1Epidemiology of acute upper gastrointestinal bleeding
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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