Drug consumption before perforation of peptic ulcer

Decreasing incidence of peptic ulcer complications after the introduction of the proton pump inhibitors, a study of the Swedish population from 1974-2002

Background

Despite a decreasing incidence of peptic ulcer disease, most previous studies report a stabile incidence of ulcer complications. We wanted to investigate the incidence of peptic ulcer complications in Sweden before and after the introduction of the proton pump inhibitors (PPI) in 1988 and compare these data to the sales of non-steroid anti-inflammatory drugs (NSAID) and acetylsalicylic acid (ASA).

Methods

All cases of gastric and duodenal ulcer complications diagnosed in Sweden from 1974 to 2002 were identified using the National hospital discharge register. Information on sales of ASA/NSAID was obtained from the National prescription survey.

Results

When comparing the time-periods before and after 1988 we found a significantly lower incidence of peptic ulcer complications during the later period for both sexes (p < 0.001). Incidence rates varied from 1.5 to 7.8/100000 inhabitants/year regarding perforated peptic ulcers and from 5.2 to 40.2 regarding peptic ulcer bleeding. The number of sold daily dosages of prescribed NSAID/ASA tripled from 1975 to 2002. The number of prescribed sales to women was higher than to males. Sales of low-dose ASA also increased. The total volume of NSAID and ASA, i.e. over the counter sale and sold on prescription, increased by 28% during the same period.

Conclusion

When comparing the periods before and after the introduction of the proton pump inhibitors we found a significant decrease in the incidence of peptic ulcer complications in the Swedish population after 1988 when PPI were introduced on the market. The cause of this decrease is most likely multifactorial, including smoking habits, NSAID consumption, prevalence of Helicobacter pylori and the introduction of PPI. Sales of prescribed NSAID/ASA increased, especially in middle-aged and elderly women. This fact seems to have had little effect on the incidence of peptic ulcer complications.

Prevention and treatment of gastrointestinal symptoms and complications due to NSAIDs

The mechanisms by which aspirin(ASA) and non-steroidal anti-inflammatory drugs (NSAIDs) cause gastrointestinal symptoms are poorly understood. They probably arise from several causes, including direct and indirect mucosal injury, exacerbation of underlying peptic ulcer disease or non-ulcer dyspepsia, exacerbation of Helicobacter pylori gastritis, and possibly motility disorders. No single form of therapy has been generally successful. Because, in most cases, symptoms abate fairly rapidly with continued treatment, there is little evidence that benefit associated with any symptom-directed drug therapy is superior to placebo beyond 4 weeks. Exceptions may be the subsets of patients with pre-existing ulcer disease or heartburn, exacerbated by the NSAID therapy, who usually benefit from acid-suppressive drug treatment. Different NSAIDs vary in the frequency with which their use leads to gastrointestinal(GI) complications such as haemorrhage, perforation, obstruction, or the symptomatic ulcers from which about 40% of the complications arise. Most gastroduodenal ulcers heal over time, albeit more slowly, with conventional doses of any of the available anti-ulcer drugs. Maintenance therapy may be needed in many patients who continue NSAID therapy. Anti-ulcer drugs have not, thus far, been shown to be more effective than placebo in preventing ulcer complications or their recurrence. The use of COX-2-selective inhibitors appears, in outcome studies, to reduce gastrointestinal bleeding, including bleeding from ulcers, but it is not established that the ulcers protected were caused by NSAIDs, as distinct from ulcers exacerbating or recurring from antecedent peptic ulcer disease. To-date, perforation or obstruction have not been shown to be affected by selective COX-2 inhibitor drugs. If the major problem giving rise to severe NSAID complications is pre-existing peptic ulcer disease, it may yet emerge that the most effective approach will be the use of proton pump inhibitor drugs, for the duration of NSAID therapy, in a small subset of high-risk patients. Most other low-risk patients may not need any special care. Co-morbid conditions have a major impact on outcome of NSAID therapy. Morbidity or even death attributable solely to NSAIDs is probably small in normal patients, and requires little in the way of prophylaxis.

Traumatic and nontraumatic perforation of hollow viscera

Hollow viscus injuries are usually managed with few complications. However, if their diagnosis is delayed, or if reparative suture closure should fail, the patient is placed at risk of multiple organ failure. This article presents diagnostic approaches, emphasizing imaging modalities, and therapeutic strategies for three clinical scenarios of hollow viscus perforation: 1) acute appendicitis, 2) gastroduodenal peptic ulcer disease, and 3) trauma.

Peptic ulcer perforation before and after the introduction of H2-receptor blockers and proton pump inhibitors

BACKGROUND

The aim of this retrospective study was to compare patients treated for perforated peptic ulcer before and after the introduction of the H2-receptor antagonists and proton pump inhibitors (PPI) with regard to their medical history, clinical features, methods of diagnosis and treatment, complications, and mortality.

METHODS AND RESULTS

During the study period 1974 to 1992 we found a significant reduction in the incidence of peptic ulcer perforation (P < 0.001). Patients admitted during the later period of the study were older and more seriously ill. The incidence of perforation among men decreased, but that among women was stable, thus changing the sex ratio towards a female preponderance at the end of the study period. After the introduction of PPI the relative number of gastric perforations decreased compared with the number of perforations in the duodenum. A relatively higher proportion of patients with gastric perforations was taking acetylsalicylic acid or non-steroid, anti-inflammatory drugs at the time of admission compared with patients with duodenal perforation. Simple suture of the perforation was the operative procedure used in 80% of the patients.

CONCLUSIONS

Even though patients were increasingly older and more ill, neither the mortality nor the rate of postoperative complications changed during the study period.

Changing trends in acute peptic ulcer surgery in a district surgical unit

Despite changes in management and the advances in therapeutics, surgeons are still required to treat the complications of peptic ulceration. A retrospective review of all open surgical interventions for complications of peptic ulcer disease between January 1983 and December 1993 was carried out. There were no exclusion criteria. Open gastric surgery accounted for 3% of all inpatient surgical procedures and 13% of all the major operations. There were 341 adult and 132 paediatric procedures performed in the 11 year period. Acute gastric procedures accounted for 34% of major gastric surgery in this district unit. 76 perforated ulcers and 39 bleeding ulcers required surgery. 38% of the patients were over 70 years. The perioperative mortality was 13.9% (4% for those under 70 years). The overall morbidity rate was 71% and procedure-related morbidity rate was 17%. Acute gastric surgery has a very high inpatient morbidity and is associated with a significant mortality particularly in elderly patients.

Review article: controversies in NSAID-induced gastroduodenal damage--do they matter?

BACKGROUND

This article reviews various issues surrounding NSAID-induced gastroduodenal ulceration, about which there appear to be conflicting views and data in the literature. These issues include the size, clinical relevance and main site of the problem; when complications occur (early or late?); the relevance of non-ulcer lesions and whether adaptation is a clinically relevant phenomenon.

METHOD

A comprehensive literature search was carried out to identify relevant new data published since 1987.

RESULTS

NSAIDs are causally associated with more gastric than duodenal ulcers but their use may be associated with duodenal ulcers or complications. Erosive lesions may progress to more severe damage. The theories of early or late onset of complications during a course of NSAID therapy may not be mutually exclusive.

CONCLUSIONS

Available data indicate that NSAID ulcers are at least as dangerous as classic peptic ulcers, and result in significant morbidity and mortality which in the patient population does not appear to be significantly reduced by processes such as adaptation.

Variation in the risk of peptic ulcer complications with nonsteroidal antiinflammatory drug therapy

OBJECTIVE

To assess the risk of perforation or hemorrhage of peptic ulcer on treatment with nonsteroidal antiinflammatory drugs (NSAIDs), both as a class and as individual agents.

METHODS

A case-control study of medication histories in 494 patients and 972 matched control subjects.

RESULTS

The increase in risk (odds ratio) with NSAID therapy was 5.1 times the risk in controls. The odds ratio for piroxicam was 6.3 (95% confidence interval [CI] 3.3-12.0), as compared with 2.9 for diclofenac, ketoprofen, and sulindac combined (95% CI 2.0-4.2). The effect of other risk factors was also considered, and the adjusted odds ratios were 4.1 for all NSAIDs, 6.4 (95% CI 2.8-15.0) for piroxicam, and 3.3 (95% CI 2.0-5.5) for diclofenac, ketoprofen, and sulindac combined.

CONCLUSION

The estimate of overall risk of peptic ulcer complications with NSAIDs is similar to that found in other studies. There appear to be differences in risk between agents.

Nonsteroidal anti-inflammatory drugs--the clinical dilemmas

Physicians using nonsteroidal anti-inflammatory drugs (NSAIDs) are concerned that effective anti-inflammatory doses cause few gastrointestinal side effects. Among the causes of discontinuing therapy, upper gastrointestinal symptoms and the development of 'ulcer' complications are major concerns; endoscopic findings in asymptomatic users are not. Initial symptoms, poorly correlated with endoscopic findings, are relieved by anti-ulcer drugs and ameliorate with time of NSAID use in most patients. Symptoms accompanied by epigastric tenderness, or unrelieved by H2 antagonists, or resulting in cessation of NSAID therapy are more predictive of underlying ulcers. Complications probably arise in several ways, including as hemorrhages due to interference with platelet function, and as complications due to exacerbations of underlying ulcer disease or of ulcers caused by the NSAIDs. Pathogenesis and effective prophylaxis (yet to be established) may therefore vary in different patients, a clinical dilemma.

Non-steroidal anti-inflammatory drug ingestion: retrospective study of 272 bleeding or perforated peptic ulcers

The ingestion of non-steroidal anti-inflammatory drugs (NSAID) in 272 patients with bleeding or perforated peptic ulcer was compared with 272 age/sex matched controls. A significantly higher proportion of patients with gastric ulcers had received NSAID than those with duodenal ulcers. Twelve of 90 (13%) patients admitted with bleeding duodenal ulcers had received NSAID compared with 11 of 26 (42%) patients with bleeding gastric ulcers (P = 0.003). Sixteen of 132 (12%) patients with perforated duodenal ulcer were taking NSAID compared with 8 of 24 (33%) patients with perforated gastric ulcer. Thirty eight percent of patients with both bleeding and perforated gastric ulcers had received NSAID compared with 13% bleeding and perforated duodenal ulcers (P less than 0.002). This study confirms the association of NSAID and complicated peptic ulcer in patients of over 65 years and highlights the particular susceptibility of the gastric mucosa to their injurious effect.

Spontaneous gastroduodenal perforation in cancer patients receiving cytotoxic therapy

Spontaneous gastroduodenal perforation (SGDP) occurs in cancer patients receiving cytotoxic drugs, corticosteroids, or radiation therapy as primary or adjuvant treatment for their tumors. A retrospective review identified 12 patients from 1974 to 1987 at the Memorial Sloan-Kettering Cancer Center who underwent surgery for SGDP while receiving anticancer therapy. There were five gastric and seven duodenal perforations. Vague abdominal pain was the most common symptom. Exploration was delayed in six patients because of an absence of physical findings. All patients received a Graham omental patch. The in-hospital operative mortality was 33%, with all major complications occurring in those that died. There were no prognostic indicators identified that would preoperatively predict outcome. Aggressive surgical intervention is advised in all patients who have a reasonable chance of worthwhile palliation if not cure.

Silent peptic ulceration: deadly silence or golden silence?

Peptic ulcer hemorrhage or perforation occur commonly in patients with hitherto silent ulceration, particularly in the elderly or in those taking nonsteroidal antiinflammatory drugs. The majority of patients dying from peptic ulceration have no symptoms of ulcer disease until the presentation of their final, fatal illness. There is a need for more studies investigating the early symptoms of the fatal ulcer disease, the effects of therapies that may prevent fatalities, and the management of potentially lethal ulcer disease upon clinical presentation. Silent ulceration also occurs in patients after successful healing with medical treatment, and the apparent point prevalence of silent ulceration (in the framework of a clinical trial) is critically dependent on the frequency of repeat endoscopic examination and the treatment modality. Maintenance treatment with H2-receptor antagonists appears to some extent to decrease the frequency of asymptomatic ulcers, but more interestingly to halt the progression of asymptomatic ulcers toward symptomatic or complicated ulceration, although more careful studies in comparison with other modalities are needed.

Proximal gastric vagotomy. The preferred operation for perforations in acute duodenal ulcer

Simple closure, the conventional operation for perforated acute duodenal ulcers, is associated with symptomatic relapse in a large proportion of patients. In order to assess the role of immediate definitive surgery, 78 fit patients with perforated acute ulcers were prospectively randomized to undergo either closure alone or proximal gastric vagotomy with closure (PGV). Patients taking potentially ulcerogenic drugs or who had severe stress were excluded from the study. Both groups were comparable with respect to age, sex, general medical health, duration of perforation, length of ulcer history, and presence of duodenal scarring. There was no hospital mortality. Minor complications occurred in 7.3% after closure and 10.8% after PGV. At 3 years follow-up, the cumulative recurrence rates were 36.6% and 10.6% after closure and PGV, respectively (p = 0.001). Eighty-five per cent of recurrences after closure were symptomatic, and half of them required reoperation. Duodenal scarring itself did not appear to influence the outcome after closure. PGV was not associated with dumping, diarrhea or other unwanted side effects. Although less than that in chronic ulcers, there is a substantial risk of symptomatic relapse after closure of perforated acute duodenal ulcers. With judicious patient selection, PGV effectively reduces this risk without incurring disabling side effects associated with other ulcer operations.

Perforated peptic ulcer

Peptic ulcer disease has declined significantly since 1950 in industrialized nations. However, the number of patients with perforated and bleeding ulcers has been constant or has declined only slightly, except for older patients, in whom the frequency has increased. In patients with perforated ulcers, operative management is preferable to non-operative treatment. The operative choices are simple closure of the perforation or definitive surgery. Patients who have significant risk factors should undergo simple closure. Closure of the ulcer with parietal cell vagotomy is the author's first choice for definitive operative treatment when this procedure can be performed.

Incidence of perforated and bleeding peptic ulcers before and after the introduction of H2-receptor antagonists

The incidence of perforated and bleeding peptic ulcer requiring emergency surgery was studied in a defined population before and after the introduction of histamine H2-blockers. The incidence of these ulcer complications was unchanged from 1974 to 1984 with an incidence of ulcer perforation from 4 to 10/100,000 per year and of bleeding ulcer from 5 to 10/100,000, indicating that the H2-blockers have not changed the incidence of severe ulcer complications.

Non-steroidal anti-inflammatory drugs and life threatening complications of peptic ulceration

Two hundred and thirty five consecutive patients with a life threatening complication of peptic ulceration, who either died or required emergency surgery, have been studied over a 36 month period. Seventy eight of these high risk patients died; 25 at home, 19 in hospital without surgery and 34 postoperatively. Ninety eight patients had bleeding ulcers, 132 perforated ulcers and five had both bleeding and perforated ulcers. One hundred and forty one of these 235 patients (60%) were taking a non-steroidal anti-inflammatory drugs (NSAID) and the individual agents have been listed. The overall incidence of NSAID use in a hospital control group was 9.9%. The first sign of an ulcer was a life threatening complication in 58.2% of patients taking a NSAID. Nearly 80% of all ulcer related deaths occurred in patients using an anti-inflammatory agent. Patients using these drugs were older, with more pre-existing medical conditions and had larger ulcers than those not taking NSAIDs. The mortality associated with a peptic ulcer complication in patients taking a NSAID was more than twice that in patients with no such drug history. There appears to be a relationship between the development of a life threatening complication of peptic ulceration and NSAID ingestion. Much of the associated mortality and morbidity may be potentially avoidable.

Gastric perforation after acute aspirin overdose

A case is presented of gastric perforation complicating acute aspirin overdose in a patient without previous evidence of peptic ulcer disease.

Non-steroidal anti-inflammatory drugs and peptic ulcer perforation

A retrospective study is reported in which the ingestion of non-steroidal anti-inflammatory drugs (NSAID) in 269 patients with perforated peptic ulceration and 269 age/sex matched controls admitted between 1973-1982 was compared. A highly significant statistical difference was found (p less than 0.001) in those aged over 65. There was no statistical difference, however, in those aged under 65. Furthermore we have shown a highly statistically significant correlation (p less than 0.0001) between the annual number of patients aged over 65 with perforated peptic ulcers taking NSAID and the annual number of prescriptions issued for these drugs in the region. No such correlation was found for patients aged under 65 years. We suggest that the elderly especially women are unduly susceptible to NSAID associated peptic ulcer perforation, and discuss factors that may account for this.

Perforated gastric ulcer

Thirty-four patients presenting with gastric perforation over a ten year period were studied, retrospectively. Five patients (14%) died either as a result of delay in treatment or wrong diagnosis. In addition, 2 patients (6%) died from postoperative complications. Twelve patients (38%) were on potentially ulcerogenic drugs. Patients who had either simple closure of ulcers (n = 17) or partial gastrectomy (n = 6) had few symptoms at follow-up, but patients who underwent truncal vagotomy and pyloroplasty (n = 7) had poorer results. There were 2 recurrent ulcers following simple closure.

What has happened to perforated peptic ulcer?

The number of elective operations for chronic peptic ulceration has decreased substantially with the widespread use of H2-receptor antagonists. We have reviewed all cases of perforated peptic ulcer in Oxford over the last 18 years (1965-82) to see if a similar change in the incidence of this major complication of peptic ulceration has occurred. Since 1976 there has been a fall in the incidence of perforated peptic ulcer from 8.7 to 6.9 cases per 100 000 population per year. The male to female ratio decreased over the review period from 4.9:1 to 1.9:1 owing to a reduced incidence of perforation in men and an increased incidence in women. The mean age of men with perforated duodenal ulcer increased from 52.3 years in 1965-70 to 59.0 years in 1977-82. One hundred and sixty-six patients treated between 1977 and 1982 have been reviewed in detail. The overall mortality in this 6 year period was 12.7 per cent with an operative mortality rate of 8.9 per cent. The majority of perforations (65 per cent) are now of acute ulcers and therefore are unlikely to be prevented by improved therapy for chronic peptic ulceration.

Resistance to medical therapy of gastric ulcers in rheumatic disease patients taking aspirin. A double-blind study with cimetidine and follow-up

Little is known about healing or recurrence of aspirin-induced gastric ulcers if aspirin intake is continued. A double-blind controlled study compared cimetidine plus antacids as needed (prn) with placebo plus prn antacids in healing aspirin-associated gastric ulcers during continued salicylate ingestion in 18 rheumatic disease patients over a 2-month period. Healing occurred in 44% of the placebo and 56% of the cimetidine-treated patients (P greater than 0.05). Subjects in both groups ingested potentially therapeutic doses of antacid. Ulcer size had an effect on healing rate, irrespective of treatment. Ninety percent of gastric ulcers less than 0.5 cm in diameter healed in 2 months but only 25% of ulcers greater than 0.5 cm. Six of seven patients with unhealed ulcers at 2 months eventually healed medically at intervals of 6--26 months. Of 11 patients managed medically and followed endoscopically for a mean of 15 months after healing, only one had a recurrent ulcer. In conclusion, placebo and antacid therapy were as effective as cimetidine and antacids in healing ulcers over a 2-month period. In spite of continued aspirin intake, most benign gastric ulcers less than 0.5 cm in diameter heal medically in two months. Aspirin-induced ulcers greater than or equal to 1 cm in diameter are relatively resistant to therapy but can be healed with prolonged cimetidine and antacid treatment; once healed, recurrence rate is low with prophylactic therapy even with continued aspirin intake.

Gastrointestinal toxicity of minor analgesics

1 The evidence for the risk of gastric erosions from aspirin is fragmentary. 2 Occult gastric bleeding following aspirin is poorly studied and the skewed distribution is unexplained; platelet factors may be relevant. 3 Overt gastric bleeding may follow aspirin; the risk is probably about one episode per two million doses. 4 There is epidemiological, clinical, experimental and histopathological evidence for an association between chronic aspirin use and chronic gastric ulcer. 5 An alternative to the Davenport hypothesis is proposed to explain the gastric action of aspirin and the non-steroidal anti-inflammatory agents. 6 Paracetamol is probably bland in its gastric actions.