M. Imhof

Time-trends in the epidemiology of peptic ulcer bleeding

Objective. Despite the introduction of effective medical treatment of peptic ulcer disease, bleeding is still a frequent complication. The aim of this study was to investigate whether the incidence and the risk profile of peptic ulcer haemorrhage have changed within a 10-year period. Material and methods. In a prospective epidemiological and observational study the incidence and risk profile of peptic ulcer haemorrhage in Düsseldorf, Germany were compared between two time periods (period A: 1.3.89–28.2.90 and period B: 1.4.99–31.3.2000), involving nine hospitals with both surgical and medical departments. Patients with proven peptic ulcer haemorrhage at endoscopy or operation were included in the study; those with bleeding under defined severe stress conditions were excluded. Results. No differences in bleeding ulcer incidence were observed between periods A and B (51.4 per 100,000 person-years versus 48.7), or for duodenal ulcer (24.9 versus 25.7) or for gastric ulcer bleeding (26.5 versus 23.0). A marked increase in incidence rates was observed with increasing age. In period B, patients with bleeding ulcers were older (56% versus 41% 70 years or older), were usually taking non-steroidal anti-inflammatory drugs (NSAIDs) (45% versus 27%) and were less likely to have a history of ulcer (25% versus 59%) compared with patients in period A. Conclusions. The persisting high incidence of peptic ulcer disease is a superimposing of two trends: a higher incidence in the growing population of elderly patient with a higher intake of NSAIDs and a lower incidence among younger patients due to a decrease in incidence and improved medical treatment.

Trends in Peptic Ulcer Bleeding and Surgical Treatment

An evidence-based approach is followed, with grading of evidence by study design, to evaluate surgical treatment of a bleeding peptic ulcer. In contrast to endoscopic treatment, reports of surgical treatment are rare, with only five randomized trials having been identified. Epidemiologic studies have demonstrated that the incidence of emergency surgery has not changed despite major improvements with endoscopic treatment. There are no proven alternatives to emergency operation for massive bleeding uncontrollable by endoscopic procedures. There is some debate about surgery for rebleeding, but no randomized trial has assessed whether a second endoscopic treatment alone is preferable to surgery with or without repeated endoscopic treatment. Concerning the type of operative procedure, the existing body of evidence, including two randomized studies, indicates that patients are best served by a relatively aggressive surgical approach. Today the value of these studies is limited owing to prevention of ulcer recurrence by eradication and technical improvements of local procedures (e.g., arterial ligation). Early elective surgery was tested in two randomized studies and several uncontrolled series, which demonstrated that it may be beneficial in high risk groups and harmful in others. Indications for early elective surgery should be refined taking into account updated prognostic information and more effective endoscopic treatment. Because of a new understanding of ulcer disease the role of surgery has changed markedly within the last years, no longer aiming to cure the disease but primarily to stop the hemorrhage. Evidence, however, is not derived from properly randomized controlled trials but is based on theoretic arguments and knowledge from studies not primarily dealing with operative treatment.

Incidence and Pattern of Peptic Ulcer Bleeding in a Defined Geographical Area

Despite the introduction of effective medical treatment for peptic ulcer disease, no decrease in the incidence of bleeding has been observed. Unfortunately, most incidence studies rely on a questionable case ascertainment and poor data. We therefore conducted a prospective study, to achieve an unbiased estimate of incidence and pattern of peptic ulcer bleeding in Düsseldorf (Germany). In a 1-year period all patients with endoscopically verified peptic ulcer bleeding who were admitted to the departments of internal medicine or surgery in nine hospitals or seen by nine general practitioners offering endoscopic service were included in the study. Incidence rates were calculated in accordance with sociodemographic variables and expressed per 100,000 person-years of observation. The overall incidence of peptic ulcer bleeding was 51.4, with almost even rates for gastric (26.5) and duodenal (24.9) ulcer. Age was associated with an increased likelihood of bleeding in gastric ulcer patients of 19 per decade from about 40 years onwards (duodenal ulcer, 15). The incidence was about twice as high in men as in women (relative risk = 1.9). The pattern of peptic ulcer bleeding was similar in gastric and duodenal ulcers with regard to ulcer size, multiple lesions, and bleeding activity at endoscopy. However, patients with gastric ulcer bleeding had significantly more often accompanying or underlying diseases. No significant differences were observed between gastric and duodenal ulcer bleeding with regard to nonsteroidal antiinflammatory drug intake and ulcer history. The incidence rates in our study are in the upper range of the literature and comparable to rates from the USA and UK both before and after the introduction of H2 blockers. We hypothesize that the persistently high incidence rate is a superposition of two trends: higher incidences due to a more elderly and diseased population and more NSAID intake, and lower incidences due to effective medical treatment.

Impact of Early Operation on the Mortality from Bleeding Peptic Ulcer – Ten Years’ Experience

In 1984, a risk-dependent combined endoscopic and operative approach for the treatment of bleeding peptic ulcer was developed. This treatment policy has as its major feature an early elective operation in patients with arterial bleeding and a visible vessel, providing that endoscopic control of the bleeding could be achieved. Using this concept in a prospective series resulted in a mortality of 5% compared to a mortality of 14% in a historical control group, where an operation was performed only on demand in case of recurrent bleeding. In 1986, the treatment policy was introduced into clinical routine circumstances at the University Hospital of Düsseldorf. In this paper the results of routine clinical application are presented. The treatment policy was followed in 47% of patients treated respectively primarily transferred to the surgical department. Mortality in arterial bleeding and visible vessel in the conservatively treated group was double the mortality in the early elective operated group (14 vs. 7%). The mortality in patients treated primarily in the department of internal medicine was double the mortality of patients treated at the surgical department (18 vs. 9%). The differences in mortality are mainly due to the procedure in the elderly patients. In patients aged 70 years or more, the mortality rate of patients treated in internal medicine was 31% compared to 16% in the surgery department. Younger patients do not seem to benefit from early elective operation. Our study clearly demonstrates the importance of avoiding late recurrent bleeding. Patients at high risk of this complication should therefore be identified as early as possible and early surgical intervention should be considered by agreed interdisciplinary and evaluated treatment concepts.

Which Peptic Ulcers Bleed?: Results of a Case-Control Study

BACKGROUND The incidence of ulcer bleeding has not decrease despite effective medical treatment of peptic ulcer disease. Numerous studies have been performed on risk factors for ulcer bleeding, but only a few studies have related the risk of developing ulcer bleeding to the risk of developing uncomplicated ulcer disease. METHODS This study was performed as a multicenter interdisciplinary case-control study and was based on diagnosis by endoscopy, prospective data collection, and multivariate analysis. To every study patient with ulcer bleeding (case) one patient with uncomplicated peptic ulcer proven at endoscopy (control) was assigned with regard to sex, ulcer localization, and age (+/-5 years). The controls were randomly taken from three sources: inpatients, outpatients, and patients treated by a private physician. RESULTS Owing to strict inclusion and exclusion criteria, 209 matched pairs were available for evaluation out of 401 patients with peptic ulcer bleeding. In univariate analysis the duration of ulcer pain and the number of previous ulcer treatments proved to be protective factors for ulcer bleeding. The intake of non-steroidal anti-inflammatory drugs (NSAID) as a whole, acetylsalicylic acid (aspirin), and paracetamol gave an increased risk for ulcer bleeding. Multivariate analysis identified four risk factors for peptic ulcer bleeding: lung disease, NSAID intake, no pretreatment with H2 blockers, and acetylsalicylic acid intake. CONCLUSIONS The following patient groups represent a risk for peptic ulcer bleeding: multimorbid patients, receiving NSAID and/or aspirin, and patients with no previous ulcer history.

Peptic ulcer bleeding: medical and surgical point of view

SummaryVarious treatment policies and clinical disciplines compete for the treatment of bleeding peptic ulcer. In a prospective multicenter and interdisciplinary study performed during a 1-year period at ten hospitals in Düsseldorf, all patients admitted for peptic ulcer bleeding were recorded. The characteristics of patients admitted to surgical and to medical departments, the distribution of endoscopic treatment, indications for surgery, type of surgical procedures, and outcome were investigated. In the study period 387 bleeding peptic ulcers were recorded. Of these patients 82% were primarily admitted to medical and 18% to surgical departments. No differences in terms of severity of ulcer disease or bleeding activity were noted between the groups of medical and surgical patients. However, accompanying or underlying diseases were detected more often in patients admitted to medical departments. Endoscopy treatment was performed in the majority of patients with arterial spurting bleeding (88%) or a visible vessel (80%). Injection therapy with epinephrine or polidocanol was mainly used (78%). In 16% of cases the patients underwent operation; 44% of the patients primarily admitted to a surgical department were operated (medical departments, 10%). About half of the operated patients underwent emergency surgery; in the majority of cases resections were performed (gastric ulcer, 76%; duodenal ulcer, 56%). Overall mortality was 11 %, with no difference between surgical and medical patients. A high mortality was observed in the subgroup of patients with late recurrent bleeding (27%). It is concluded that for optimal treatment of peptic ulcer bleeding intensive cooperation between physicians and surgeons is necessary, and that agreed and evaluated treatment policies are needed.

Operative Therapie beim unkomplizierten Ulkus: Ergebnisse einer prospektiven epidemiologischen Studie

In einer prospektiven multizentrischen und interdisziplinaren Beobachtungsstudie wurde der heutige Stellenwert der Operation im therapeutischen Vorgehen beim unkomplizierten Ulkus untersucht. In die Studie wurden 1030 Patienten eingebracht, davon 605 ambulante und 425 stationare Patienten. 2/3 der Operationen entfielen auf 3 Krankenhauser, in 3 Kliniken wurden keine und in 4 Kliniken hochstens 3 Operationen durchgefuhrt. Nur 4 der primar in der Inneren Medizin behandelten Patienten wurden einer Operation zugefuhrt. Der Anteil der operierten Patienten an allen klinischen Patienten mit unkomplizierten Ulkus ist gering: 43/1030 (4%). Die Mehrzahl der Kliniken fuhren elektive Ulkusoperationen uberhaupt nicht mehr oder vernachlassigbar selten durch. Erhebliche Auswirkungen auf die Ausbildung und Operationsergebnisse sind langfristig zu befurchten.

Ulkusblutung: Ist eine aggressive chirurgische Therapie noch zu vertreten?

Von 1992 bis 1995 wurden 155 Patienten mit einer peptischen Ulkusblutung und arteriell spritzender Blutung oder sichtbarem Gefasstumpf (Forrest 1a/2a) prospektiv erfast. Bei 8 von 42 Patienten mit spritzender Blutung gelang keine initiale endoskopische Blutstillung. Von 124 primar konservativ behandelten Patienten erlitten 34 (27,4%) eine Rezidivblutung, 9 (34,6%) mit einer Forrest la- und 25 (25,5%) mit einer Forrest 2a-Blutung. 4 (44,4%) bzw. 10 (40%) Patienten musten sich deswegen einer Notfalloperation unterziehen. Die Mortalitat betrug 10,5%, der stationare Aufenthalt im Mittel 21 Tage. 23 Patienten wurden fruhelektiv operiert, davon erlitt 1 Patient (4,3%) eine Rezidivblutung. Die Mortalitat in dieser Gruppe betrug 8,7%, die stationare Aufenthaltsdauer im Mittel 26 Tage. Diese Ergebnisse zeigen eine deutliche Reduzierung der Rezidivblutungsrate durch ein fruhelektives Operationskonzept, allerdings nur eine geringe Reduzierung der Mortalitat. Unseres Erachtens nach mus vor allem bei Patienten mit sichtbarem Gefasstumpf die Operationsindikation neu gefast werden.

Endoskopische versus operative Therapie bei der gastroduodenalen Ulkusblutung — Ergebnisse einer randomisierten Studie

Die Etablierung wirkungsvoller medikamentoser Therapie peptischer Ulkuskrankheit zeigte bis dato keine Auswirkung auf die Inzidenz komplizierter Ulcera [7]. Die aktive Blutung aus gastroduodenalen Ulcera reprasentiert nach wie vor die schwerste und potentiell lebensbedrohliche Komplikation der Ulkuskrankheit mit einer Mortalitat von 10%. Die Blutungsaktivitat ist der wichtigste prognostische Faktor fur den weiteren Verlauf des Patienten. Patienten mit einem hohen Risiko fur eine persistierende bzw. rezidivierende Ulkusblutung stellen diejenigen mit einer arteriellen Blutung (FIa) resp. einem sog. sichtbaren Gefasstumpf im Ulkusgrund (FIIa) dar. Patienten mit niedrigem Risiko (venose Blutung (FIb), mit Blutungsstigmata (FIIb) bzw. ohne Blutungszeichen (FIII)) konnen heutzutage definitiv endoskopisch bzw. medikamentos therapiert werden. Die Behandlung des Hochrisikopatienten ist nach wie vor Gegenstand heftiger Kontroversen. In einigen Studien konnten exzellente Resultate mit einem fruhelektiv-operativen Vorgehen erzielt werden, wahrend andere Autoren, insbesondere nach Etablierung der Fibrinklebung, ein rein endoskopisches Vorgehen favorisieren. Kontrollierte Studien, die ein rein endoskopisches Behandlungskonzept mit dem Konzept der fruhelektiven Operation beim Hochrisikopatienten vergleichen, existieren bisher nicht. Es kann daher zum jetzigen Zeitpunkt von einer fortbestehenden Ungewisheit hinsichtlich der Beurteilung des Wertes einer alleinigen endoskopischen Behandlung mit Fibrin und einem kombinierten endoskopisch-operativen Vorgehen bei Risikopatienten ausgegangen werden.

Multizentrische und Interdisziplinäre Studie zur Epidemiologie der Gastroduodenalen Ulkuskomplikation

Fur die Behandlung der gastroduodenalen Ulkuskrankheit stehen heute mehrere wirkungsvolle Medikamente, z.B. H2-Blocker, Omeprazol und Sucralfat, zur Verfugung (1). Diese Verbesserungen haben leider nicht zu einer Verringerung des eigentlichen Problemes der Ulkuskrankheit, den haufig lebensbedrohlichen Komplikationen Blutung und Perforation, gefuhrt (2). Wir haben daher eine epidemiologische Studie durchgefuhrt, um einerseits die Haufigkeit von Ulkuskomplikationen in einer definierten geographischen Region zu bestimmen und andererseits Risikofaktoren fur eine Komplikation bei bestehender Ulkuskrankheit zu identifizieren. In dieser Arbeit soll vorrangig die Studienmethodik beschrieben werden und nur beispielhaft sollen einige Ergebnisse prasentiert werden. Die Publikation der vollstandigen Studienergebnisse erfolgt in klinischen Zeitschriften.