Risk factors influencing the outcome of peptic ulcer bleeding in chronic kidney disease after initial endoscopic hemostasis: A nationwide cohort study

Comprehensive insights on treatment modalities with conventional and herbal drugs for the treatment of duodenal ulcers

Areas of the body accessible to gastric secretions, such as the stomach and duodenum, are most commonly damaged by circumscribed lesions of the upper gastrointestinal tract mucosa. Peptic ulcer disease is the term for this illness (PUD). About 80% of peptic ulcers are duodenal ulcers, with stomach ulcers accounting for the remaining 20%. Duodenal ulcers are linked to the two primary results about Helicobacter pylori infection and COX inhibitor users. Additional causes might include drinking, smoking, stress, and coffee consumption. The indications and symptoms of a duodenal ulcer depend on the patient's age and the lesion's location. For duodenal ulcers, proton pump inhibitors (PPIs) are the usual course of treatment. This comprehensive study included an in-depth literature search in the literature and methods section using electronic databases such as PubMed, ScienceDirect, and Google Scholar. The search method included publications published from the inception of the relevant database to the present. Inclusion criteria included studies investigating different treatment options for duodenal ulcer disease, including traditional pharmacotherapy and naturopathic treatments. Data mining includes information on treatment techniques, treatment outcomes, and possible synergies between conventional and herbal treatments. In addition, this review critically examines the available information on the effectiveness, safety, and possible side effects of different treatments. The inclusion of conventional and herbal treatments is intended to provide a comprehensive overview of the many treatment options available for duodenal ulcer disease. A more comprehensive and personalized treatment plan can be achieved by incorporating dietary changes, lifestyle modifications, and, if necessary, herbal therapies to complement other treatments normally.

Mortality and risk factors associated with peptic ulcer bleeding among adult inpatients of Damascus Hospital, Syria: A cross-sectional study

Peptic ulcer bleeding is associated with significant morbidity and mortality, while monitoring mortality is extremely beneficial to public health, and the latest estimates date back to 2010 for the Syrian population. This study aims to estimate the in-hospital mortality rate and risk factors associated with peptic ulcer bleeding among adult inpatients at Damascus Hospital, Syria. A cross-sectional study with systematic random sampling. Sample size (n) was calculated using the proportional equation: [n = Z2P (1 - P)/d2], with the following hypothesis: Z = 1.96 for the 95% confidence level, P = .253 for mortality in patients hospitalized with complicated peptic ulcers, a margin of error (d) = 0.05, 290 charts were reviewed, and the Chi-square test (χ2 test) was used for categorical variables, and the t test for continuous data. We reported the odds ratio in addition to mean and standard deviation with a 95% confidence. A P value less than .05 was considered statistically significant. Data were analyzed using a statistical package for the social sciences (SPSS). The mortality rate was 3.4%, and the mean age was 61.76 ± 16.02 years. The most frequent comorbidities were hypertension, diabetes mellitus, and ischemic heart disease. The most commonly used medications were NSAIDs, aspirin, and clopidogrel. 74 patients (25.52%) were using aspirin with no documented indication P < .01, odds ratio = 6.541, 95% CI [2.612-11.844]. There were 162 (56%) Smokers. Six patients (2.1%) suffered from recurrent bleeding, and 13 (4.5%) needed surgery. Raising awareness about the risks of using non-steroidal anti-inflammatory drugs may reduce the occurrence of peptic ulcers and, as a result, peptic ulcer complications. Larger, nationwide studies are needed to estimate the real mortality rate in complicated peptic ulcer patients in Syria. There is a lack of some critical data in the patients' charts, which necessitates action to correct.

Association between chronic kidney disease and major hemorrhage in older persons: data from the ASPREE randomized trial

Introduction

Data on the association between chronic kidney disease (CKD) and major hemorrhage in older adults are lacking.

Methods

We used data from a double-blind randomized controlled trial of aspirin in persons aged ≥ 70 years with prospective capture of bleeding events, including hemorrhagic stroke and clinically significant bleeding. CKD was defined as an estimated glomerular filtration rate (eGFR) < 60 ml/min per 1.73 m² and/or urinary albumin-to-creatinine ratio (UACR) ≥ 3 mg/mmol (26.6 mg/g). We compared bleeding rates in those with and without CKD, undertook multivariable analyses, and explored effect modification with aspirin.

Results

Of 19,114 participants, 17,976 (94.0%) had CKD status recorded, of whom 4952 (27.5%) had CKD. Participants with CKD had an increased rate of major bleeding events compared with those without CKD (10.4/1000 vs. 6.3/1000 person-years [py], respectively) and increased bleeding risk (risk ratio [RR] 1.60; 95% confidence interval [CI]: 1.40, 1.90 for eGFR < 60 ml/min per 1.73 m²) and RR (2.10; 95% CI: 1.70, 2.50) for albuminuria. In adjusted analyses, CKD was associated with a 35% increased risk of bleeding (hazard ratio [HR] 1.37; 95% CI: 1.15, 1.62; P < 0.001). Other risk factors were older age, hypertension, smoking, and aspirin use. There was no differential effect of aspirin on bleeding by CKD status (test of interaction P = 0.65).

Conclusion

CKD is independently associated with an increased risk of major hemorrhage in older adults. Increased awareness of modifiable risk factors such as discontinuation of unnecessary aspirin, blood pressure control, and smoking cessation in this group is warranted.

Increased rebleeding and mortality in patients with gastrointestinal bleeding treated with anticoagulant drugs compared to antiplatelet drugs

BACKGROUND/AIM

We determined the effect of antiplatelet and anticoagulant agents on rebleeding and mortality in patients with gastrointestinal bleeding.

METHODS

This was a prospective study of patients admitted with gastrointestinal bleeding between 2013 and 2018. Outcomes were compared among patients on antiplatelet agents only, anticoagulant drugs only, combination therapy, and none. The association between mortality, rebleeding, and type of antithrombotic medication on admission and discharge was determined using multivariate analysis.

RESULTS

A total of 509 patients were followed up for a median of 19 months. End of follow-up rebleeding and mortality rates were 19.4% and 23.0%, respectively. Independent predictors of mortality were age [hazard ratio (HR) = 1.025 per year increase, P = 0.002], higher Charlson Comorbidity Index (HR = 1.4, P < 0.0001), severe bleeding (HR = 2.1, P < 0.0001), and being on anticoagulants (HR = 2.3, P = 0.002). Being on antiplatelets was protective against rebleeding (HR = 0.6, P = 0.047). Those on anticoagulants were more likely to die (HR = 2.5, P < 0.0001) and to rebleed (HR = 2.1, P = 0.01) than those on antiplatelets. Antithrombotic drug discontinuation upon discharge was associated with increased mortality in patients with cardiovascular disease.

CONCLUSION

In gastrointestinal bleeding, rebleeding and mortality were associated with being on anticoagulant drugs, while being on antiplatelet agents was protective against rebleeding. Discontinuation of antithrombotics upon discharge increased the risk of death. The findings inform risk stratification and decisions regarding continuation or discontinuation of antithrombotics.

Impact of Subjective and Objective Sleep Quality on Peptic Ulcer Rebleeding in Older Adults

OBJECTIVE

This study aimed to examine the association of subjective and objective sleep quality with subsequent peptic ulcer rebleeding among older patients.

METHODS

Of 1196 older patients with peptic ulcer bleeding (PUB) recruited from 12 grade A hospitals in the People's Republic of China, 1106 achieved full recovery from PUB, and they were followed up for up to 30 days. Using multiple measures at 1-week intervals, patients who presented PUB symptoms were invited to have an esophagogastroduodenoscopy examination. Subjective sleep quality was measured using the Pittsburgh Sleep Quality Index. Objective sleep quality domains were measured using an accelerometer, including sleep onset latency, sleep efficiency, total sleep time, and the number of awakenings.

RESULTS

This study documented a 30-day cumulative ulcer rebleeding rate of 15.3%. Multivariate analyses showed that longer sleep onset latency (hazard ratio [HR] = 2.136 [1.336-2.558]) and more nighttime awakenings (HR = 1.698 [1.169-2.666]) increased the risk of ulcer rebleeding. However, a longer total sleep time (HR = 0.768 [0.698-0.887]) and better sleep efficiency (HR = 0.795 [0.682-0.975]) protected against ulcer rebleeding. Older patients who perceived poorer sleep quality were also more likely to experience ulcer rebleeding (HR = 2.295 [1.352-3.925]).

CONCLUSIONS

The present results highlight the importance of proper treatment and prevention of sleep problems in older adults after successful PUB treatment. Our results, if replicable in future studies with more rigorous design and representative samples, might shed light on the etiology of ulcer rebleeding and suggest new pathways for preventing this disease.

Resuming aspirin in patients with non-variceal upper gastrointestinal bleeding: a systematic review and meta-analysis

Background

Our primary and secondary aims were to analyze the evidence surrounding mortality and re-bleeding risks in patients on aspirin with non-variceal upper gastrointestinal bleeding (NVUGIB) as a function of whether or not aspirin was resumed after the bleeding episode, and to determine whether aspirin intake upon admission affected the outcomes.

Methods

A search for randomized controlled trials (RCTs) and prospective observational studies was performed. Data extraction and risk of bias assessment were done. Generic inverse variance and random-effects model were employed. Heterogeneity across studies was assessed using the I² test. Certainty of evidence was assessed using the GRADE approach for each comparison and outcome, and an evidence profile was created.

Results

Evidence from 1 RCT and 4 observational studies suggests that early aspirin resumption reduced mortality (hazard ratio [HR] 0.20, 95% confidence interval [CI] 0.06-0.63) while increasing re-bleeding risk (HR 1.90, 95%CI 0.60-6.00); moderate certainty of evidence. The observational evidence was inconsistent for both mortality (HR 0.84, 95%CI 0.54-1.33) and re-bleeding (HR 0.85, 95%CI 0.47-1.55); very low certainty of evidence. Nine observational studies addressed our secondary aim: 6 provided inconsistent results regarding mortality (pooled odds ratio [OR] 1.1, 95%CI 0.80-1.50) and 4 provided inconsistent results regarding re-bleeding risk (pooled OR 0.92, 95%CI 0.53-1.59); very low certainty of evidence for both outcomes.

Conclusion

Evidence supporting a protective effect of aspirin resumption soon after NVUGIB is of low-to-moderate certainty, and is not informative as to the optimal timing of aspirin resumption.

Risk factors of poor prognosis and impairment of activities of daily living in patients with hemorrhagic gastroduodenal ulcers

Background

Impairment of activities of daily living (ADL) due to hemorrhagic gastroduodenal ulcers (HGU) has rarely been evaluated. We analyzed the risk factors of poor prognosis, including mortality and impairment of ADL, in patients with HGU.

Methods

In total, 582 patients diagnosed with HGU were retrospectively analyzed. Admission to a care facility or the need for home adaptations during hospitalization were defined as ADL decline. The clinical factors were evaluated: endoscopic features, need for interventional endoscopic procedures, comorbidities, symptoms, and medications. The risk factors of outcomes were examined with multivariate analysis.

Results

Advanced age (> 75 years) was a significant predictor of poor prognosis, including impairment of ADL. Additional significant risk factors were renal disease (odds ratio [OR] 3.43; 95% confidence interval [CI] 1.44–8.14) for overall mortality, proton pump inhibitor (PPIs) usage prior to hemorrhage (OR 5.80; 95% CI 2.08–16.2), and heart disease (OR 3.05; 95% CI 1.11–8.43) for the impairment of ADL. Analysis of elderly (> 75 years) subjects alone also revealed that use of PPIs prior to hemorrhage was a significant predictor for the impairment of ADL (OR 8.24; 95% CI 2.36–28.7).

Conclusion

In addition to advanced age, the presence of comorbidities was a risk of poor outcomes in patients with HGU. PPI use prior to hemorrhage was a significant risk factor for the impairment of ADL, both in overall HGU patients and in elderly patients alone. These findings suggest that the current strategy for PPI use needs reconsideration.

Risk of Recurrent Peptic Ulcer Disease in Patients Receiving Cumulative Defined Daily Dose of Nonsteroidal Anti-Inflammatory Drugs

The purpose of this population-based case-control study was to clarify the impact of cumulative dosage of nonsteroidal anti-inflammatory drugs (NSAIDs) on recurrent peptic ulcers among chronic users after Helicobacter pylori (H. pylori) eradication. We analyzed data of 203,407 adult peptic ulcer disease (PUD) patients from the National Health Insurance Research Database in Taiwan entered between 1997 and 2013. After matching for age/gender frequencies and the length of follow-up time in a ratio of 1:1, the matched case-control groups comprised 1150 patients with recurrent PUD and 1150 patients without recurrent PUD within 3 years of follow-up. More recurrent PUDs occurred in NSAID users than in the control group (75.30% versus 69.74%; p = 0.0028). Independent risk factors for recurrent PUD included patients using NSAIDs (adjusted OR (aOR): 1.34, p = 0.0040), H. pylori eradication (aOR: 2.73; p < 0.0001), concomitant H2 receptor antagonist (aOR: 1.85; p < 0.0001) and anti-coagulant (aOR: 4.21; p = 0.0242) use. Importantly, in the initial subgroup analysis, the risk ratio of recurrent PUD did not increase in NSAID users after H. pylori eradication compared with that in non-users (p = 0.8490) but a higher risk for recurrent PUD with the increased doses of NSAIDs without H. pylori eradication therapy (aOR: 1.24, p = 0.0424; aOR: 1.47, p = 0.0074; and aOR: 1.64, p = 0.0152 in the groups of ≤28, 29-83, and ≥84 cumulative defined daily doses, respectively). The current study suggested that H. pylori eradication therapy could decrease the risk of recurrent PUD among patients with high cumulative doses of NSAIDs.

First-Line Helicobacter pylori Eradication in Patients with Chronic Kidney Diseases in Taiwan

Aims

Patients with chronic kidney disease (CKD) and Helicobacter pylori (H. pylori) infection have a higher incidence of gastroduodenal diseases and therefore are recommended to receive eradication therapies. This study aimed to assess the efficacy of a 7-day standard triple therapy in patients with CKD (eGFR < 60 ml/min/1.73 m²) and to investigate the clinical factors influencing the success of eradication.

Methods

A total of 758 patients with H. pylori infection receiving a 7-day standard first-line triple therapy between January 1, 2013, and December 31, 2014, were recruited. Patients were divided into two groups: CKD group (N = 130) and non-CKD group (N = 628).

Results

The eradication rates attained by the CKD and non-CKD groups were 85.4% and 85.7%, respectively, in the per-protocol analysis (p = 0.933). The eradication rate in CKD stage 3 was 84.5% (82/97), in stage 4 was 88.2% (15/17), and in those who received hemodialysis was 87.5% (14/16). There were no significant differences in the various stages of CKD (p = 0.982). The adverse events were similar between the two groups (3.1% versus 4.6%, p = 0.433). Compliance between the two groups was good (100.0% versus 99.8%, p = 0.649). There was no significant clinical factor influencing the H. pylori eradication rate in the non-CKD and CKD groups.

Conclusions

This study suggests that the H. pylori eradication rate and adverse rate in patients with CKD are comparable to those of non-CKD patients.

Hepatointestinal complications in polycystic kidney disease

Background

The objective of this study was to determine the incidence of major hepatointestinal complications in patients with polycystic kidney disease (PKD).

Methods

We analyzed the Taiwan National Health Insurance claims data (2000-2010) of 6031 patients with PKD and 23,976 non-PKD hospitalized controls. The control cohort was propensity score matched with the PKD cohort at a 1:4 ratio. All patients were followed up from the index date to the first inpatient diagnosis of hepatointestinal complications, death, or 31 December, 2011. Cox proportional hazard regression models were used to identify the risk of outcome after adjustment for potential confounders.

Results

The incidence rates of acute pancreatitis, cholangitis, peptic ulcer bleeding, and cirrhosis were 5.72, 4.01, 19.9, and 5.46 per 1000 person-years, respectively, in the PKD cohort. Compared with the non-PKD controls, patients with PKD exhibited an increased risk of hospitalization for acute pancreatitis, cholangitis, peptic ulcer bleeding, and cirrhosis (adjusted subhazard ratio [aSHR]: 2.36, 95% confidence interval [95% CI], 1.95-2.84]; 2.36, [95% CI, 1.95-2.84]; 2.41, [95% CI, 1.93-3.01]; 2.41, [95% CI, 2.17-2.67]; and 1.39, [95% CI, 1.16-1.66], respectively; all p < 0.001). PKD, chronic kidney disease, and alcoholism were independent predictors of all these hepatointestinal complications. Kaplan-Meier analysis revealed an increased overall mortality in patients with PKD who developed acute pancreatitis and peptic ulcer bleeding (log-rank p < 0.05).

Conclusion

PKD is associated with clinically significant extrarenal complications including acute pancreatitis, cholangitis, peptic ulcer bleeding, and cirrhosis.

Association between complicated liver cirrhosis and the risk of hepatocellular carcinoma in Taiwan

Hepatic encephalopathy, ascites, and variceal bleeding are the three major complications of cirrhosis. It is well known that cirrhosis is the most important risk factor of hepatocellular carcinoma (HCC). However, little is known about whether the severity of liver cirrhosis has an effect on the incidence of HCC. This population-based cohort study aimed to explore the association between complicated cirrhosis and HCC, and identify the risk factors of HCC in patients with complicated cirrhosis. Data of the years 1997–2011 were extracted from the National Health Insurance Research Database of Taiwan. A total of 2568 patients with complicated cirrhosis without HCC at baseline were enrolled. After propensity score matching, another 2568 patients with non-complicated cirrhosis were included. Hazards Cox regression analysis by using a competing risk regression model to control for possible confounding factors was utilized to estimate the association of the complications of liver cirrhosis with the risk of HCC. We observed by using competing risk analysis that the adjusted hazard ratio (HR) for developing HCC during the follow-up period after the initial hospitalization was higher among the patients with baseline complicated cirrhosis than in those with uncomplicated cirrhosis (HR, 1.23; 95% confidence interval, CI, 1.10–1.37, p<0.001). Additionally, older patients (HR, 1.01; 95% CI, 1.01–1.02, p<0.001), males (HR, 0.84; 95% CI, 0.74–0.96, p = 0.009), and patients with alcohol-related cirrhosis (HR, 1.93; 95% CI, 1.65–2.26, p<0.001) had a statistically significant difference in the incidence of HCC. In conclusion, complicated liver cirrhosis is associated with a higher risk of HCC in Taiwan compared with cirrhosis without complications.