated with aspirin therapy and have been associated with increased aspirin adherence. However, widespread under-prescribing of PPIs and potential noncompliance with their use means that substantial numbers of patients are at unnecessary risk of upper GI toxicity and-if aspirin therapy is discontinued-CVD events. Provision of aspirin and an immediate-release PPI as a coordinated-delivery combination tablet has been shown to both reduce the risk of gastric ulcer formation and improve patient compliance. This strategy, which may ultimately reduce the incidence of CVD outcomes because of the associated reduction in GI symptoms and the potential for greater patient adherence to aspirin, warrants further investigation under both randomized controlled conditions (explanatory trials), and in real-life settings (pragmatic trials).

Chronic obstructive pulmonary disease is associated with increased recurrent peptic ulcer bleeding risk

BACKGROUND

The association between chronic obstructive pulmonary disease (COPD) and the risk of recurrent peptic ulcer bleeding (PUB) remains unclear. In this study, we compared the risk of recurrent PUB between patients with and those without COPD.

METHODS

Using the Taiwan National Health Insurance Research Database, we first selected patients newly diagnosed with PUB in 2002-2009. Two groups comprising 13,732 COPD cases and 13,732 non-COPD matched controls were created using propensity score matching, thereby making the differences in basic demographics, medication use, and disease conditions between the two groups negligible. Cox proportional hazard regression was used to evaluate the risk of recurrent PUB during the follow-up period.

RESULTS

The cumulative recurrence rate of PUB was significantly higher in the patients with COPD than in the non-COPD matched controls (2years: 10.8% vs 9.3%; 6years: 18.3% vs 15.7%, P all <0.05), with an adjusted hazard ratio (HR) of 1.17 (95% confidence interval [CI], 1.08-1.26, P<0.001) and 1.19 (95% CI, 1.12-1.26, P<0.001) within 2-year and 6-year follow-ups, respectively. Patients with COPD using steroids were at a marginally higher risk of recurrent PUB than those who did not use steroids. Multivariate stratified analysis revealed similar results in many subgroups.

CONCLUSIONS

The risk of recurrent PUB is higher in patients with COPD than in patients without COPD.

Association between ulcer site and outcome in complicated peptic ulcer disease: a Danish nationwide cohort study

OBJECTIVE

Mortality rates in complicated peptic ulcer disease are high. This study aimed to examine the prognostic importance of ulcer site in patients with peptic ulcer bleeding (PUB) and perforated peptic ulcer (PPU).

DESIGN

a nationwide cohort study with prospective and consecutive data collection.

POPULATION

all patients treated for PUB and PPU at Danish hospitals between 2003 and 2014.

DATA

demographic and clinical data reported to the Danish Clinical Registry of Emergency Surgery.

OUTCOME MEASURES

90- and 30-d mortality and re-intervention.

STATISTICS

the crude and adjusted association between ulcer site (gastric and duodenal) and the outcome measures of interest were assessed by binary logistic regression analysis.

RESULTS

Some 20,059 patients with PUB and 4273 patients with PPU were included; 90-d mortality was 15.3% for PUB and 29.8% for PPU; 30-d mortality was 10.2% and 24.7%, respectively. Duodenal bleeding ulcer, as compared to gastric ulcer (GU), was associated with a significantly increased risk of all-cause mortality within 90 and 30 d, and with re-intervention: adjusted odds ratio (OR) 1.47 (95% confidence interval 1.30-1.67); p < 0.001, OR 1.60 (1.43-1.77); p < 0.001, and OR 1.86 (1.68-2.06); p < 0.001, respectively. There was no difference in outcomes between gastric and duodenal ulcers (DUs) in PPU patients: adjusted OR 0.99 (0.84-1.16); p = 0.698, OR 0.93 (0.78 to 1.10); p = 0.409, and OR 0.97 (0.80-1.19); p = 0.799, respectively.

CONCLUSIONS

DU site is a significant predictor of death and re-intervention in patients with PUB, as compared to GU site. This does not seem to be the case for patients with PPU.

Editorial: Intravenous Proton Pump Inhibitors for Bleeding Peptic Ulcer: What is the Most Cost-Effective Approach?

During their lifetime, about 10% of the population will develop a peptic ulcer. Despite major advancements in the approach to peptic ulcer bleeding over the last 10-20 years including newer endoscopic hemostatic techniques and the advent of proton pump inhibitors (PPIs), upper gastrointestinal bleeding due to peptic ulcers results in substantial morbidity, mortality, and cost. Both oral and intravenous PPIs have proven to be effective in preventing recurrent bleeding from peptic ulcers. However, the dosing and administration of PPIs have been a source of ongoing debate, specifically in relation to cost. In this issue of the Journal, Lu et al. perform cost analysis demonstrating that costs from bleeding peptic ulcers are influenced more by efficient triage and discharge of patients than the nuances of variations in administration of intravenous PPI's.

Eradication therapy for peptic ulcer disease in Helicobacter pylori-positive people

BACKGROUND

Peptic ulcer disease is the cause of dyspepsia in about 10% of people. Ninety-five percent of duodenal and 70% of gastric ulcers are associated with Helicobacter pylori. Eradication of H. pylori reduces the relapse rate of ulcers but the magnitude of this effect is uncertain. This is an update of Ford AC, Delaney B, Forman D, Moayyedi P. Eradication therapy for peptic ulcer disease in Helicobacter pylori-positive patients. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD003840. DOI: 10.1002/14651858.CD003840.pub4.

OBJECTIVES

To assess the proportion of peptic ulcers healed and the proportion of participants who remained free from relapse with eradication therapy against placebo or other pharmacological therapies in H. pylori-positive people.To assess the proportion of participants that achieved complete relief of symptoms and improvement in quality of life scores.To compare the incidence of adverse effects/drop-outs (total number for each drug) associated with the different treatments.To assess the proportion of participants in whom successful eradication was achieved.

SEARCH METHODS

In this update, we identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (1950 to March 2016) and Ovid EMBASE (1980 to March 2016). To identify further relevant trials, we handsearched reference lists from trials selected by electronic searching, and published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut) and Digestive Disease Week (published in Gastroenterology). The search was last updated in March 2016. We contacted members of Cochrane Upper GI and Pancreatic Diseases, and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials.

SELECTION CRITERIA

We analysed randomised controlled trials of short- and long-term treatment of peptic ulcer disease in H. pylori-positive adults. Participants received at least one week of H. pylori eradication compared with ulcer healing drug, placebo or no treatment. Trials were included if they reported assessment from two weeks onwards.

DATA COLLECTION AND ANALYSIS

We collected data on ulcer healing, recurrence, relief of symptoms and adverse effects. We calculated the risk ratio (RR) with 95% confidence intervals (CI) using both fixed-effect and random-effects models with Review Manager software (RevMan 5.3) based on intention-to-treat analysis as far as possible.

MAIN RESULTS

A total of 55 trials were included for one or more outcomes for this review.In duodenal ulcer healing, eradication therapy was superior to ulcer healing drug (UHD) (34 trials, 3910 participants, RR of ulcer persisting = 0.66, 95% confidence interval (CI) 0.58 to 0.76; 381/2286 (adjusted proportion: 12.4%) in eradication therapy plus UHD versus 304/1624 (18.7%) in UHD; low quality evidence) and no treatment (two trials, 207 participants, RR 0.37, 95% CI 0.26 to 0.53; 30/125 (adjusted proportion: 21.7%) in eradication therapy versus 48/82 (58.5%) in no treatment; low quality evidence).In gastric ulcer healing, the differences were imprecise between eradication therapy and UHD (15 trials, 1974 participants, RR 1.23, 95% CI 0.90 to 1.68; 220/1192 (adjusted proportion: 16.0%) in eradication therapy plus UHD versus 102/782 (13.0%) in UHD; very low quality evidence). In preventing duodenal ulcer recurrence the differences were imprecise between maintenance therapy with H.pylori eradication therapy and maintenance therapy with UHD (four trials, 319 participants, RR of ulcer recurring 0.73; 95% CI 0.42 to 1.25; 19/159 (adjusted proportion: 11.9%) in eradication therapy versus 26/160 (16.3%) in UHD; very low quality evidence), but eradication therapy was superior to no treatment (27 trials 2509 participants, RR 0.20, 95% CI 0.15 to 0.26; 215/1501 (adjusted proportion: 12.9%) in eradication therapy versus 649/1008 (64.4%) in no treatment; very low quality evidence).In preventing gastric ulcer recurrence, eradication therapy was superior to no treatment (12 trials, 1476 participants, RR 0.31, 95% CI 0.22 to 0.45; 116/697 (adjusted proportion: 16.3%) in eradication therapy versus 356/679 (52.4%) in no treatment; very low quality evidence). None of the trials reported proportion of people with gastric ulcer not healed after initial therapy between H.pylori eradication therapy and no active treatment or the proportion of people with recurrent gastric ulcer or peptic ulcers during maintenance therapy between H.pylori eradication therapy and ulcer healing drug therapy.

AUTHORS' CONCLUSIONS

Adding a one to two-week course of H. pylori eradication therapy is an effective treatment for people with H. pylori-positive duodenal ulcer when compared to ulcer healing drugs alone and no treatment. H. pylori eradication therapy is also effective in preventing recurrence of duodenal and gastric ulcer compared to no treatment. There is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer healing drug. However, confidence intervals were wide and significant benefits or harms of H. pylori eradication therapy in acute ulcer healing of gastric ulcers compared to no treatment, and in preventing recurrence of duodenal ulcers compared to ulcer healing drugs cannot be ruled out.

Clinical effects of triple therapy with omeprazole, clarithromycin and amoxicillin in children with Helicobacter pylori infection

AIM: To evaluate the efficacy of triple therapy with omeprazole, clarithromycin and amoxicillin for eradication of Helicobacter pylori (H. pylori) in children.

METHODS: One hundred and twenty-six children with H. pylori infection treated from November 2012 to November 2015 at our hospital were randomly divided into two groups: a control group and an observation group, with 63 cases in each group. The control group underwent triple therapy with lansoprazole, clarithromycin and amoxicillin, and the observation group underwent triple therapy with omeprazole, clarithromycin and amoxicillin. Clinical effects were compared between the two groups.

RESULTS: After treatment, scores of somatic symptoms (somatization, interpersonal sensitivity, obsession-compulsion, anxiety, depression, paranoia, terror, hostility, psychoticism) were significantly reduced in both groups (P < 0.05). Scores of somatic symptoms, mucosal inflammation rate, and incidence of adverse reactions were significantly lower in the observation group than in the control group (P < 0.05). Times to disappearance of abdominal pain, acid reflux, and burning sensation were significantly shorter in the observation group than in the control group (P < 0.05). The total response rate, H. pylori eradication rate, and ulcer healing rate were significantly higher in the observation group than in the control group (P < 0.05).

CONCLUSION: Triple therapy with omeprazole, clarithromycin and amoxicillin for eradication of H. pylori in children is effective and can significantly improve symptoms and cure rates.

Medical versus surgical treatment for refractory or recurrent peptic ulcer

BACKGROUND

Refractory peptic ulcers are ulcers in the stomach or duodenum that do not heal after eight to 12 weeks of medical treatment or those that are associated with complications despite medical treatment. Recurrent peptic ulcers are peptic ulcers that recur after healing of the ulcer. Given the number of deaths due to peptic ulcer-related complications and the long-term complications of medical treatment (increased incidence of fracture), it is unclear whether medical or surgical intervention is the better treatment option in people with recurrent or refractory peptic ulcers.

OBJECTIVES

To assess the benefits and harms of medical versus surgical treatment for people with recurrent or refractory peptic ulcer.

SEARCH METHODS

We searched the specialised register of the Cochrane Upper GI and Pancreatic Diseases group, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and trials registers until September 2015 to identify randomised trials and non-randomised studies, using search strategies. We also searched the references of included studies to identify further studies.

SELECTION CRITERIA

We considered randomised controlled trials and non-randomised studies comparing medical treatment with surgical treatment in people with refractory or recurrent peptic ulcer, irrespective of language, blinding, or publication status for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and extracted data. We planned to calculate the risk ratio, mean difference, standardised mean difference, or hazard ratio with 95% confidence intervals using both fixed-effect and random-effects models with Review Manager 5 based on intention-to-treat analysis.

MAIN RESULTS

We included only one non-randomised study published 30 years ago in the review. This study included 77 participants who had gastric ulcer and in whom medical therapy (histamine H2 receptor blockers, antacids, and diet) had failed after an average duration of treatment of 29 months. The authors do not state whether these were recurrent or refractory ulcers. It appears that the participants did not have previous complications such as bleeding or perforation. Of the 77 included participants, 37 participants continued to have medical therapy while 40 participants received surgical therapy (antrectomy with or without vagotomy; subtotal gastrectomy with or without vagotomy; vagotomy; pyloroplasty and suture of the ulcer; suture or closure of ulcer without vagotomy or excision of the ulcer; proximal gastric or parietal cell vagotomy alone; suture or closure of the ulcer with proximal gastric or parietal cell vagotomy). Whether to use medical or surgical treatment was determined by participant's or treating physician's preference.The study authors reported that two participants in the medical treatment group (2 out of 37; 5.4%) had gastric cancer, which was identified by repeated biopsy. They did not report the proportion of participants who had gastric cancer in the surgical treatment group. They also did not report the implications of the delayed diagnosis of gastric cancer in the medical treatment group. They did not report any other outcomes of interest for this review (that is health-related quality of life (using any validated scale), adverse events and serious adverse events, peptic ulcer bleeding, peptic ulcer perforation, abdominal pain, and long-term mortality).

AUTHORS' CONCLUSIONS

We found no studies that provide the relative benefits and harms of medical versus surgical treatment for recurrent or refractory peptic ulcers. Studies that evaluate the natural history of recurrent and refractory peptic ulcers are urgently required to determine whether randomised controlled trials comparing medical versus surgical management in patients with recurrent or refractory peptic ulcers or both are necessary. Such studies will also provide information for the design of such randomised controlled trials. A minimum follow-up of two to three years will allow the calculation of the incidence of complications and gastric cancer (in gastric ulcers only) in recurrent and refractory peptic ulcers. In addition to complications related to treatment and disease, health-related quality of life and loss of productivity should also be measured.

Upper gastrointestinal bleeding due to peptic ulcer disease is not associated with air pollution: a case-crossover study

Background

Recent studies have demonstrated an association between short-term elevations in air pollution and an increased risk of exacerbating gastrointestinal disease. The objective of the study was to evaluate if day-to-day increases in air pollution concentrations were positively associated with upper gastrointestinal bleeding (UGIB) secondary to peptic ulcer disease (PUD).

Methods

A time-stratified case-crossover study design was used. Adults presenting to hospitals with their first UGIB secondary to PUD from 2004–2010 were identified using administrative databases from Calgary (n = 1374; discovery cohort) and Edmonton (n = 1159; replication cohort). Daily concentrations of ozone, nitrogen dioxide, sulfur dioxide, carbon monoxide, and particulate matter (PM₁₀ and PM_2.5) were estimated in these two cities. Conditional logistic regression models were employed, adjusting for temperature and humidity. Odds ratios (OR) with 95 % confidence intervals (CI) were expressed relative to an interquartile range increase in the concentration of each pollutant.

Results

No statistically significant associations were observed for any of the individual pollutants based on same-day, or 1-day lag effects within the Calgary discovery cohort. When the air pollution exposures were assessed as 3-, 5-, and 7-day averages, some pollutants were inversely associated with UGIB in the discovery cohort; for example, 5-day averages of nitrogen dioxide (OR = 0.68; 95 % CI: 0.53–0.88), and particulate matter <2.5 μm (OR = 0.75; 95 % CI: 0.61–0.90). However, these findings could not be reproduced in the replication cohort.

Conclusion

Our findings suggest that short-term elevations in the level of ambient air pollutants does not increase the incidence of UGIB secondary to PUD.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-015-0363-6) contains supplementary material, which is available to authorized users.

Gastrointestinal causes of abdominal pain

Gastrointestinal causes of abdominal pain are numerous. These causes are reviewed in brief here, divided into 2 categories: acute abdominal pain and chronic abdominal pain. They are further subcategorized by location of pain as it pertains to the abdomen.

Risk of uncomplicated peptic ulcer disease in a cohort of new users of low-dose acetylsalicylic acid for secondary prevention of cardiovascular events

BACKGROUND

The aim of this study was to analyse the risk of uncomplicated peptic ulcer disease (PUD) in a cohort of new users of low-dose acetylsalicylic acid (ASA) for secondary prevention of cardiovascular events in a UK primary care setting.

METHODS

New users of low-dose ASA for secondary prevention of cardiovascular events, aged 50-84 years in 2000-2007, were identified from The Health Improvement Network. Among those 38,975 individuals, 309 patients were considered to be incident cases of uncomplicated PUD. Incidence of uncomplicated PUD was calculated and a nested case-control analysis adjusted for potential confounding factors was performed to calculate the odds ratios (ORs) for the association of potential risk factors with uncomplicated PUD.

RESULTS

The crude incidence of uncomplicated PUD was 1.41 per 1000 person-years (95% confidence interval [CI], 1.26-1.58). Individuals with a history of PUD were more likely to develop uncomplicated PUD than those without such a history (hazard ratio [HR], 2.22, 95% CI, 1.60-3.09). In nested case-control analyses, the risk of uncomplicated PUD was associated with current use of non-steroidal anti-inflammatory drugs, oral steroids or acid suppressants. Other risk factors for developing uncomplicated PUD included smoking, stress, depression, anaemia and social deprivation.

CONCLUSION

Our results indicate that several risk factors significantly increase the risk of development of uncomplicated PUD in new users of low-dose ASA. Therefore, physicians should monitor ASA users for gastrointestinal symptoms and signs of ulcer, particularly if they have additional risk factors.

Using stool antigen to screen for Helicobacter pylori in immigrants and refugees from high prevalence countries is relatively cost effective in reducing the burden of gastric cancer and peptic ulceration

OBJECTIVES

Refugees and immigrants from developing countries settling in industrialised countries have a high prevalence of Helicobacter pylori (H. pylori). Screening these groups for H. pylori and use of eradication therapy to reduce the future burden of gastric cancer and peptic ulcer disease is not currently recommended in most countries. We investigated whether a screening and eradication approach would be cost effective in high prevalence populations.

METHODS

Nine different screening and follow-up strategies for asymptomatic immigrants from high H. pylori prevalence areas were compared with the current approach of no screening. Cost effectiveness comparisons assumed population prevalence's of H. pylori of 25%, 50% or 75%. The main outcome measure was the net cost for each cancer prevented for each strategy. Total costs of each strategy and net costs including savings from reductions in ulcers and gastric cancer were also calculated.

RESULTS

Stool antigen testing with repeat testing after treatment was the most cost effective approach relative to others, for each prevalence value. The net cost per cancer prevented with this strategy was US$111,800 (assuming 75% prevalence), $132,300 (50%) and $193,900 (25%). A test and treat strategy using stool antigen remained relatively cost effective, even when the prevalence was 25%.

CONCLUSIONS

H. pylori screening and eradication can be an effective strategy for reducing rates of gastric cancer and peptic ulcers in high prevalence populations and our data suggest that use of stool antigen testing is the most cost effective approach.

Risk factors associated with uncomplicated peptic ulcer and changes in medication use after diagnosis

Background

Few epidemiologic studies have investigated predictors of uncomplicated peptic ulcer disease (PUD) separately from predictors of complicated PUD.

Objective

To analyze risk factors associated with uncomplicated PUD and medication use after diagnosis.

Methods

Patients diagnosed with uncomplicated PUD (n = 3,914) were identified from The Health Improvement Network database among individuals aged 40–84 years during 1997–2005, with no previous history of PUD. Prescription records for the year after the date of diagnosis were reviewed and a nested case–control analysis was performed to calculate the odds ratios for the association of potential risk factors with PUD.

Results

Medications associated with developing uncomplicated PUD included current use of acetylsalicylic acid (ASA), nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol, selective serotonin reuptake inhibitors, antidepressants, antihypertensives or acid suppressants. Uncomplicated PUD was significantly associated with being a current or former smoker and having had a score of at least 3 on the Townsend deprivation index. Approximately 50% of patients who were users of ASA (19% of patients) or chronic users of NSAIDs (7% of patients) at diagnosis did not receive another prescription of the medication in the 60 days after diagnosis, and 30% were not represcribed therapy within a year. Among patients who were current users of ASA or chronic NSAIDs at the time of the PUD diagnosis and received a subsequent prescription for their ASA or NSAID during the following year, the vast majority (80–90%) also received a proton pump inhibitor coprescription.

Conclusions

Our results indicate that several risk factors for upper gastrointestinal bleeding are also predictors of uncomplicated PUD, and that some patients do not restart therapy with ASA or NSAIDs after a diagnosis of uncomplicated PUD. Further investigation is needed regarding the consequences for these patients in terms of increased cardiovascular burden due to discontinuation of antiplatelet therapy.