Peptic ulcer in Central Scotland

Hospital admissions and primary care attendances for nonulcer dyspepsia, reflux oesophagitis and peptic ulcer in Scotland 1981-2004

AIM

The aim of this study was to assess the recent time trends of oesophageal disorders, nonulcer dyspepsia, gastric and duodenal ulcer in the light of such risk factors as age, sex, deprivation and urban versus rural residence.

METHODS

The Scottish National Health Service provided diagnostic data on all admissions to all Scottish hospitals from 1981 to 2004 and patient visits to general practitioners (GP) from 1998 to 2004.

RESULTS

In the last quarter of a century in Scotland, there were sevenfold increases in annual hospitalizations for dyspepsia (from 900 to 6000 per million population) and for oesophageal disorders (from 500 to 3700). Annual hospitalisations for gastric and duodenal ulcer changed from 590 to 1100 and from 1400 to 1130 per million population, respectively. The variation of hospital admissions for dyspepsia among various Scottish regions closely matched the variation of deprivation among them. GP contacts for dyspepsia (27 600 per million population) and oesophageal disorders (10,000) were common compared with relatively infrequent contacts for gastric ulcer (500) and duodenal ulcer (1200). Dyspepsia showed a rise of GP contacts with increasing scores of deprivation. This rise occurred similarly among urban and rural residents and applied to data for each individual year between 1998 until 2004. None of the other diagnoses showed any clear-cut correlation with grade of deprivation.

CONCLUSION

Gastric and duodenal ulcer are relatively rare causes for hospital admission as well as outpatient physician visits. Their former predominant role in upper gastrointestinal disease has been replaced by gastro-oesophageal reflux disease and nonulcer dyspepsia, both increasing sevenfold in the last quarter of a century.

Causative factors in the etiology of peptic ulcer disease become effective before the age of 15 years

Peptic ulcer mortality in Western Europe, Japan, and the United States is characterized by marked temporal changes which suggest that environmental factors are important in the etiology of gastric and duodenal ulcer. The present study examines at what age these factors start becoming effective. When the average age-specific death rates from 18 countries are plotted vs the year of birth, the fall of gastric and duodenal ulcer mortality related to successive birth-cohorts is continuously preserved in the age group of 15-19 years. Although the younger age groups also display a decline in ulcer mortality, it is not possible to discern unequivocally whether they follow the temporal pattern of birth-cohort risks. In the second analysis, the number of deaths from each individual country is accumulated over time, and the geographic variation in the age-specific mortality is compared for these countries. The death rates of consecutive age groups from different countries change in a parallel manner. The linear relationships between each two consecutive age groups start at the age of 5 years in gastric ulcer and at the age of 15 years in duodenal ulcer. These findings again suggest that the determinants for the risk of dying from gastric and duodenal ulcer begin to act at an age lower than 15. The contention of environmental factors starting to act before the age of 15 would remain valid, even if factors unrelated to etiology, such as different reporting for childhood and adult mortality, contributed to the different patterns of childhood and adult death rates. However, the actual cut-off age of gastric and duodenal ulcer would then be shifted towards younger ages.

Epidemiological aspects of peptic ulcer disease on the Faroe Islands. An interim report

A prospective epidemiological study was carried out from 1981 to 1983 to determine the incidence of peptic ulcer on the Faroe Islands. The annual incidence of first-time-diagnosed peptic ulcer was on the average 3.3 per 1000 inhabitants aged 15 years and older. No significant changes in incidence were observed during the 3-year period. The male to female ratio of peptic ulcer was 2.1:1. The annual incidences of duodenal and gastric ulcer were 2.3 per 1000 and 1.0 per 1000, respectively. The duodenal to gastric ulcer ratio was approximately 2:1 in both male and female patients. The incidence of peptic ulcer observed in the Faroe Islands is very high compared with other countries. The incidence of duodenal ulcer is of the same high magnitude as observed in Scotland, whereas the incidence of gastric ulcer is twice as high as generally found in Western countries and in accordance with the rates found in Arctic areas.

Benign gastric ulceration in a health district: incidence and presentation

In a survey of benign gastric ulceration conducted in the Hounslow Health District from 1981 to 1982, there was an annual incidence for this condition of 43.6 per 100,000 of the population older than 14 y, with a male:female ratio of 0.9:1. This incidence is comparable to that found in other surveys over the last 30 y, but the male:female ratio is lower than in the past. This reduction is accounted for by a rise in the peak age incidence for gastric ulcer, particularly in women, and a greater proportion of the total population in this higher age group being women. In spite of a large local Asian population, no gastric ulcers occurred in this ethnic group. Thirty-eight per cent of the patients presented with acute bleeding, and 44% of these bleeders gave a history of previous ingestion of non-steroidal anti-inflammatory drugs compared with only 14% of the non-bleeding group (P less than 0.015).

Geographic and temporal variations in the occurrence of peptic ulcer disease

The epidemiology of peptic ulcer is characterised by marked geographic and temporal variations. Gastric ulcer occurs about 5-10 times more often than duodenal ulcer in Japan. In most European countries and the USA, duodenal ulcer is about twice as frequent as gastric ulcer. The variation among different European countries does not show any clear-cut relationship to European geography. The reported differences in healing rate, relapse rate after discontinuation of treatment with histamine2 (H2)-blockers, and harmful effects of smoking are probably related to the varying fraction of bad healers recruited for controlled clinical trials in different countries. In male migrant workers who emigrated from Southern to Central Europe, duodenal ulcer occurs twice as frequent as in the native population. A similar phenomenon has been reported from South Africa. Peptic ulcer used to be a rare disease before the 19th century. In the beginning of the 19th century acute perforations of gastric ulcers were first reported in young girls. With progress of the 19th century peptic ulcer became more frequent also in men. By the end of the century the incidence of duodenal ulcer had surpassed that of gastric ulcer. Studies from the USA and England reported that the number of hospital admissions, surgical operations, and deaths due to duodenal or gastric ulcer had declined during the last 20 years. A cohort analysis demonstrates that the temporal changes of peptic ulcer in all European countries, in Japan, and in the USA occur in a fashion characteristic of those due to changes in birth-cohort risks. Generations born in the last 30 years of the 19th century manifested the highest risk of developing peptic ulcer and carried it throughout their lives. The birth-cohorts with a high risk for duodenal ulcer lagged 10-30 years behind those with a high risk for gastric ulcer. The cohort phenomenon starts at an age below 5 years for both gastric and duodenal ulcer. The cohort phenomenon implies that important determinants for the development of peptic ulcer disease occur very early in the life of a cohort and that it is these early determinants that are changing with time. The migration phenomenon shows that the relevant environmental factors are still with us.