Aspirin ingestion and perforated peptic ulcer

Perforated peptic ulcer--a complication in acute salicylate intoxication

A patient with perforated peptic ulcer following acute salicylate intoxication is presented. The patient had reversible renal failure requiring dialysis therapy, but no abdominal symptoms were noticed until six days after arrival. At this time haematemesis and melaena were observed. Symptoms and objective findings were vague, but further investigations revealed a perforated prepyloric ulcer, which was successfully treated with cimetidine, The delay from intoxication to symptoms has previously been described and might be due to the analgetic properties of salicylates.

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.

Diagnostic procedures and health outcomes. Upper gastrointestinal tract investigations in the elderly

OBJECTIVES

To examine the use of upper gastrointestinal endoscopy in people 65 years of age and over in New South Wales, and compare its use between geographic areas, sex and age groups. Also, to investigate the relationship between endoscopy use and peptic ulcer mortality.

DESIGN

A retrospective review of upper gastrointestinal tract (GIT) endoscopy hospital separation data for NSW from 1986 to 1989-1990 and peptic ulcer mortality data from 1979 to 1989.

MAIN OUTCOME MEASURES

Rates per 1000 population aged 65 years and over were calculated for upper GIT endoscopy for each of the four-year age groups and by sex. Peptic ulcer and other digestive system disease rates for endoscopy patients were determined. Correlations between hospital standardised separation rates for endoscopy and standardised mortality rates for gastric cancer and peptic ulcers were calculated. Age and sex standardised death rates were calculated for each year between 1979 and 1989, and changes in death rates over time were determined by regression analysis.

RESULTS

The rate of endoscopies increased significantly (P < 0.001) over the period 1986 to 1989-1990, with the highest rate and greatest increase occurring in patients aged 70 years and over. Men had significantly higher endoscopy rates than women (P < 0.001). Geographic variations in the use of endoscopy were found and were not explained by geographic differences in the proportion of peptic ulcers diagnosed, deaths from peptic ulcers or malignant neoplasms. Despite the increase in endoscopies performed, there was no corresponding significant increase in the rate of peptic ulcers detected. Between 1979 and 1989 peptic ulcer mortality rates for women over 74 years of age increased significantly (P < 0.05); the rate for men did not change.

CONCLUSION

Many endoscopies are performed in people aged 65 years and over in NSW and there has been a substantial increase in endoscopy rates in recent years. While the increase in upper GIT endoscopy may have resulted in a number of health benefits, it does not appear to have resulted in a reduction in peptic ulcer related mortality.

Perforated peptic ulcer disease in children: association of corticosteroid therapy

Four children were treated at the Oregon Health Sciences University for perforated peptic ulcer disease over the last 15 years. All children were being treated for other severe underlying diseases at the time of perforation. All of the children were receiving corticosteroids; one was receiving ulcer prophylaxis. Presenting symptoms were those of a perforated viscus, and pneumoperitoneum was present in all patients. Simple closure and omental patching of the ulcer resulted in no operative mortality or morbidity. None of the ulcers have recurred. In reviewing the literature, corticosteroids were associated with perforated peptic ulcer disease in 17.8% of children with perforated peptic ulcer. Despite controversy regarding the role of corticosteroids in the causation of peptic ulcer, we recommend prophylaxis for all children receiving corticosteroids.

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.

Peptic ulcer and non-steroidal anti-inflammatory agents

Aspirin is generally regarded as a cause of gastric ulcer but the role of non-steroidal anti-inflammatory agents and paracetamol in the aetiology of peptic ulcer is unclear. To investigate this we conducted a case control study of 180 matched pairs of peptic ulcer patients and controls obtained from surgical and dermatology outpatient clinics. There were 95 gastric ulcer and 85 duodenal ulcer patients. A statistically and clinically association (relative risk = 5) was found between the regular use of non-steroidal anti-inflammatory agents and gastric ulcer. There was also evidence of positive associations between gastric ulcer and aspirin containing preparations with or without non-steroidal anti-inflammatory agents. By contrast, duodenal ulcer was unrelated to these drugs. Too few patients used paracetamol for any conclusion to be drawn on its role.

Gastrointestinal intolerance and bleeding with non-narcotic analgesics

Aspirin and paracetamol (acetaminophen) are the most commonly used minor analgesics, but their effects on the gastrointestinal tract differ widely. The effects of other nonsteroidal anti-inflammatory drugs (NSAIDs), including phenylbutazone, are intermediate. Aspirin is significantly associated with major upper gastrointestinal haemorrhage, whereas paracetamol is not. Short term use of aspirin produces erythema, erosions and occasionally ulcers; paracetamol does not, while other NSAIDs do so to varying degrees. Chronic gastric ulcer is linked to aspirin intake in patients with rheumatic disease, and epidemiologically in all heavy aspirin users. In only one epidemiological study was a paradoxical significant association reported between paracetamol intake and chronic gastric ulcer. Faecal occult blood loss is increased in most regular aspirin users but not in those taking paracetamol. Although formal studies in children have apparently not been made, in isolated small clinical series it has been reported that gastrointestinal bleeding and anaemia do occur in the paediatric age group after the use of aspirin. Pathophysiologically, aspirin alters the gastric mucosal barrier to hydrogen ions and lowers gastric potential difference; paracetamol has no effect on these parameters. Such changes correlate ultrastructurally with damage in surface epithelial cells and microerosions after the use of aspirin, but not after the use of paracetamol. Aspirin and other NSAIDs cause a dramatic reduction in the ability of gastric mucosa to generate protective prostaglandins; however, paracetamol also reduces prostaglandins. Other postulated mechanisms of aspirin damage include reduction in gastric mucosal secretion, reduction in bicarbonate output, and alteration of cell turnover. Because damage to gastric mucosa by aspirin and NSAIDs is often 'silent', the clinician needs a high level of suspicion and awareness regarding this problem. In patients prone to gastric damage, or in those with a past history of aspirin-induced gastric damage, paracetamol is the drug of choice when a minor, non-inflammatory problem requires an analgesic.

What's new in steroid and nonsteroid drug effects on gastroduodenal mucosa?

A survey is given on the damaging effect of acetylsalicylic acid, other nonsteroidal antiinflammatory drugs and corticosteroids on the gastroduodenal mucosa. The results of blood loss studies and endoscopic investigations are reviewed. Also, the histologic aspects of such damage are discussed. Modern concepts of the pathophysiology of these lesions stress the cytoprotective role of endogenous prostaglandins. Epidemiologic data strongly support an association between frequent and heavy intake of acetylsalicylic acid and gastric ulcer as well as gastrointestinal bleeding, whereas the association with duodenal ulcers is far less clearly established. Conclusive evidence is currently unavailable proving the superiority of other nonsteroidal antiinflammatory drugs in this regard. The ulcerogenic potency of corticosteroids at least in the small or medium dose range probably has been overstated in the past. Intensive ulcer therapy making use of H2 receptor antagonists often allows healing of small ulcers with a diameter up to 1 cm despite continued treatment with low dose corticosteroids or nonsteroidal antiinflammatory drugs, whereas continuation of these drugs is associated with very poor healing in ulcers larger than this size. The danger of perforation has to be taken into consideration.

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.

The prevalence of duodenal lesions in patients with rheumatic diseases on chronic aspirin therapy

Peroral endoscopy was performed in 56 patients with rheumatic disease who had been taking 8 or more aspirin tablets daily for more than 3 months yet who had no major gastrointestinal symptoms or history of peptic ulcer disease. Duodenal mucosal lesions were observed in 16 patients; 15 (27%) had erythema, 7 (13%) had erosions, and 2 (4%) had ulcers. The prevalence of duodenal lesions was the same in patients taking regular, buffered, or enteric-coated aspirin preparations. Patients with duodenal lesions were more likely to have associated gastric lesions.

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.

Epidemiology of gastrointestinal disorders

Irritable bowel syndrome occurs most frequently in young adults in response to emotional and other factors. The 20th century western epidemic of diverticular disease may be linked to low dietary fiber intake. Peptic ulceration is determined by genetic and environmental factors including tobacco and coffee. Aspirin specifically predisposes to gastric ulcer. The incidence of peptic ulcer is declining. Crohn's disease is increasing in frequency although the incidence of ulcerative colitis is fairly steady. Gastrointestinal cancer is closely related to dietary factors including ingested procarcinogens, excessive carbohydrate, fat and animal protein. There is potential for control of some intestinal cancers.

Acute upper-gastrointestinal hemorrhage. New observations on an old problem

In a two-year period, 289 patients with acute upper-gastrointestinal hemorrhage were evaluated. The site of hemorrhage was proven by endoscopy in more than 90% of cases. The frequency of any particular bleeding site was characterized for several subgroups and was found to correlate with: (1) the severity of the bleeding episode; (2) the iatrotropic stimulus of hemorrhage, and (3) the history of ethanol consumption. No difference was found in the frequency of ulcer and acute mucosal lesions as sites of hemorrhage between patients who consumed aspirin and those who did not. A history of symptoms of peptic ulcer correlated with the presence of an ulcer as the bleeding site. It is possible that failure to identify important patient subgroups may be partially responsible for the disagreement between previous reports.

Drug consumption before perforation of peptic ulcer

In a retrospective study of 195 patients with a perforated peptic ulcer 18 per cent of the patients had taken aspirin, phenylbutazone or corticosteroids during the period before the perforation. In a controlled prospective trial, 18 of 22 patients (82 per cent) had taken drugs known to be potentially harmful to the stomach. Aspirin was the drug mainly used. Thirteen of 22 patients had taken the drugs within 12 hours of the perforation, usually because of symptoms not related to the gastro-intestinal tract. Drug consumption and perforation of pre-pyloric ulcers were most closely associated; the latter applies particularly to female patients, who either had only a short history of upper gastro-intestinal dyspepsia or were asymptomatic.

Perforated peptic ulcer: an analysis of 246 cases

An analysis of 246 cases of perforated peptic ulcer, treated at the Royal Newcastle Hospital from 1964 to 1974, is presented. The incidence has fallen considerably over that period. The rising proportion of women has reached a plateau. A perforated peptic ulcer in an Australian women is still just as likely to be located in the stomach as in the duodenum. In men, however, 84% of perforations are pyloroduodenal. A perforated gastric ulcer is closely associated with the use of salicylate preparations. The mortality rate has remained steady at 15% over the last 30 years. It is significantly higher in women. There is a highly significant relationship between the mortality and (a) the duration of perforation; and (b) the size of the perforation, particularly if it is located in the stomach.

Hour-glass stomach: an explanation

A personally observed series of 19 patients with hour-glass stomach is presented. In two cases carcinoma was proven. Among the remaining 17 patients with benign ulcer, females outnumbered males by 15 to 2. In neither of the carcinoma patients, but all of the benign ulcer patients, there was clear evidence of abuse of aspirin-containing analgesic preparation. The hypothesis is proposed that hour-glass stomach is produced by gross scarring around a severe benign chronic gastric ulcer under the influence of prolonged exposure to aspirin.

Factors relevant to the prognosis of chronic gastric ulcer

The factors that determine the recurrence rate of chronic gastric ulcer were studied in 105 patients. It was found that complete healing of the ulcer significantly reduced the recurrence rate and subsequent need for hospital admission because of ulcer symptoms when this group was compared with those who left hospital with their ulcers unhealed. Those admitted with large ulcers also had a higher recurrence rate. The age and sex of the patient, ingestion of analgesics and cigarette smoking did not influence recurrence. The initial healing rate of the ulcer also had no effect on the subsequent course of the patient.