Recent trends in admissions and mortality due to peptic ulcer in England: increasing frequency of haemorrhage among older subjects

Trends in hospital admissions and prescribing due to diseases of the digestive system in England and Wales between 1999 and 2019: An ecological study

This study aimed to investigate the trends in diseases of the digestive system hospital admissions (DDSHA) in England and Wales between (1999-2019). Secondary objectives were to investigate the type of admission and medication prescribing related to the digestive system in England. This is an ecological study using data from the Hospital Episode Statistics (HES) database and the Patient Episode Database between April 1999 and March 2019. The rate of hospital admissions with 95% confidence intervals (CIs) was calculated by dividing the number of DDSHA by the mid-year population. The trend in hospital admissions was assessed using a Poisson model. Overall, the rate of DDSHA rose by 84.2% (from 2231.27 [95% CI 2227.26-2235.28] in 1999 to 4109.33 [95% CI 4104.29-4114.38] in 2019 per 100,000 persons, trend test, P < .001). The most remarkable rise in hospital admission was seen in liver diseases, followed by other diseases of intestines with 1.85-fold, and 1.59-fold, respectively. Between 2004 and 2019, the overall prescribing rate for medications related to the gastrointestinal system increased by 74.6%, and stoma care related medications prescribing rate increased by 2.25-fold, followed by drugs affecting intestinal secretions and antisecretory drugs and mucosal protectants. There was an increase in hospital admission rate due to GI diseases in the United Kingdom (UK) by 84.2% from 1999 to 2019. The most remarkable rise in the rate of hospital admissions was seen in diseases of the liver and intestine.

A nomogram to predict in-hospital mortality of gastrointestinal bleeding patients in the intensive care unit

Background

Gastrointestinal bleeding (GIB) is a common condition in clinical practice, and predictive models for patients with GIB have been developed. However, assessments of in-hospital mortality due to GIB in the intensive care unit (ICU), especially in critically ill patients, are still lacking. This study was designed to screen out independent predictive factors affecting in-hospital mortality and thus establish a predictive model for clinical use.

Methods

This retrospective study included 1,442 patients with GIB who had been admitted to the ICU. They were selected from the Medical Information Mart for Intensive Care IV (MIMIC-IV) 1.0 database and divided into a training group and a validation group in a ratio of 7:3. The main outcome measure was in-hospital mortality. Least absolute shrinkage and section operator (LASSO) regression was used to screen out independent predictors and create a nomogram.

Results

LASSO regression picked out nine independent predictors: heart rate (HR), activated partial thromboplastin time (aPTT), acute physiology score III (APSIII), sequential organ failure assessment (SOFA), cerebrovascular disease, acute kidney injury (AKI), norepinephrine, vasopressin, and dopamine. Our model proved to have excellent predictive value with regard to in-hospital mortality (the area under the receiver operating characteristic curve was 0.906 and 0.881 in the training and validation groups, respectively), as well as a good outcome on a decision curve analysis to assess net benefit.

Conclusion

Our model effectively predicts in-hospital mortality in patients with GIB, indicating that it may prove to be a valuable tool in future clinical practice.

Haematological risk factors predicting clinical success in transarterial embolisation for acute gastrointestinal bleeding

OBJECTIVES

Evaluate clinical outcomes in transarterial embolisation (TAE) for acute gastrointestinal bleeding (GIB) and determine risk factors for 30-day reintervention for rebleeding and mortality.

METHODS

TAE cases were retrospectively reviewed between March 2010 and September 2020 at our tertiary centre. Technical success (angiographic haemostasis following embolisation) was measured. Uni- and multivariate logistic regression analysis were performed to identify risk factors for clinical success (absence of 30-day reintervention or mortality) following embolisation for active GIB or empirical embolisation for suspected bleeding.

RESULTS

TAE was conducted in 139 patients (92 (66.2%) male; median age:73, range: 20-95 years) for acute upper GIB (n = 88) and lower GIB (n = 51). TAE was technically successful in 85/90 (94.4%) and clinically successful in 99/139 (71.2%); with 12 (8.6%) reintervention cases for rebleeding (median interval 2 days) and 31 (22.3%) cases of mortality (median interval 6 days). Reintervention for rebleeding was associated with haemoglobin drop > 40 g l^-1 from baseline based on univariate analysis (p = 0.047). 30-day mortality was associated with pre-intervention platelet count < 150×10⁹ l^-1 (p < 0.001, OR 7.35, 95% CI 3.05-17.71) and INR > 1.4 (p < 0.001, OR 4.75, 95% CI 2.03-11.09) on multivariate logistic regression analysis. No associations were found for patient age, gender, antiplatelet/anticoagulation prior to TAE, or when comparing upper and lower GIB with 30-day mortality.

CONCLUSION

TAE had excellent technical success for GIB with relatively high (1-in-5) 30-day mortality. INR > 1.4 and platelet count < 150×10⁹ l^-1 were individually associated with TAE 30-day mortality, and pre-TAE > 40 g l^-1 haemoglobin decline with rebleeding requiring reintervention.

ADVANCES IN KNOWLEDGE

Recognition and timely reversal of haematological risk factors may improve TAE periprocedural clinical outcomes.

[Gastrointestinal Disease in the Population Aged 80 Years and above in Korea during Recent Decades: Multi-center Cross-sectional Study]

BACKGROUND/AIMS

Globally, the population aged 80 years or older is growing faster due to the rising life expectancy. Korea has already entered into an advanced aged society, and a post-aged society is expected in 2025. This study evaluated the patterns of gastrointestinal disease in the population aged 80 years or older during the recent decade in Korea.

METHOD

This study retrospectively reviewed the medical records of patients admitted to the gastrointestinal department of Suwon St. Vincent's hospital, Incheon St. Mary's hospital, and Uijeongbu St. Mary's Hospital - general hospitals of Seoul-Gyeonggi province in Korea. It was a repeated cross-sectional study in 2009 and 2019.

RESULTS

The number of admitted patients aged 80 years or older increased from 549 (9.0%) in 2009 to 1,073 (14.4%) in 2019 (p<0.01). As for the in-hospital mortality, there was no significant difference (p=0.25). On the other hand, the combined morbidities increased, and the duration of admission also increased (7.2±7.8 days vs. 8.1±8.2 days, p=0.03). The number of upper gastrointestinal hemorrhage and patients who are bleeding associated with drugs users increased (p<0.01). The proportion of lower gastrointestinal disease decreased (p<0.01) because of the decrease in procedure-related admissions (p<0.01). The number of those with pancreaticobiliary tract disease increased markedly (p<0.01), and the rate of cases that could not perform the procedure decreased (p=0.04).

CONCLUSION

The patterns of gastrointestinal disease in the population aged 80 years or older have changed in the recent decade in Korea. Hence, more preparation for this medical environment is needed.

VALIDATION OF THE ROCKALL SCORE IN UPPER GASTROINTESTINAL TRACT BLEEDING IN A COLOMBIAN TERTIARY HOSPITAL

ABSTRACT Background Rockall score is the most widely used prognostic scale for assessing risk of complications from non-varicose upper gastrointestinal bleeding (UGIB). Several studies have been conducted in adult populations with non-varicose UGIB in different parts of the world, with conflicting findings regarding the extent of association between the score and some morbidity and mortality outcomes. Also, there is controversy regarding the best cut-off point for the score. Moreover, no studies validating this score in Colombia have been carried out. Objective To assess the diagnostic performance of the Rockall score in predicting rebleeding and mortality in patients with non-varicose UGIB. Methods A prospective cohort study was conducted in patients requiring upper gastrointestinal endoscopy (UGIE) for non-varicose bleeding. The pre-and post-endoscopy Rockall scores were calculated and outcomes, including mortality, UGIB-associated mortality and in hospital rebleeding were determined at the 1 and 3-month time points. The association between the scores and these outcomes was assessed using the chi2 or the Fisher test, whereas the discrimination ability of the score was determined using the areas under the ROC curve (AUC). High discrimination ability was considered to exist in cases in which an AUC ≤0.7 with α=0.05 could be rejected. Results Overall, 177 patients were analyzed. In-hospital outcomes at 1 and 3 months were 12%, 17% and 23% for general mortality, 6%, 12% and 15% for UGIB mortality, and 19%, 30% and 37% for rebleeding. The post-endoscopy Rockall score was associated with the three outcomes at the three time points assessed, while the pre-endoscopy score was only associated with general mortality at the three time points, and rebleeding at 1 and 3 months. Regarding discrimination ability, although the AUC was greater than expected by randomness (0.5) in all cases, only one AUC ≤0.7 was rejected in the post-endoscopy score for in-hospital UGIB mortality (AUC=0.901; 95%CI: 0.845—0.958), at 1 month (AUC=0.836; 95%CI: 0.717—0.954) and at 3 months (AUC=0.869; 95%CI: 0.771—0.967), and for rebleeding at 1 month (AUC=0.793; 95%CI: 0.725—0.861) and at 3 months (AUC=0.806; 95%CI: 0.741—0.871). Conclusion An association was found between the Rockall score and rebleeding and mortality in patients with non-varicose UGIB. Only the post-endoscopy score had a high predictive ability for rebleeding and UGIB mortality.

Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding

BACKGROUND

Upper gastrointestinal (GI) bleeding is a common reason for emergency hospital admission. Proton pump inhibitors (PPIs) reduce gastric acid production and are used to manage upper GI bleeding. However, there is conflicting evidence regarding the clinical efficacy of proton pump inhibitors initiated before endoscopy in people with upper gastrointestinal bleeding.

OBJECTIVES

To assess the effects of PPI treatment initiated prior to endoscopy in people with acute upper GI bleeding.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase and CINAHL databases and major conference proceedings to October 2008, for the previous versions of this review, and in April 2018, October 2019, and 3 June 2021 for this update. We also contacted experts in the field and searched trial registries and references of trials for any additional trials.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) that compared treatment with a PPI (oral or intravenous) versus control treatment with either placebo, histamine-2 receptor antagonist (H₂RA) or no treatment, prior to endoscopy in hospitalised people with uninvestigated upper GI bleeding.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed study eligibility, extracted study data and assessed risk of bias. Outcomes assessed at 30 days were: mortality (our primary outcome), rebleeding, surgery, high-risk stigmata of recent haemorrhage (active bleeding, non-bleeding visible vessel or adherent clot) at index endoscopy, endoscopic haemostatic treatment at index endoscopy, time to discharge, blood transfusion requirements and adverse effects. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included six RCTs comprising 2223 participants. No new studies have been published after the literature search performed in 2008 for the previous version of this review. Of the included studies, we considered one to be at low risk of bias, two to be at unclear risk of bias, and three at high risk of bias. Our meta-analyses suggest that pre-endoscopic PPI use may not reduce mortality (OR 1.14, 95% CI 0.76 to 1.70; 5 studies; low-certainty evidence), and may reduce rebleeding (OR 0.81, 95% CI 0.62 to 1.06; 5 studies; low-certainty evidence). In addition, pre-endoscopic PPI use may not reduce the need for surgery (OR 0.91, 95% CI 0.65 to 1.26; 6 studies; low-certainty evidence), and may not reduce the proportion of participants with high-risk stigmata of recent haemorrhage at index endoscopy (OR 0.80, 95% CI 0.52 to 1.21; 4 studies; low-certainty evidence). Pre-endoscopic PPI use likely reduces the need for endoscopic haemostatic treatment at index endoscopy (OR 0.68, 95% CI 0.50 to 0.93; 3 studies; moderate-certainty evidence). There were insufficient data to determine the effect of pre-endoscopic PPI use on blood transfusions (2 studies; meta-analysis not possible; very low-certainty evidence) and time to discharge (1 study; very low-certainty evidence). There was no substantial heterogeneity amongst trials in any analysis.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that PPI treatment initiated before endoscopy for upper GI bleeding likely reduces the requirement for endoscopic haemostatic treatment at index endoscopy. However, there is insufficient evidence to conclude whether pre-endoscopic PPI treatment increases, reduces or has no effect on other clinical outcomes, including mortality, rebleeding and need for surgery. Further well-designed RCTs that conform to current standards for endoscopic haemostatic treatment and appropriate co-interventions, and that ensure high-dose PPIs are only given to people who received endoscopic haemostatic treatment, regardless of initial randomisation, are warranted. However, as it may be unrealistic to achieve the optimal information size, pragmatic multicentre trials may provide valuable evidence on this topic.

Underutilization of Peptic Ulcer Disease Prophylaxis Among Elderly Users of Antiplatelets and Anticoagulants

INTRODUCTION

Peptic ulcer disease (PUD) develops in approximately 25% of chronic users of non-steroidal anti-inflammatory drugs (NSAIDs). The incidence of uncomplicated PUD has been declining over the past 3 decades unlike that of complicated PUD in the elderly. An expert consensus document published jointly in 2008 by the American College of Gastroenterology (ACG), the American College of Cardiology Foundation (ACCF), and the American Heart Association (AHA) provided recommendations on prevention of PUD among users of antiplatelets and anticoagulants. This work aimed to evaluate physicians' compliance with these guidelines in a tertiary academic setting.

METHODS

We examined our medical record database for the 9 month period extending from April 2018 until December 2018. Using this database, we identified elderly patients (> 64 years old) who were chronic (> 3 months) users of low dose aspirin (81 mg once daily) and had an indication for PUD prophylaxis as per the ACG-ACCF-AHA guideline document. We performed a retrospective chart review of patients included in this study. Descriptive statistics were compared using χ² and independent sample t tests.

RESULTS

A total of 852 patients were included in this study. The mean age was 75 years old, and 43% of patients were females. In addition to aspirin, patients were prescribed P2Y12 inhibitors (45.5%), direct oral anticoagulants (DOACs) (23%), warfarin (12%), steroids (9%) or enoxaparin (1%). Users of DOACs were most commonly prescribed apixaban (16%), followed by rivaroxaban (6%) and dabigatran (1%). Overall, only 40% of patients with an indication for PUD prophylaxis received a proton pump inhibitor.

CONCLUSION

PUD prophylaxis may be underutilized in elderly patients. This finding, along with increasing rates of NSAID use and an aging population, may help explain the increased incidence of complicated PUD in the elderly. Efforts are needed to raise physician awareness of PUD prophylaxis guidelines.

Hizikia fusiformis: Pharmacological and Nutritional Properties

The brown seaweed Hizikia fusiformis (syn. Sargassum fusiforme), commonly known as “Hijiki”, has been utilized in traditional cuisine and medicine in East Asian countries for several centuries. H. fusiformis has attracted much attention owing to its rich nutritional and pharmacological properties. However, there has been no comprehensive review of the nutritional and pharmacological properties of H. fusiformis. The aim of this systematic review was to provide detailed information from the published literature on the nutritional and pharmacological properties of H. fusiformis. A comprehensive online search of the literature was conducted by accessing databases, such as PubMed, SpringerLink, ScienceDirect, and Google Scholar, for published studies on the nutritional and pharmacological properties of H. fusiformis between 2010 and 2021. A total of 916 articles were screened from all the databases using the preferred reporting items for systematic reviews and meta-analyses method. Screening based on the setdown criteria resulted in 59 articles, which were used for this review. In this review, we found that there has been an increase in the number of publications on the pharmacological and nutritional properties of H. fusiformis over the last 10 years. In the last 10 years, studies have focused on the proximate, mineral, polysaccharide, and bioactive compound composition, and pharmacological properties, such as antioxidant, anticancer, antitumor, anti-inflammatory, photoprotective, neuroprotective, antidiabetic, immunomodulatory, osteoprotective, and gastroprotective properties of H. fusiformis extracts. Overall, further studies and strategies are required to develop H. fusiformis as a promising resource for the nutrition and pharmacological industries.

A Nationwide Cohort Study Shows a Sex-Dependent Change in the Trend of Peptic Ulcer Bleeding Incidence in Korea between 2006 and 2015

Background/Aims

The incidence of peptic ulcer disease has decreased in past decades; however, the trends in peptic ulcer bleeding (PUB) are inconsistent among regions. This study aimed to investigate the trends in PUB incidence and the effect of risk factors on PUB in Korea.

Methods

The records of patients hospitalized with PUB from 2006 to 2015 were retrieved from the Korean National Health Insurance Service Database. Standardized incidences of PUB were calculated, and the clinical characteristics such as age, sex, Helicobacterpylori infection, drug exposure, comorbidities, and mortality were obtained.

Results

In total, 151,507 hospitalizations with PUB were identified. The overall annual hospitalization rate was 34.98 per 100,000 person-years. The incidence of PUB showed no significant change from 2006 to 2008 and decreased from 2008 to 2015, with an annual change of –2.7% (p<0.05); however, this change was only significant in men. The incidence of PUB was higher in men than in women between 40 and 70 years old and higher in women than in men older than 80 years. From 2006 to 2015, the H. pylori infection rate increased significantly in patients with PUB; however, there was no significant change in exposure to nonsteroidal anti-inflammatory drugs or other drugs that increase the risk of PUB.

Conclusions

Over the past decade, the incidence of PUB has decreased in a sex-specific manner. There has been a decreasing trend in the H. pylori infection rate and no change in exposure to drugs that increase the risk of PUB in Korea.

A pilot study to evaluate the effectiveness and safety of urgent endoscopy for gastroduodenal perforation

BACKGROUND

Gastroduodenal perforation is potentially life threatening and requires early diagnosis and treatment. Urgent endoscopy facilitates detecting bleeding sites and achieving hemostasis. However, there is no consensus on urgent endoscopy for gastroduodenal perforation in Japan.

METHODS

We evaluated the effectiveness and safety of urgent endoscopy for gastroduodenal perforation. We compared clinical characteristics between 140 patients who underwent urgent endoscopy (urgent endoscopy group) and 16 patients did not (no urgent endoscopy group) at Hiroshima City Asa Citizens Hospital between December 2005 and December 2018.

RESULTS

Endoscopic diagnosis was possible in all urgent endoscopy group. In contrast, correct diagnosis of the perforation site was made on CT in 99 cases (63%). Furthermore, the proportion of cases with correct diagnosis of the perforation site by CT findings differed significantly between the urgent endoscopy group and the no urgent endoscopy group (66% vs. 38%, p < 0.05). No complications of urgent endoscopy were observed. Primary perforation site was gastric in 42 cases and duodenal in 114. In the 42 gastric perforation cases, 12 gastric perforation cases (29%) were managed conservatively, successfully in 9 (75%); 2 cases (17%) required delayed emergency surgery for worsening peritonitis. In the 114 duodenal perforation cases (duodenal ulcer in all cases), 52 cases (46%) were managed conservatively, successfully in 48 (92%); 3 cases (6%) required delayed emergency surgery for worsening peritonitis. A significantly higher proportion of gastric perforation cases than duodenal perforation cases required surgical treatment (76% vs. 57%, p < 0.05). Multivariate analysis revealed localized abdominal pain (no peritonism) (OR 0.25; 95% CI 0.08-0.75; p < 0.01) and perforation diameter ≤ 5 mm (OR 0.13; 95% CI 0.04-0.36; p < 0.01) as significant independent clinical factors for successful conservative management of duodenal ulcer perforation.

CONCLUSIONS

Urgent endoscopy in gastroduodenal perforation enabled primary diagnosis and perforation site identification, and facilitated deciding the management strategy.

Acute Upper Gastrointestinal Bleeding in Hexagenerians or Older (≥60 Years) Versus Younger (<60 Years) Patients: Clinico-Endoscopic Profile and Outcome

Background and aims

Acute upper gastrointestinal (UGI) bleeding is one of the serious and potentially life-threatening medical emergencies, causing significant mortality and morbidity. This study aimed to evaluate the clinico-endoscopic profile and outcome among patients aged <60 years who presented for UGI bleeding compared to those aged ≥60 years.

Methods

This prospective observational study was conducted among 194 patients who presented with symptoms or signs of UGI bleed. All patients were divided into two groups, group A (age <60 years), and group B (age ≥60 years). UGI endoscopy was performed using Olympus N19 Endoscope. Rockall scoring (RS) system and Glasgow Blatchford score (GBS) were used to predict the prognosis and re-bleeding.

Results

Of the total, group A included 150 (77.31%) patients and group B 44 (22.69%) patients. The most common presentation was hematemesis and melena in both groups, whilst isolated hematochezia was more common in group A (6.67%, vs. 2.27%, p>0.05). The main cause of bleeding was a variceal bleed in both groups, but it was significantly higher in group A patients (p<0.05). Elderly patients had a significantly higher number of peptic ulcer and malignancy-related bleed (p<0.05). Group A patients had a significantly higher proportion of patients with tachycardia (45.33%, vs. 27.27%, p<0.05), shock (43.33% vs. 13.63%, p<0.05), pallor (76.66% vs. 56.81%, p<0.05), and blood transfusion requirement (64% vs. 45.45%, p<0.05) as compared to group B. Thirty days re-bleeding and mortality rate were similar in both the groups. RS in both groups was 5.02±2.12 vs. 5.98±1.91, p>0.05. GBS was 11.65±4.61 vs. 10.68±4.65, p>0.05. Mortality was significantly higher in patients with RS ≥6 and GBS ≥10.

Conclusion

This study concluded variceal bleeding as a predominant cause of UGI bleed in both age groups, and it was significantly higher in younger. Interestingly, younger patients were more hemodynamically unstable, probably due to the presence of more severe anemia, shock, and hematochezia. The presence of multiple co-morbidities in both the group kept the 30 days mortality and re-bleed rates similar.

Inflammatory Cytokines and Atherosclerotic Plaque Progression. Therapeutic Implications

PURPOSE OF THE REVIEW

Inflammatory cytokines play a major role in atherosclerotic plaque progression. This review summarizes the rationale for personalized anti-inflammatory therapy.

RECENT FINDINGS

Systemic inflammatory parameters may be used to follow the clinical outcome in primary and secondary prevention. Medical therapy, both in patients with stable cardiovascular disease, or with acute events, may be tailored taking into consideration the level and course of systemic inflammatory mediators. There is significant space for improvement in primary prevention and in the treatment of patients who have suffered from severe cardiovascular events, paying attention to not only blood pressure and cholesterol levels but also including inflammatory parameters in our clinical analysis. The potential exists to alter the course of atherosclerosis with anti-inflammatory drugs. With increased understanding of the specific mechanisms that regulate the relationship between inflammation and atherosclerosis, new, more effective and specific anti-inflammatory treatment may become available.

Gastrointestinal bleeding due to peptic ulcers and erosions - a prospective observational study (BLUE study)

OBJECTIVES

Acute upper gastrointestinal bleeding is a well-recognized complication of peptic ulcers and erosions. The aim of this study was to assess the incidence rate and identify risk factors for this complication in southeastern Norway.

MATERIALS AND METHODS

Between March 2015 and December 2017, a prospective observational study was conducted at two Norwegian hospitals with a total catchment area of approximately 800,000 inhabitants. Information regarding patient characteristics, comorbidities, drug use, H. pylori status and 30-day mortality was recorded.

RESULTS

A total of 543 adult patients were included. The incidence was 30/100,000 inhabitants per year. Altogether, 434 (80%) of the study patients used risk medication. Only 46 patients (8.5%) used proton pump inhibitors (PPIs) for more than 2 weeks before the bleeding episode. H. pylori testing was performed in 527 (97%) patients, of whom 195 (37%) were H. pylori-positive. The main comorbidity was cardiovascular disease. Gastric and duodenal ulcers were found in 183 (34%) and 275 (51%) patients, respectively. Simultaneous ulcerations at both locations were present in 58 (10%) patients, and 27 (5%) had only erosions. Overall, the 30-day mortality rate was 7.6%.

CONCLUSIONS

The incidence of upper gastrointestinal bleeding due to peptic ulcers and erosions was found to be lower than previously demonstrated in comparable studies, but the overall mortality rate was unchanged. The consumption of risk medication was high, and only a few patients had used prophylactic PPIs. Concurrent H. pylori infection was present in only one-third of the patients.

CLINICAL TRIAL REGISTRATION

Bleeding Ulcer and Erosions Study 'BLUE Study', ClinicalTrials.gov Identifier. NCT03367897.

Mesenchymal stem cells promote healing of nonsteroidal anti-inflammatory drug-related peptic ulcer through paracrine actions in pigs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most important causes of peptic ulcer disease in high-income countries. Proton pump inhibitors are the current standard treatment; however, safety and long-term adverse effects of using these drugs are attracting more and more concerns in recent years. Using a porcine model of NSAID-related gastric ulcer, we herein show that adipose-derived mesenchymal stem cells (ADMSCs) delivered by endoscopic submucosal injection promoted ulcer healing with less inflammatory infiltration and enhanced reepithelization and neovascularization at day 7 and day 21 when compared with the controls (saline injection). However, only few engrafted ADMSCs showed myofibroblast and epithelial cell phenotype in vivo, suggesting the ulcer healing process might be much less dependent on the stem cell transdifferentiation. Further experiment with submucosal injection of MSC-derived secretome revealed a therapeutic efficacy comparable to that of stem cell transplantation. Profiling analysis showed up-regulation of genes associated with inflammation, granulation formation, and extracellular matrix remodeling at day 7 after injection of MSC-derived secretome. In addition, the extracellular signal-regulated kinase/mitogen-activated protein kinase and the phosphoinositide-3-kinase/protein kinase B pathways were activated after injection of ADMSCs or MSC-derived secretome. Both signaling pathways were involved in mediating the major events critical to gastric ulcer healing, including cell survival, migration, and angiogenesis. Our data suggest that endoscopic submucosal injection of ADMSCs serves as a promising approach to promote healing of NSAID-related peptic ulcer, and the paracrine effectors released from stem cells play a crucial role in this process.

Transcatheter arterial embolization for upper gastrointestinal tract bleeding

Introduction

Transcatheter arterial embolization is a possible treatment for patients with recurrent bleeding from the upper gastrointestinal tract after failed endoscopic management and is also an alternative to surgical treatment.

Aim

To analyze the outcomes of transcatheter arterial embolization and identify the clinical and technical factors that influenced the rates of morbidity and mortality.

Material and methods

A retrospective analysis was carried out, based on the data of 36 patients who underwent transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding in 2013 to 2015 in our center. An analysis was performed between early rebleeding rates, mortality and the following factors: patient sex, age, number of units of packed red blood cells and packed plasma administered to the patients, length of hospital stay, therapeutic or prophylactic embolization.

Results

The technical success rate of the embolization procedure was 100%. There were 15 (41.70%) therapeutic embolizations and 21 (58.3%) prophylactic embolizations. There was a 77.8% clinical success rate. Following embolization, 10 (27.80%) patients had repeated bleeding and 9 (25.0%) patients died. Significant associations were found between rebleeding and prophylactic embolization (OR = 10.53; p = 0.04) and between mortality and prophylactic embolization (OR = 10.53; p = 0.04) and units of packed red blood cells (OR = 1.25; p < 0.01).

Conclusions

In our experience, transcatheter arterial embolization is a safe treatment method for acute nonvariceal upper gastrointestinal bleeding and a possible alternative to surgery for high-risk patients.

Is it possible to reduce the surgical mortality and morbidity of peptic ulcer perforations?

Objective

Peptic ulcer perforation is a life-threatening situation requiring urgent surgical treatment. A novel vision in peptic ulcer perforation is necessary to fill the gaps created by antiulcer medication, aging of the patients, and presentation of resistant cases in our era. In this study, we aimed to share our findings regarding the effects of various risk factors and operative techniques on the mortality and morbidity of patients with peptic ulcer perforation.

Material and Methods

Data from 112 patients presenting at our Training and Research Hospital Emergency Surgery Department between January 2010 and December 2015 who were diagnosed with PUP through physical examination and laboratory and radiological tests and operated at the hospital have been retrospectively analyzed. Patients were divided into three groups based on morbidity (Group 1), mortality (Group 2), and no complication (Group 3).

Results

Of the 112 patients included in the study, morbidity was observed in 21 (18.8%), mortality in 11 (9.8%), and no complication was observed in 80 (71.4%), who were discharged with cure. The differences between group for the average values of the perforation diameter and American Society of Anesthesiologists, Acute Physiology and Chronic Health Evaluation II, and Mannheim Peritonitis Index scores were statistically significant (p<0.001 for each). The average values for the group with mortality were significantly higher than those of the other groups.

Conclusion

In this study where we investigated risk factors for increased morbidity and mortality in PUPs, there was statistically significant difference between the average values for age, body mass index, perforation diameter, and Acute Physiology and Chronic Health Evaluation II and Mannheim Peritonitis Index scores among the three groups, whereas the amount of subdiaphragmatic free air did not differ.

Protective effects of polysaccharide from Dendrobium nobile against ethanol-induced gastric damage in rats

Dendrobium nobile is a medicinal herb in traditional China and Southeast Asian countries. Employing a rat model of ethanol-induced gastric ulcer, we examined the protective effect of polysaccharide (JCP) extracted from Dendrobium nobile and explored the related mechanisms. Oral administration with 100mg/kg and 300mg/kg body weight JCP for days can significant prevent the formation of gastric ulcer. Moreover, JCP pretreatment could alleviate ethanol-induced histological damage, antioxidant activities, the level of epidermal growth factor, gastric concentration of prostaglandin E, and regulate the signaling pathways of mitogen-activated protein kinases and matrix metalloproteinases. This study investigated the ethanol-induced gastric ulcer protective effect of JCP for the first time, and elucidated that the protective mechanisms.

Gastric Ulcer Complications after the Introduction of Proton Pump Inhibitors into Clinical Routine: 20-Year Experience

BACKGROUND

The aim of this study was to analyze the admissions and the management of peptic ulcer disease (PUD) in a tertiary care surgical center.

METHODS

We evaluated the medical records of all patients admitted to the University Hospital of Tübingen, Germany, for treatment of PUD during 1989-2008. Patients were included into the study if the diagnosis was verified endoscopically or surgically. Annual number of admissions, length of hospitalization, mortality rate, age, rate of non-steroidal anti-inflammatory drugs (NSAIDs) and proton pump inhibitor (PPI) medication, rate of Helicobacter pylori infection, and complications of PUD and surgery performed were recorded. Data were analyzed by descriptive analyses, Pearson's chi-square test, and regression analysis.

RESULTS

This study included 614 admissions. The number of annual admissions (31 ± 12), the length of hospitalization (9 ± 3 days), and the mortality rate (5 ± 4% per year) remained constant, whereas the age increased (1989: 52 ± 14 years vs. 2008: 67 ± 16 years). The rates of patients with H. pylori infection (47 ± 28% per year), NSAIDs treatment (29 ± 15% per year), and PPI treatment (31 ± 27% per year) remained constant. The most frequent PUD complication was hemorrhage (42 ± 16% per year), followed by perforation (9 ± 8% per year). During 1999-2008, more hemorrhages (125 vs. 121; p < 0.05) and perforations (40 vs. 21; p < 0.05) were registered than during 1989-1998. The rate of emergency surgery increased from 70% during 1989-1998 to 87% during 1999-2008. In contrast, elective surgery decreased from 21% during 1989-1998 to 7% during 1999-2008. Ulcer excision and oversewing was the most frequent surgical procedure performed (59%), with decreasing rates of acid-reducing surgery.

CONCLUSION

Despite recent advances in PUD management, ulcer hemorrhage and perforation remain a significant health burden and a surgical disease.

Use of over-the-scope clips (OTSC) for hemostasis in gastrointestinal bleeding in patients under antithrombotic therapy

Background and study aims In patients taking different regimens of antithrombotic and/or anticoagulant therapy, endoscopic management of gastrointestinal bleeding represents a major challenge due to failing endogenous hemostasis. In this retrospective study we report on success rates with the over-the-scope clip (OTSC) system in upper and lower gastrointestinal bleeding in this high-risk patient population. Patients and methods Between February 2011 and June 2014, 75 patients were treated with an OTSC for active gastrointestinal bleeding. Success rates with the first endoscopic therapy, rebleeding episodes, their management and the influence of antithrombotic or anticoagulant therapy were analyzed retrospectively. Results Application of the OTSC resulted in immediate hemostasis (primary success rate) in all 75 patients. However, in 34.7 % a rebleeding episode was noted that could be treated by further endoscopic interventions. Only 3 patients had to be sent to the operating room because of failure of endoscopic therapy. In the rebleeding group the use of antiplatelet therapies was higher (73.1 % vs. 48.9 %). Conclusions Application of the OTSC in GI bleeding results in a high rate of primary hemostasis. Rebleeding occurs in up to 35 % of patients receiving antithrombotic/anticoagulant therapy but can be managed successfully with further endoscopic treatments. Patients in the rebleeding group were more frequently treated with antiplatelet agents. Radiological or surgical therapy was reserved for a small subgroup not successfully managed by repeated endoscopic therapies. OTSC application is the treatment of choice in high-risk patients when conventional clips used as first-line treatment fail.

Nonvariceal upper gastrointestinal bleeding in elderly people: Clinical outcomes and prognostic factors

OBJECTIVE

To analyze the clinical characteristics, outcomes and prognostic factors in elderly patients (aged 75 years and elder) with acute nonvariceal upper gastrointestinal bleeding (UGIB).

METHODS

Consecutive patients admitted with acute nonvariceal UGIB who underwent upper gastrointestinal endoscopy were prospectively recruited and subdivided into two age-based groups, elderly (aged ≥75 years) and younger patients (<75 years). The patients' characteristics and outcomes were recorded.

RESULTS

Altogether 1136 patients were included in the study, 276 (24.3%) aged ≥75 years. Peptic ulcers, gastroduodenal erosions and esophagitis represented the three most common endoscopic lesions found in 87.7% of the elderly patients compared with 80.8% in younger patients ( P  = 0.008). Overall, the rebleeding rate (4.0% vs 3.3%, P = 0.568), need for blood transfusion (66.3% vs 61.0%, P = 0.122), surgery rate (1.2% vs 1.4%, P = 0.947) and in-hospital mortality (13.0% vs 10.0%, P = 0.157) were not different between the two groups. In elderly patients, serum albumin was the only predictive variable independently associated with mortality in the overall analysis (OR 5.867, 95% CI 2.206-15.604, P < 0.001) and in the subgroup patients with peptic ulcers (OR 5.230, 95% CI 2.099-13.029, P = 0.001). Elderly patients with serum albumin >23.5 g/L at admission presented a low mortality (negative predictive value 97.3%).

CONCLUSIONS

Clinical evolution and mortality do not differ between the elderly and younger patients with acute nonvariceal UGIB. Serum albumin level at admission is a prognostic marker for mortality in elder patients.

Outcome of nonsurgical intervention in patients with perforated peptic ulcers

BACKGROUND

Although surgical intervention is the favorable treatment modality for perforated peptic ulcer, nonsurgical treatment is another option. The aim of this study is to analyze the results of conservative treatment for perforated peptic ulcer.

METHODS

Between 2003 and 2014, 403 patients were admitted to our hospital for perforated peptic ulcer, and 383 patients underwent surgery, whereas 20 were allocated to conservative treatment. The results of nonsurgical intervention in these patients were analyzed retrospectively.

RESULTS

The overall mortality rate of conservative treatment was 40%. Eleven patients remained hospitalized less than 2 weeks; among them, patients with a high (≥IV) American Society of Anesthesiologists class at admission had higher mortality than those with a low (<IV) American Society of Anesthesiologists class (83.3% vs 0%, P=.015). However, when patients remained hospitalized longer than 2 weeks, the mortality rates did not differ between patients with the low and high American Society of Anesthesiologists classes. Eight patients presented with a high American Society of Anesthesiologists class, of which 3 received early enteral feeding, and all of them survived. In contrast, the survival of patients without early enteral feeding was 0%, suggesting that early enteral feeding improved survival of patients with the high American Society of Anesthesiologists class (P=.018).

CONCLUSIONS

A higher American Society of Anesthesiologists class correlated with mortality in patients undergoing conservative treatment during the first 2 weeks of hospitalization. Early enteral feeding might improve the outcome of conservative treatment in patients with high American Society of Anesthesiologists class.

Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding

Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding using evidence-based methods. The major cause of non-variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug-related ulcers has become predominant in comparison with bleeding from Helicobacter pylori (HP)-related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first-line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research.

Epidemiology and Risk Factors for Upper Gastrointestinal Bleeding

Although the incidence of nonvariceal upper gastrointestinal bleeding (UGIB) has been decreasing worldwide, nonvariceal UGIB continues to be a significant problem. Even with the advent of advanced endoscopic procedures and potent medications to suppress acid production, UGIB carries significant morbidity and mortality. Some of the most common risk factors for nonvariceal UGIB include Helicobacter pylori infection, nonsteroidal antiinflammatory drugs (NSAIDs), aspirin, selective serotonin reuptake inhibitors, and other antiplatelet and anticoagulant medications. In patients with cardiovascular disease and kidney disease, UGIB tends to be more severe and has greater morbidity. Many of the newer NSAIDs have been removed from the market.

Peptic ulcer andHelicobacter pylori

As evidence about the relationship between Helicobacter pylori infection and peptic ulcers accumulates, accurate testing and treatment are becoming increasingly important. However, big questions remain about the best strategies for detecting and managing this infection. In this article, the authors discuss the association between H pylori and peptic ulcer disease, the available tests for detecting the infection, and the latest treatment strategies for effective eradication.

North vs south differences in acute peptic ulcer hemorrhage in Croatia: hospitalization incidence trends, clinical features, and 30-day case fatality

Aim

To assess the seven-year trends of hospitalization incidence due to acute peptic ulcer hemorrhage (APUH) and associated risk factors, and examine the differences in these trends between two regions in Croatia.

Methods

The study collected sociodemographic, clinical, and endoscopic data on 2204 patients with endoscopically confirmed APUH who were admitted to the Clinical Hospital Center “Sestre Milosrdnice,” Zagreb and Clinical Hospital Center Split between January 1, 2005 and December 31, 2011. We determined hospitalization incidence rates, 30-day case fatality rate, clinical outcomes, and incidence-associated factors.

Results

No differences were observed in APUH hospitalization incidence rates between the regions. Age-standardized one-year cumulative APUH hospitalization incidence rate calculated using the European Standard Population was significantly higher in Zagreb than in Split region (43.2/100 000 vs 29.2/100,000). A significantly higher APUH hospitalization incidence rates were observed in the above 65 years age group. Overall 30-day case fatality rate was 4.9%.

Conclusion

The hospitalization incidence of APUH in two populations did not change over the observational period and it was significantly higher in the Zagreb region. The incidence of acute duodenal ulcer hemorrhage also remained unchanged, whereas the incidence of acute gastric ulcer hemorrhage increased. The results of this study allow us to monitor epidemiological indicators of APUH and compare data with other countries.

Protective effects of garlic extract, PMK-S005, against nonsteroidal anti-inflammatory drugs-induced acute gastric damage in rats

BACKGROUND

PMK-S005 is synthetic s-allyl-L-cysteine (SAC), a sulfur-containing amino acid, which was initially isolated from garlic. The antioxidant and anti-inflammation activities of SAC have been demonstrated in diverse experimental animal models.

AIMS

The purpose of this study was to investigate the gastroprotective effects of PMK-S005 against NSAIDs-induced acute gastric damage in rats.

METHODS

Eight-week SD rats were pretreated with PMK-S005 (1, 5, or 10 mg/kg) or rebamipide (50 mg/kg) 1 h before administration of NSAIDs including aspirin (200 mg/kg), diclofenac (80 mg/kg), and indomethacin (40 mg/kg). After 4 h, the gross ulcer index, histological index, and gastric mucus level were determined. Myeloperoxidase (MPO), TNF-α, IL-1β, PGE2, and LTB4 levels were estimated in the gastric mucosal tissue by ELISA. Protein expressions of cPLA2, COX-1, and COX-2 were assessed by Western blot analysis.

RESULTS

Pretreatment with PMK-S005 significantly attenuated the NSAIDs-induced gastric damage and increased the gastric mucus level. In addition, PMK-S005 attenuated increases in MPO, TNF-α, and IL-1β production. The expressions of cPLA2 and COX-2 induced by NSAIDs were decreased by PMK-S005 pretreatment. PMK-S005 did not cause suppression of PGE2 synthesis induced by NSAIDs, but LTB4 production was significantly suppressed by PMK-S005. The effects of PMK-S005 were consistently maximized at a concentration of 5 mg/kg, which were frequently superior to those of rebamipide.

CONCLUSIONS

These results strongly suggest that PMK-S005 can be a useful gastroprotective agent against acute gastric mucosal damage by suppressing proinflammatory cytokines, down-regulating cPLA2, COX-2 and LTB4 expression, and increasing the synthesis of mucus.

Severe bleeding after percutaneous transhepatic drainage of the biliary system: effect of antithrombotic agents--analysis of 34 606 cases from a Japanese nationwide administrative database

PURPOSE

To investigate the relationship between antithrombotic agents (antiplatelet agents and anticoagulants) and severe bleeding after percutaneous transhepatic biliary drainage (PTBD) for biliary obstruction, or cholecystostomy for acute cholecystitis.

MATERIALS AND METHODS

This retrospective study was institutional review board-approved, and patient consent was waived. Between July 2007 and March 2012, 34 606 patients who underwent PTBD (23 375 patients) or cholecystostomy (11 231 patients) were identified in the Diagnosis Procedure Combination database covering 1119 Japanese hospitals. The association between oral administration of antithrombotic agents prior to the procedure and severe bleeding was evaluated, with adjustment for other potential risk factors, such as age, chronic renal failure, liver cirrhosis, and procedure type. Users of antithrombotic agents were categorized as the continuation group, when they took these agents on the procedure day, or as the discontinuation group, when none were taken. Severe bleeding was defined as bleeding which required red blood cell transfusion or transcatheter arterial embolization within 3 days of the procedure. Univariate and multivariate logistic regression models fitted with generalized estimating equations were performed to evaluate the effect of antithrombotic agents on the bleeding complication.

RESULTS

Overall, 780 of 34 606 patients (2.3%) experienced severe bleeding. In the multivariate model, continuation of antiplatelet agents was significantly associated with severe bleeding versus nonuse (odds ratio [OR], 1.87; 95% confidence interval [CI]: 1.14, 3.05; P = .013), whereas discontinuation of antiplatelet agents showed no association (OR, 0.92; 95% CI: 0.70, 1.20; P = .517). The effect of neither continuation nor discontinuation of anticoagulants on severe bleeding was significant. Other significant risk factors for bleeding included older age, chronic renal failure, liver cirrhosis, academic hospital, and PTBD.

CONCLUSION

The continuation of antiplatelet agents can increase severe bleeding after percutaneous transhepatic drainage, whereas the effect of continuation of anticoagulants was inconclusive.

Helicobacter pylori infection in older people

Since the discovery of Helicobacter pylori (H. pylori) infection as the major cause of gastroduodenal disorders three decades ago, H. pylori has been the focus of active research and debate in the scientific community. Its linkage to several diseases, such as peptic ulcer disease, gastritis and gastric malignancy is incontestable. In particular, it has been noticed that, as the aged population is increasing worldwide, older people are at increased risk of developing several gastroduodenal diseases and related complications. At the same time, gastric cancer is definitely more frequent in elderly than in adult and young people. In addition, it has been showed that peptic ulcer and related complications occur much more commonly in aged individuals than in young people, resulting in a significantly higher mortality. Although this infection plays a crucial role in gastrointestinal disorders affecting all age groups and in particular older people, only a few studies have been published regarding the latter. This article presents an overview of the epidemiology, diagnosis, clinical manifestations and therapy of H. pylori infection in elderly people.

Risk factors associated with NSAID-induced upper gastrointestinal bleeding resulting in hospital admissions: A cross-sectional, retrospective, case series analysis in valencia, spain

Abstract.

BACKGROUND

NSAIDs are a significant cause of drug-related hospital admissions and deaths. The therapeutic effects of NSAIDs have been associated with the risk for developing adverse events, mainly in the gastrointestinal tract.

OBJECTIVES

The focus of this study was to identify the most common risk factors associated with NSAID-induced upper gastrointestinal bleeding (UGIB) resulting in hospital admissions. A secondary end point was the relationship between use of gastroprotective treatment and relevant risk factors to NSAID-induced UGIB in the selected population.

METHODS

This study was a cross-sectional, retrospective, case-series analysis of NSAID-induced UGIB resulting in hospital admission to the Requena General Hospital, Valencia, Spain, occurring from 1997 to 2005. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify UGIB admissions associated with NSAIDs. To estimate the probability of association between UGIB and the use of NSAIDs, the Naranjo adverse drug reaction probability was used. Patients were categorized as high-risk to develop UGIB if they met ≥1 of the following risk criteria (relevant risk factors): aged ≥65 years (age risk factor); peptic ulcer disease or NSAID gastropathy occurring in the year before their hospital admission (history risk factor); and concomitant use of other NSAIDs, systemic corticoids, oral anticoagulants, or platelet aggregation inhibitors (concomitant medication risk factor). Patients were categorized as candidates to use gastroprotections if they met ≥1 of the relevant risk factors. Patients were categorized as users of gastroprotective treatment if they used proton pump inhibitors, histamine H2-receptor antagonists, or misoprostol at hospital admission.

RESULTS

This study comprised 209 cases of NSAID-induced UGIB (129 men, 80 women: mean [SD] age, 71.5 [13.8] years; 128 [61.2%] receiving acetyl salicylic acid [ASA], with 72 [34.4%] receiving low-dose [80-325 mg] ASA). Prevalence of relevant risk factors for UGIB were as follows: age, 158 (75.6%) patients; history, 37 (17.7%); and concomitant medication, 35 (16.7%). One hundred seventy-eight (85.2%) patients met ≥1 criterion for using a gastroprotective agent; 28 (15.6%) were actually using one. Only the history risk factor was significantly associated with the use of gastroprotective treatment (P = 0.007; odds ratio = 3.17).

CONCLUSIONS

In this study of NSAID-induced UGIB resulting in hospital admission, age was the most common risk factor. However, this criterion was not associated with the use of gastroprotective agents. A large number of cases were associated with the use of ASA, primarily in those receiving low doses. A significant lack of gastroprotective agent use was observed in patients who met the criteria to use them.

Epidemiology of perforated peptic ulcer: Age- and gender-adjusted analysis of incidence and mortality

AIM: To investigate the epidemiological trends in incidence and mortality of perforated peptic ulcer (PPU) in a well-defined Norwegian population.

METHODS: A retrospective, population-based, single-center, consecutive cohort study of all patients diagnosed with benign perforated peptic ulcer. Included were both gastric and duodenal ulcer patients admitted to Stavanger University Hospital between January 2001 and December 2010. Ulcers with a malignant neoplasia diagnosis, verified by histology after biopsy or resection, were excluded. Patients were identified from the hospitals administrative electronic database using pertinent ICD-9 and ICD-10 codes (K25.1, K25.2, K25.5, K25.6, K26.1, K26.2, K26.5, K26.6). Additional searches using appropriate codes for relevant laparoscopic and open surgical procedures (e.g., JDA 60, JDA 61, JDH 70 and JDH 71) were performed to enable a complete identification of all patients. Patient demographics, presentation patterns and clinical data were retrieved from hospital records and surgical notes. Crude and adjusted incidence and mortality rates were estimated by using national population demographics data.

RESULTS: In the study period, a total of 172 patients with PPU were identified. The adjusted incidence rate for the overall 10-year period was 6.5 per 100 000 per year (95%CI: 5.6-7.6) and the adjusted mortality rate for the overall 10-year period was 1.1 per 100 000 per year (95%CI: 0.7-1.6). A non-significant decline in adjusted incidence rate from 9.7 to 5.6 occurred during the decade. The standardized mortality ratio for the whole study period was 5.7 (95%CI: 3.9-8.2), while the total 30-d mortality was 16.3%. No difference in incidence or mortality was found between genders. However, for patients ≥ 60 years, the incidence increased over 10-fold, and mortality more than 50-fold, compared to younger ages. The admission rates outside office hours were high with almost two out of three (63%) admissions seen at evening/night time shifts and/or during weekends. The observed seasonal variations in admissions were not statistically significant.

CONCLUSION: The adjusted incidence rate, seasonal distribution and mortality rate was stable. PPU frequently presents outside regular work-hours. Increase in incidence and mortality occurs with older age.

Excess long-term mortality following non-variceal upper gastrointestinal bleeding: a population-based cohort study

BACKGROUND

It is unclear whether an upper gastrointestinal bleed is an isolated gastrointestinal event or an indicator of a deterioration in a patient's overall health status. Therefore, we investigated the excess causes of death in individuals after a non-variceal bleed compared with deaths in a matched sample of the general population.

METHODS AND FINDINGS

Linked longitudinal data from the English Hospital Episodes Statistics (HES) data, General Practice Research Database (GPRD), and Office of National Statistics death register were used to define a cohort of non-variceal bleeds between 1997 and 2010. Controls were matched at the start of the study by age, sex, practice, and year. The excess risk of each cause of death in the 5 years subsequent to a bleed was then calculated whilst adjusting for competing risks using cumulative incidence functions. 16,355 patients with a non-variceal upper gastrointestinal bleed were matched to 81,523 controls. The total 5-year risk of death due to gastrointestinal causes (malignant or non-malignant) ranged from 3.6% (≤ 50 years, 95% CI 3.0%-4.3%) to 15.2% (≥ 80 years, 14.2%-16.3%), representing an excess over controls of between 3.6% (3.0%-4.2%) and 13.4% (12.4%-14.5%), respectively. In contrast the total 5-year risk of death due to non-gastrointestinal causes ranged from 4.1% (≤ 50 years, 3.4%-4.8%) to 46.6% (≥ 80 years, 45.2%-48.1%), representing an excess over controls of between 3.8% (3.1%-4.5%) and 19.0% (17.5%-20.6%), respectively. The main limitation of this study was potential misclassification of the exposure and outcome; however, we sought to minimise this by using information derived across multiple linked datasets.

CONCLUSIONS

Deaths from all causes were increased following an upper gastrointestinal bleed compared to matched controls, and over half the excess risk of death was due to seemingly unrelated co-morbidity. A non-variceal bleed may therefore warrant a careful assessment of co-morbid illness seemingly unrelated to the bleed.

Molecular mechanisms elucidating why old stomach is more vulnerable to indomethacin-induced damage than young stomach

BACKGROUND/AIMS

Detailed underlying changes have never been explored to explain how old stomach is more susceptible to non-steroidal anti-inflammatory drugs (NSAIDs)-induced gastric damage than young stomach, although presumptively speculated as weakened mucosal defense system as well as attenuated regenerating capacity in old stomach.

METHODS

In order to investigate molecular mechanisms relevant to NSAID-induced gastric damage, we administered indomethacin to 6-week-old and 60-week-old rats.

RESULTS

In spite of the same oral administration of indomethacin (0.1 mg indomethacin dissolved in 1 ml carboxyl methylcellulose) irrespective of body weights of rat, gastric mucosal damages were significantly increased in the older rats compared to the younger rats (p < 0.05). Before indomethacin administration, inflammatory mediators including cytokines, chemokines, proteases, and adhesion molecules were significantly increased in old stomach and these differences were further increased after indomethacin administration (p < 0.05). Furthermore, the levels of total oxidants and apoptotic executors were significantly increased in old stomach, whereas lipoxin A4 and anti-apoptotic proteins such as survivin and Bcl-2 were significantly decreased. Increased NF-κB-DNA binding activity as well as the activation of JNK and p38 was responsible for the increased expressions of inflammatory mediators as well as oxidants.

CONCLUSIONS

A preventive strategy to reduce either redox activation or pro-inflammatory mediators should be considered in older patients taking long-standing NSAID administration.

Long-term tolerability of topical diclofenac sodium 1% gel for osteoarthritis in seniors and patients with comorbidities

Background

Adverse events associated with nonsteroidal anti-inflammatory drugs (NSAIDs) used to treat knee and hand osteoarthritis may be more frequent in certain patient populations. Topical NSAIDs, such as diclofenac sodium 1% gel (DSG), have equivalent efficacy and fewer adverse events compared with oral NSAIDs. This post hoc analysis assessed the long-term tolerability of DSG in elderly patients and patients with an elevated risk of gastrointestinal, cardiovascular, and renal adverse events.

Methods

Patients ≥ 35 years of age with knee osteoarthritis applied DSG (4 g) to one or both knees for 12 weeks during either of two primary studies and for 9 months during a long-term extension study. Other patients entered the long-term extension study directly and applied DSG for 12 months. Safety was assessed by reported adverse events. Subpopulations were defined based on age, or the comorbidities of hypertension, type 2 diabetes mellitus, and cerebrovascular or cardiovascular disease.

Results

The safety population consisted of 947 patients who received at least one dose of DSG during the primary or extension study. Patients aged < 65 years (68.2%) and ≥65 years (67.2%) experienced any adverse event at similar rates. The percentage of patients who experienced any adverse event was similar between patients with and without hypertension (65.5% versus 69.7%, respectively), type 2 diabetes mellitus (64.0% versus 68.2%), or cerebrovascular or cardiovascular disease (61.9% versus 68.5%). Among the 15 patients with all three comorbidities, the percentage of patients with any adverse event (53.3%) was less than that of patients who did not have all three comorbidities (68.0%).

Conclusion

These results suggest that long-term DSG treatment is safe in patient subpopulations with an elevated risk of NSAID-related adverse events, such as the elderly and those with the comorbidities of hypertension, type 2 diabetes mellitus, and cerebrovascular or cardiovascular disease.

Trends in Peptic Ulcer Disease and the Identification of Helicobacter Pylori as a Causative Organism: Population-based Estimates from the US Nationwide Inpatient Sample

Background:

Peptic ulcer disease can lead to serious complications including massive hemorrhage or bowel perforation. The modern treatment of peptic ulcer disease has transitioned from the control of gastric acid secretion to include antibiotic therapy in light of the identification of Helicobacter pylori as a causative infectious organism. We sought to determine trends related to this discovery by using a national database.

Materials and Methods:

Patient discharges with peptic ulcer disease and associated sequelae were queried from the Nationwide Inpatient Sample, 1993 to 2007, under the auspices of a data user agreement. To account for the Nationwide Inpatient Sample weighting schema, design-adjusted analyses were used. Standard error was calculated using SUDAAN software (Research Triangle International, NC, USA).

Results:

Decreases in the incidences of gastrointestinal perforation, gastrointestinal hemorrhage, and surgical procedures most specific to peptic ulcer disease were statistically significant over the study period [range of P value (two tailed) = 0.000 – 0.00353; significant at P < 0.001 to < 0.01]. The incidence of H. pylori rose dramatically, peaking at an estimated 97,823 cases in 1998 [SE = 3155; 95% CI = 6,184]. Since that time it has decreased and then stabilized.

Conclusions:

The identification of H. pylori as the causative agent in the majority of peptic ulcer disease has revolutionized the understanding and management of the disease. Medical conditions and surgical procedures associated with end-stage peptic ulcer disease have significantly decreased according to analysis of selected index categories. Resident physician education objectives may need to be modified in light of these trends.

Review Criteria:

We reviewed patients with peptic ulcer disease. The database used was the Nationwide Inpatient Sample, 1993 to 2007.

Message for the Clinic:

Medical therapy has resulted in decreased morbidity from H. pylori infection as it is the causative agent in the majority of peptic ulcer disease. Aggressive screening and treatment of this infection will lead to further reduction in morbidity.

Perforated duodenal ulcer in high risk patients: is percutaneous drainage justified?

Background:

Conservative treatment was recommended as the treatment of choice in perforated acute peptic ulcer. Here, we adjunct percutaneous peritoneal drainage with nonoperative conservative treatment in high risk elderly patients with perforated duodenal ulcer.

Aim:

The work was to study the efficacy of percutaneous peritoneal drainage under local anesthesia supported by conservative measures in high risk elderly patients, according to the American Society of Anesthesiologists grading, with perforated duodenal ulcer.

Patients and Methods:

Twenty four high risk patients with age >65 years having associated medical illness with evidence of perforated duodenal ulcer.

Results:

The overall morbidity and mortality were comparable with those treated by conservative measures alone.

Conclusion:

In high risk patients with perforated peptic ulcer and established peritonitis, percutaneous peritoneal drainage under local anesthesia seems to be effective with least operative trauma and mortality rate.

The relative contribution of NSAIDs and Helicobacter pylori to the aetiology of endoscopically-diagnosed peptic ulcer disease: observations from a tertiary referral hospital in the UK between 2005 and 2010

BACKGROUND

Recent data from Western countries indicate that the aetiology of peptic ulcer disease (PUD) is changing as the prevalence of Helicobacter pylori is decreasing while the use of low-dose aspirin (LDA, ≤325 mg/day) is increasing.

AIM

To investigate the changing aetiology and demographics of PUD in a well-characterised patient cohort at a large tertiary hospital in the UK between July 2005 and June 2010.

METHODS

Patients diagnosed with PUD following endoscopy were categorised as non-steroidal anti-inflammatory drug (NSAID)-users or non-users, and their H. pylori status determined. Comparisons between NSAID-users and non-users, and between non-aspirin NSAID-users and LDA-users were summarised using counts and corresponding percentages (for categorical variables) and means and standard deviations (for continuous variables).

RESULTS

Overall, 386 patients were enrolled; 57% used NSAIDs (51% LDA only) and 43% were non-users. 57% of the whole cohort was H. pylori-positive (including 66% with duodenal ulcers and 47% with gastric ulcers). Compared with non-users, NSAID-users were older (mean age 68 vs. 61 years) and fewer were H. pylori-positive (52% vs. 63%). LDA-users were older (mean age 71 vs. 62 years) and more likely to be H. pylori-positive (61% vs. 41%) than those using non-aspirin NSAIDs. Twelve per cent of the patients were neither using NSAIDs nor were H. pylori-positive.

CONCLUSIONS

The NSAIDs, particularly LDA, were most commonly associated with PUD in this cohort. Our findings are compatible with the decline in the prevalence of H. pylori-positive PUD and increase in non-NSAID, non-H. pylori PUD previously reported.

Incidence and 30-day mortality of peptic ulcer bleeding in Korea

OBJECTIVES

To estimate the rates of peptic ulcer bleeding (PUB) incidence and the association of demographic factors with 30-day mortality after PUB.

METHODS

Diagnostic algorithms for PUB were derived and validated on the basis of 115 true PUB patients at one tertiary hospital in 2005, followed by estimation of age-specific PUB incidence and 30-day mortality rates, using the Korean National Health Insurance claim database. A Cox proportional hazard model was used to determine the impact of demographic factors on the 30-day mortality rate ratio (MRR) after PUB.

RESULTS

The diagnostic algorithm showed 89 and 88% positive predictive value and sensitivity, respectively. On the basis of this algorithm, the rate of PUB incidence was 22.1 per 100 000 during 2006-2007 and the age-specific incidence rate increased with advanced age. This incidence rate was more than three times higher among men than women. Among 21 107 PUB patients, the overall 30-day mortality rate was 2.15%, but it ranged from 0.83% for patients younger than 60 years to 7.65% for patients older than 80 years. The adjusted 30-day mortality rate ratio for patients older than 80 was 8.13 (95% confidence interval 6.10-10.8) compared with those younger than 60 and 7.09 (95% confidence interval 2.78-4.51) for patients with a high level of comorbidity compared with a low level of comorbidity.

CONCLUSION

PUB incidence was higher among men and increased with advanced age. Increased 30-day mortality was observed in association with increasing age, after adjusting for comorbidity.

Gastrointestinal bleeding in patients aged 85 years and older

The aging of the population is associated with the increased risk of chronic diseases, and greater consumption of drugs used in their treatment, which may lead towards gastrointestinal bleeding.The aim of the study was to analyze the reasons, treatment results, complications and mortality connected with gastrointestinal bleeding in patients aged 85 years and older.Material and methods. The study comprised the retrospective analysis of 84 patients, aged between 85 and 97 years admitted to the Department of General Surgery with diagnosis of gastrointestinal bleeding, during the period between 2005 and 2010. The results were compared to a younger control group of 151 patients (mean age-53 years) with gastrointestinal bleeding, admitted to the department during the same period. Diagnosis was based on the history, physical examination, endoscopy, morphology and biochemical lab results. Analysis considered the therapeutic method used, treatment results, complications and hospital mortality. The endoscopic picture and risk of recurrent bleeding in patients with upper gastrointestinal hemorrhage was evaluated by means of the clinical Forrest scale. Results were subject to statistical analysis.Results. Most of the gastrointestinal bleeding cases considering patients aged 85 years and older concerned the upper gastrointestinal tract (41.67%). Thirty (35.71%) patients were on drugs affecting the coagulation system. On admission, the average hemoglobin concentration level in the elderly was comparable to results observed in case of the control group. Considering patients aged 85+, drugs affecting the coagulation system were used statistically more frequently, as compared to younger patients. Recurrence of bleeding was observed in 10 (11.9%) study group patients.Overall mortality due to gastrointestinal bleeding in elderly patients amounted to 20.24% and was statistically higher, as compared to the control group- 7.2%.Conclusions. Treatment results in case of gastrointestinal bleeding in the elderly patients (above 85 years) are burdened with a higher mortality rate. Different diagnostic and therapeutic methods should be applied in case of elderly patients (above 85 years), in order to increase their chance of survival. The problem of aging is an epidemiological phenomenon and gastrointestinal bleeding will become an increasing problem, needing to be solved in everyday clinical practice.

Diagnostic indicators for peptic ulcer perforation at a tertiary care hospital in Thailand

Introduction

Limited data currently exists regarding the diagnostic indicators of peptic ulcer perforation for early detection among patients in Thailand. Delayed diagnosis and treatment for an ulcer can be life-threatening, resulting in shock or death.

Objective

To determine the diagnostic indicators of peptic ulcer perforation.

Material and methods

A cohort study was conducted in a tertiary care hospital in Thailand from 2005 to 2009. Peptic ulcer patients aged 15 years and over admitted to the surgical department were included. The diagnostic indicators used criteria of the patients’ final diagnoses and operations, coded according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, which included patient profiles, gender, age, coexisting illnesses, personal habits, signs and symptoms, laboratory investigations, radiological finding, and treatment role. Exponential risk regression analyses to obtain relative risk (RR) estimates for diagnostic indicators were analyzed using Stata^® statistical software package, version 11 (StataCorp LP, College Station, TX).

Results

The study included 1290 patients. Of these, 57% reported perforated peptic ulcer. Multivariate analysis showed five diagnostic indicators: signs and symptoms including intense abdominal pain (RR = 1.53, 95% confidence interval [CI] 1.14–2.06), tenderness (RR = 1.94, 95% CI 1.17–3.21), and guarding (RR = 1.52, 95% CI 1.05–2.20); X-ray with free air (RR = 2.80, 95% CI 2.08–3.77); and referral from other hospitals (RR = 1.37, 95% CI 1.03–1.82).

Conclusion

Five diagnostic indicators for peptic ulcer perforation monitoring were suggested from this study. Improving diagnostic indicators for medical care may improve the outcome of patients that have perforated peptic ulcer.

Epidemiology and demographics of upper gastrointestinal bleeding: prevalence, incidence, and mortality

Despite major advances in diagnosis, prevention, and treatment, nonvariceal upper gastrointestinal bleeding still is a serious problem in clinical practice. Current evidence indicates that most peptic ulcer bleeding-linked deaths are not a direct sequela of the bleeding ulcer itself. Instead, mortality derives from multiorgan failure, cardiopulmonary conditions, or terminal malignancy, suggesting that improving further current treatments for the bleeding ulcer may have a limited impact on mortality unless supportive therapies are developed for the global management of these patients.