Bleeding peptic ulcer: characteristics and outcomes in Newcastle, NSW.

BACKGROUND: Peptic ulcer disease risk factors have changed, as has the impact of treatment on morbidity and mortality. Recent data on clinical presentation and outcome are sparse in Australia. AIM: To determine the characteristics and outcome of patients presenting with a bleeding peptic ulcer to a tertiary referral centre. METHODS: We evaluated patients diagnosed with peptic ulcer bleeding between 2004 and 2008 at a tertiary referral hospital. Variables assessed included demographic data, comorbidities, medication use and Rockall score. Outcomes of interest were the time to endoscopy, peptic ulcer treatment, transfusion requirements, urgent surgery and survival. RESULTS: Peptic ulcers were confirmed in 265 patients (55% male), of which 145 were gastric and 119 duodenal. The mean age was 71 years. On admission 38% of patients had haemodynamic instability and 92% had one or more comorbidity. Consumption of ulcerogenic medications at the time of admission was frequent (non-steroidal anti-inflammatory drugs (NSAIDs) 22%, aspirin 41%, clopidogrel or warfarin 10%) and proton pump inhibitors infrequent (15%). A gastroenterologist managed all patients according to their usual practice. Only a minority of patients received over three units of packed red cells. Few patients were referred for surgery (3%) or died (3%), but both events were significantly higher for the duodenal ulcer group. CONCLUSION: The characteristics and outcomes in patients with peptic ulcer bleeding have changed. Peptic ulcer disease remains a public health problem with modifiable risk factors, such as Helicobacter pylori infection and NSAIDs, which should be targeted to reduce the burden of illness.

Accuracy of provisional diagnoses of dyspepsia in patients undergoing first endoscopy.

BACKGROUND: This study assessed agreement between provisional and endoscopic diagnoses for patients with dyspepsia undergoing initial endoscopy, and examined variation between clinicians at 2 hospitals. METHODS: This was a retrospective review of 423 consecutive patients. RESULTS: Crude percentage agreement ranged from 55% to 97%. Kappa scores revealed poor agreement: peptic ulcers (0.11: 95% CI [0.05, 0.17]); gastroesophageal reflux disease (0.29: 95% CI [0.20, 0.38]); benign esophageal stricture (0.33: 95% CI [0.08, 0.58]); and cancer (0.12: 95% CI [-0.12, 0.36]). Positive and negative predictive values for cancer and benign esophageal stricture showed that agreement for a negative diagnosis was almost perfect, whereas agreement for a positive diagnosis was low. Only 17% of patients with cancer were given an accurate provisional diagnosis. Accuracy of diagnosis did not vary substantially between hospitals. CONCLUSIONS: Crude percentage agreement is misleading. Emphasis should be placed on better prediction of cancer, benign esophageal stricture, and peptic ulcer disease. Accuracy of provisional diagnosis in everyday practice is no worse than that found in prospective studies in which clinicians knew a priori that diagnoses would be scrutinized. The difficulty of predicting diagnoses supports increased reliance on endoscopy.

Group B streptococcal prosthetic joint infections.

We report 6 cases of group B streptococcal prosthetic joint infections seen in our institution and review 8 previously reported cases. These 14 patients (6 men and 8 women) had an average age of 69. Seven hip joints and 7 knee joints were affected. Only 4 patients had risk factors for prosthetic joint infection (diabetes mellitus in 2, cancer in 1, and myelodysplasia in 1). The average time from surgery to onset of symptoms was approximately 4 years (range, 5 months to 10 years). Pain in the affected joint was the chief complaint. Six patients had bacteremia. Seven patients had known or suspected foci of infection, which were genitourinary tract (1), skin and soft tissue trauma sites (1), gastrointestinal tract (1), and oropharynx (1). Nine patients required prosthesis removal in addition to antibiotic therapy. Two patients had apparent cure of the infection with retention of the prosthesis. Group B streptococcal prosthetic joint infections appear to be a late complication of prosthetic joint replacement surgery.

Long-term survival among patients operated upon for peptic ulcer disease.

BACKGROUND: Although surgery has been used widely for treating peptic ulcer disease, there is conflicting evidence with respect to subsequent life expectancy and the determinants of mortality. Our aim was to compare long-term survival in a large, population-based cohort of operated patients with that expected in the general population. METHODS: We followed 471 Rochester, Minnesota residents who had surgery for peptic ulcer at the Mayo Clinic during 1956-85 for a total of 6174 person-years. Patients were followed through their complete (inpatient and outpatient) medical records in the community until death or last clinical contact and death certificates were obtained for all who succumbed. We compared observed survival and cause-specific death rates in this cohort with expected values and identified the determinants of short (30 day) and long-term mortality. RESULTS AND CONCLUSIONS: Survival was worse than expected, but excess deaths were confined to those with perforated ulcers (42 deaths observed; 18.8 expected). Independent predictors of death included age, male gender, emergency operation, gastric ulcer and cigarette smoking. Most deaths were due to heart disease and cancer, but only those due to digestive diseases (standardized mortality ratio (SMR) 3.8, 95% CI 2.4-5.7) and respiratory diseases (SMR 1.9, 95% CI 1.3-2.7) were increased compared to expected figures. Overall survival was reduced in this cohort but was normal among those whose ulcers were not perforated. However, the data suggest an adverse role for alcohol and smoking in these patients.

Quality in healthcare in the United Kingdom: lessons for Australia.

The United Kingdom has a strong emphasis on quality in healthcare and clinical audit. Many quality activities are funded by the government but managed by professional bodies, a model that should be trialed in Australia.

Down's syndrome is strongly associated with coeliac disease.

BACKGROUND: There is evidence of an increased prevalence of coeliac disease in Down's syndrome. AIMS: To investigate the association, patients with Down's syndrome and matched controls were examined. METHODS: Fifty nine patients with Down's syndrome residing in government institutions in the Hunter region of New South Wales were studied. Four were excluded (terminally ill = 1, uncooperative = 3). Each of 55 patients was matched for age, sex, and residence with a control patient. Patients with both positive IgA and IgG antigliadin antibodies were considered for endoscopical duodenal biopsy. RESULTS: Twenty one patients and two controls had raised IgA and IgG antibodies (chi 2 = 19.4; p < 0.001). Tissue was obtained in 18 patients. Two had characteristic flat, five pronounced lymphocytic infiltration not diagnostic of coeliac disease, two giardiasis, and eight were normal. In one the tissue was not suitable for analysis. There were few differences between the subgroups in their anthropomorphic, biochemical, or haematological findings. CONCLUSIONS: The prevalence of coeliac disease in these 51 patients with Down's syndrome is at least two (3.9%; 95% confidence interval (95% CI) 0%-9.2%) and could be as many as seven (13.7%; 95% CI 4.3%-23.2%). In this community the prevalence of coeliac disease in Down's syndrome is increased more than 100-fold (x135-473).

Recent developments in our understanding of adult coeliac disease.

Coeliac disease, previously regarded as unusual and florid, is now seen as having an extraordinary breadth of manifestations. Many cases are unrecognised or latent. Diarrhoea and abdominal complaints may be present in low key but chronic ill health; anaemia, endocrine and neurological changes are increasingly recognised. Suspicion should lead straight to serological tests, of which the antiendomysial antibody test is best. If suspicion is high, endoscopic duodenal biopsy is mandatory. A gluten free diet, while difficult to maintain, effectively cures and prevents complications.

Achromobacter xylosoxidans bacteremia: report of four cases and review of the literature.

Seventy-seven cases of bacteremia due to Achromobacter xylosoxidans were reviewed, and susceptibility studies were performed on 11 clinical isolates of A. xylosoxidans. Nosocomial bacteremia was noted in 54 of 77 patients (70%), and 28 (36%) had infection associated with an outbreak or acquired from a discrete point source. The most common underlying illnesses were malignancies (30%) and cardiac disease (21%); immunosuppression affected 27%. The most common clinical syndromes were primary and catheter-associated bacteremia (19% each) and pneumonia (16%). The case-fatality rate was 30%; only 3% of patients with primary or catheter-associated bacteremia died, but 65% of patients with meningitis, endocarditis, and pneumonia died. The case-fatality rate in neonates was 80%. Susceptibility studies showed that all strains were resistant to aminoglycosides, most were resistant to quinolones, and all were susceptible to broad-spectrum penicillins, imipenem, ceftazidime, and trimethoprim-sulfamethoxazole. Two-disk approximation and time-kill studies showed synergy or additive effects for the combination of gentamicin and piperacillin against most strains.

Pneumococcal vertebral osteomyelitis.

Vertebral osteomyelitis is an unusual complication of pneumococcal infection. This report describes a patient who presented with back pain and lower extremity weakness after bacteremic pneumococcal pneumonia. Magnetic resonance imaging showed destruction of the L-4-L-5 vertebral bodies and thecal sac compression, and Streptococcus pneumoniae was isolated from an aspirate of the disk space. We found only 10 other cases of pneumococcal vertebral osteomyelitis in a review of the literature. In these 11 cases the presentations were usually subacute, and the onset of back pain was insidious. Elevated erythrocyte sedimentation rates were commonly noted. Computed tomography and magnetic resonance imaging were most helpful in delineating the extent of involvement in patients seen in the last decade. Successful treatment included surgery alone in 2 cases that occurred before the antibiotic era, surgery plus 6 weeks of antibiotic therapy in 1, and antibiotics alone for 4 weeks to 7 months in 5. Two patients seen in the preantibiotic era died.

Changing trends in perforated peptic ulcer during the past 45 years.

Since 1944 there has been a dramatic change in the pattern of admissions for perforated peptic ulcer (PPU) to the Royal Newcastle Hospital, the main teaching hospital of the Hunter Region, Australia. Between 1944 and 1950, females accounted for 6% of all perforations; since then the proportion of females admitted with this complication has risen to 32%. Simultaneously, the modal age for PPU has shifted from the fifth to the seventh decade and the ratio of gastric to pyloroduodenal perforations has fallen from 1.1:1 to 0.6:1. No good explanation for this change in the natural history of PPU, also noted elsewhere, is evident.

Perforated peptic ulcer in the Hunter region: a review of 174 cases.

A review of 174 consecutive patients admitted with a diagnosis of perforated peptic ulcer to eight Hunter Region hospitals during 1979-86 is presented. Among the female admissions, the proportion of patients greater than 70 years of age was twice that in males. One-third of all perforations were in females who accounted for two-thirds of all perforated gastric ulcers. Multivariate analysis revealed that perforations located in the stomach and older age were both significant independent variables adversely affecting outcome following surgery. In contrast, shock at presentation and delay in operating were not statistically significant independent risk factors.

Diabetes mellitus and operated peptic ulcer disease.

There is some evidence of an antagonism between peptic ulcer and diabetes mellitus. This antagonism is possibly related to anomalous insulin metabolism in duodenal ulcer patients. To evaluate this issue, 471 Rochester, Minnesota residents who had surgery for peptic ulcer were examined and then followed for up to 34 years. Their experience of diabetes mellitus was compared with that of Rochester residents generally, for whom data on diabetes incidence and prevalence were available. At surgery, the prevalence of diabetes was somewhat increased for gastric and slightly diminished for duodenal ulcer patients. Of the 445 patients who were free of diabetes at surgery, 27 developed it. By 20 years, the cumulative incidence of diabetes (9.1%) was less than expected (10.3%), but over the 20 years the difference was not significant for either gastric or duodenal ulcer patients. The risk of diabetes was not influenced by age, gender, or smoking status but analysis for relative weight at surgery indicated that obese patients had a 2.6-fold increase in risk of subsequent diabetes, whereas those with less than 1.2 relative weight had reduced risk. Relative weight was the only significant predictor of the time to subsequent diabetes in a proportional hazards regression analysis. The proposition of an antagonism between peptic ulcer and diabetes is not supported by the data.

Is the patient with an arthritic neck at risk during endoscopy?

To determine whether upper gastrointestinal endoscopy poses a risk to patients with arthritis of the neck, 486 members of the Gastroenterology Society of Australia were surveyed by postal questionnaire. Replies were obtained from 323 members. More than 1.5 million endoscopies were covered and 11 respondents had experienced major complications related to neck arthritis. With one exception these were perforations of the upper gastrointestinal tract. There were no reports of serious neurological sequelae. Deaths resulted in two cases. We conclude that neck arthritis rarely causes complications from endoscopy.

Peptic ulcer and non-steroidal anti-inflammatory agents.

Aspirin is generally regarded as a cause of gastric ulcer but the role of non-steroidal anti-inflammatory agents and paracetamol in the aetiology of peptic ulcer is unclear. To investigate this we conducted a case control study of 180 matched pairs of peptic ulcer patients and controls obtained from surgical and dermatology outpatient clinics. There were 95 gastric ulcer and 85 duodenal ulcer patients. A statistically and clinically association (relative risk = 5) was found between the regular use of non-steroidal anti-inflammatory agents and gastric ulcer. There was also evidence of positive associations between gastric ulcer and aspirin containing preparations with or without non-steroidal anti-inflammatory agents. By contrast, duodenal ulcer was unrelated to these drugs. Too few patients used paracetamol for any conclusion to be drawn on its role.

Haematemesis patients should be managed in special units.

This report outlines the results of 568 episodes of acute upper gastrointestinal haemorrhage managed in the Gastroenterology Unit of The Royal Newcastle Hospital during 1964-1974. In this Unit a conservative regimen of blood transfusion and surgery was used with the aim of operating immediately on the recurrence of bleeding for patients with chronic gastric ulcers. In comparison with the 523 patients who were bleeding who were treated in other medical units in the same hospital during 1964-1969, the mortality rate was lower for all peptic ulcers (4.9% compared with 10.6%; P less than 0.025) and for gastric ulcers (8.9% compared with 23.1%; P less than 0.01), but differences for duodenal ulcers (3.6% compared with 5.8%) and in the other diagnostic sub-groups were not significant. The results are also compared with those from units that manage all admissions for upper gastrointestinal bleeding at Prince Henry's Hospital, Melbourne (which has an aggressive transfusion and surgical policy), and The Royal North Shore Hospital of Sydney (which has a "standard" approach). In spite of radically different policies, all three gastrointestinal units obtained rather similar results, with the Newcastle mortality rate from bleeding ulcers of 4.9% being the lowest of all. It is suggested that all large hospitals should have haematemesis and melaena units, as they do coronary care units, but that there is no advantage to be gained by a policy of aggressive treatment.

Ten year follow-up of gastrointestinal hemorrhage patients.

The mortality and morbidity of the 241 survivors of an acute gastrointestinal hemorrhage treated between 1958 and 1964 are reported. The major purpose of this study was to assess the subsequent risk to life and health of patients presenting with acute upper gastrointestinal bleeding. Patients without dyspepsia and with a negative single contrast barium meal study had an excellent prognosis. Life Table analysis showed that the gastric ulcer patients had a mortality not significantly different from that of the Australian population, with the higher risk of death from ulcer balanced by a lower risk of fatal vascular disease. Duodenal ulcer patients had an increased mortality attributable to a 290% increase in deaths from vascular disease, but only one of the 84 died of an ulcer complication. The association between duodenal ulcer and vascular disease has been present for decades. It is unlikely to be associated with hypertension, diabetes mellitus, diet, stress, or smoking and deserves further study.