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Epidemiology of acute upper gastrointestinal bleeding

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Acute upper gastrointestinal bleeding is an important emergency situation. Population-based epidemiology data are important to get insight in the actual healthcare problem. There are only few recent epidemiological surveys regarding acute upper gastrointestinal bleeding. Several surveys focusing on peptic ulcer disease showed a significant decrease in admission and mortality of peptic ulcer disease. Several more recent epidemiological surveys show a decrease in incidence of all cause upper gastrointestinal bleeding. The incidence of peptic ulcer bleeding remained stable. Peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, responsible for about 50% of all cases, followed by oesophagitis and erosive disease. Variceal bleeding is the cause of bleeding in cirrhotic patients in 50–60%. Rebleeding in upper gastrointestinal bleeding occurs in 7–16%, despite endoscopic therapy. Rebleeding is especially high in variceal bleeding and peptic ulcer bleeding. Mortality ranges between 3 and 14% and did not change in the past 10 years. Mortality is increasing with increasing age and is significantly higher in patients who are already admitted in hospital for co-morbidity. Risk factors for peptic ulcer bleeding are NSAIDs use and H. pylori infection. In patients at risk for gastrointestinal bleeding and using NSAIDs, a protective drug was only used in 10%. COX-2 selective inhibitors do cause less gastroduodenal ulcers compared to non-selective NSAIDs, however, more cardiovascular adverse events are reported. H. pylori infection is found in about 50% of peptic ulcer bleeding patients. H. pylori should be tested for in all ulcer patients and eradication should be given.

Introduction

Acute upper gastrointestinal bleeding (UGIB) remains an important emergency situation. In the last two decades major developments took place influencing incidence, aetiology and outcome of patients with acute UGIB. The introduction of H2-receptor antagonist (H2RA) in the mid seventies and proton pump inhibitors (PPI's) in the late eighties of the last century has brought new opportunities to prevent the development of ulcer complications, reduce rebleeding and enhance ulcer healing. Helicobacter pylori (H. pylori) is recognised as an important etiologic factor for the development of peptic ulcer disease and eradication prevents ulcer recurrence. Endoscopy facilitates determination of the cause of bleeding and the performance of endoscopic therapy. Counteracting is the fact that the population is aging, resulting in more co-morbidity and increasing use of medicine. Non-steroidal anti-inflammatory drugs (NSAIDs) are an important risk factor for peptic ulcer complications. The introduction of COX-2 selective inhibitors might have influenced the incidence of peptic ulcer bleeding (PUB). Despite all, rebleeding and mortality hardly decreased in the past decades. This chapter will focus on epidemiology of and time trends in acute UGIB en will describe the role of H. pylori and NSAIDs as important risk factors of peptic ulcer bleeding.

Section snippets

Epidemiology

Population-based epidemiological data regarding acute upper gastrointestinal bleeding are important to give clinicians insight in the extent of the healthcare problem and are necessary to determine risk factors. Before the mid-nineties of the last century there are hardly any population-based data regarding acute UGIB. Many published studies often rely on retrospective data from case notes or unvalidated discharge codes or summaries made without endoscopy in most cases. This will result in

Peptic ulcer bleeding

Peptic ulcer bleeding is the main cause of bleeding, responsible for 28–59% of UGIB (Table 4). Duodenal ulcers are more common than gastric ulcers. Especially in the United States of America and in Greece, the percentage of PUB is high compared to other European populations.18, 23 This might be caused by a high proportion of NSAID use, in both studies around 50%. Another important factor might be the prevalence of Helicobacter pylori infection, but these data are lacking in the American and

Time trends

There are only few comparative epidemiological studies regarding time trends in characteristics and outcome of acute UGIB (Table 2). In a single centre study from Greece, inclusions were retrospectively conducted in 1986–87 and in 2000–01.23 No data regarding incidence or decrease in admissions are available. Patients presenting with acute UGIB in the latter period were significantly older, used more NSAIDs or aspirin (44% vs 64%, p < 0.01) and had more co-morbidity (43 vs 58%, p < 0.01). In both

Non-steroidal anti-inflammatory drugs

NSAID use is high in UGIB patients, but especially in PUB patients. Both NSAID use and H pylori infection independently and significantly increase the risk of PUD and PUB.*45, 46, 47, 48 In a meta-analyses, NSAID use was significantly more common in patient with PUB than in matched controls (Odds Ratio (OR) 4.85, 95% CI 3.77–6.23). H. pylori infection only marginally increased the risk of ulcer bleeding (OR 1.79, 95% CI 0.79–3.32). When both risk factors coexist, the magnitude of the risk was

Summary

There is a marked decline in admission, surgery and mortality for ulcer disease in Europe, America and Asia. There are only few epidemiology surveys regarding upper gastrointestinal bleeding. Recent surveys showed an incidence of upper gastrointestinal bleeding ranging from 37 to 172/100 000 adults. The incidence of UGIB decreased in the past two decades. Furthermore, patients' characteristics changed. Patients tend to be older and are having more severe and life-threatening co-morbidity.

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