Ulcer Bleeding in the United States: Epidemiology, Treatment Success, and Resource Utilization.

BACKGROUND AND GOALS: Peptic ulcer disease is the most frequent cause of upper gastrointestinal bleeding. We sought to establish the epidemiology and hemostasis success rate of the different treatment modalities in this setting. METHODS: Retrospective cohort study using the National Inpatient Sample. Non-elective adult admissions with a principal diagnosis of ulcer bleeding were included. The primary outcome was endoscopic, radiologic and surgical hemostasis success rate. Secondary outcomes were patients' demographics, in-hospital mortality and resource utilization. On subgroup analysis, gastric and duodenal ulcers were studied separately. Confounders were adjusted for using multivariate regression analysis. RESULTS: A total of 136,425 admissions (55% gastric and 45% duodenal ulcers) were included. The mean patient age was 67 years. The majority of patients were males, Caucasians, of lower income and high comorbidity burden. The endoscopic, radiological and surgical therapy and hemostasis success rates were 33.6, 1.4, 0.1, and 95.1%, 89.1 and 66.7%, respectively. The in-hospital mortality rate was 1.9% overall, but 2.4% after successful and 11.1% after failed endoscopic hemostasis, respectively. Duodenal ulcers were associated with lower adjusted odds of successful endoscopic hemostasis, but higher odds of early and multiple endoscopies, endoscopic therapy, overall and successful radiological therapy, in-hospital mortality, longer length of stay and higher total hospitalization charges and costs. CONCLUSIONS: The ulcer bleeding endoscopic hemostasis success rate is 95.1%. Rescue therapy is associated with lower hemostasis success and more than a ten-fold increase in mortality rate. Duodenal ulcers are associated with worse treatment outcomes and higher resource utilization compared with gastric ulcers.

Urban-Rural Disparities and Temporal Trends in Peptic Ulcer Disease Epidemiology, Treatment, and Outcomes in the United States.

INTRODUCTION: The incidence of peptic ulcer disease (PUD) has been decreasing over time with Helicobacter pylori eradication and use of acid-suppressing therapies. However, PUD remains a common cause of hospitalization in the United States. We aimed to evaluate contemporary national trends in the incidence, treatment patterns, and outcomes for PUD-related hospitalizations and compare care delivery by hospital rurality. METHODS: Data from the National Inpatient Sample were used to estimate weighted annual rates of PUD-related hospitalizations. Temporal trends were evaluated by joinpoint regression and expressed as annual percent change with 95% confidence intervals (CIs). We determined the proportion of hospitalizations requiring endoscopic and surgical interventions, stratified by clinical presentation and rurality. Multivariable logistic regression was used to assess independent predictors of in-hospital mortality and postoperative morbidity. RESULTS: There was a 25.8% reduction (P < 0.001) in PUD-related hospitalizations from 2005 to 2014, although the rate of decline decreased from -7.2% per year (95% CI: 13.2% to -0.7%) before 2008 to -2.1% per year (95% CI: 3.0% to -1.1%) after 2008. In-hospital mortality was 2.4% (95% CI: 2.4%-2.5%). Upper endoscopy (84.3% vs 78.4%, P < 0.001) and endoscopic hemostasis (26.1% vs 16.8%, P < 0.001) were more likely to be performed in urban hospitals, whereas surgery was performed less frequently (9.7% vs 10.5%, P < 0.001). In multivariable logistic regression, patients managed in urban hospitals were at higher risk for postoperative morbidity (odds ratio 1.16 [95% CI: 1.04-1.29]), but not death (odds ratio 1.11 [95% CI: 1.00-1.23]). DISCUSSION: The rate of decline in hospitalization rates for PUD has stabilized over time, although there remains significant heterogeneity in treatment patterns by hospital rurality.

Risk Factors Associated with Mortality and Increased Drug Costs in Nonvariceal Upper Gastrointestinal Bleeding.

BACKGROUND/AIMS: To determine risk factors associated with mortality and increased drug costs in patients with nonvariceal upper gastrointestinal bleeding. METHODOLOGY: We retrospectively analyzed data from patients hospitalized with nonvariceal upper gastrointestinal bleeding between January 2001-December 2011. Demographic and clinical characteristics and drug costs were documented. Univariate analysis determined possible risk factors for mortality. Statistically significant variables were analyzed using a logistic regression model. Multiple linear regression analyzed factors influencing drug costs. p < 0.05 was considered statistically significant. RESULTS: The study included data from 627 patients. Risk factors associated with increased mortality were age > 60, systolic blood pressure<100 mmHg, lack of endoscopic examination, comorbidities, blood transfusion, and rebleeding. Drug costs were higher in patients with rebleeding, blood transfusion, and prolonged hospital stay. CONCLUSION: In this patient cohort, re-bleeding rate is 11.20% and mortality is 5.74%. The mortality risk in patients with comorbidities was higher than in patients without comorbidities, and was higher in patients requiring blood transfusion than in patients not requiring transfusion. Rebleeding was associ-ated with mortality. Rebleeding, blood transfusion, and prolonged hospital stay were associated with increased drug costs, whereas bleeding from lesions in the esophagus and duodenum was associated with lower drug costs.

Assessment of vagotomy status with postprandial urinary alkaline tide.

AIM: This study was carried out to assess whether the postprandial urinary alkaline tide, as a marker for the completeness of vagotomy, is dependent on the nature of the test meal, whether it is affected by proton pump inhibitor therapy, and whether it is reliable. METHODS: The postprandial urinary alkaline tide (PUAT) pattern was prospectively assessed in three different study groups and one control group of healthy volunteers. The three study groups were as follows; A (n = 20) i.e. the Proton Pump Inhibitor (PPI) Group; B (n = 25) i.e. the Truncal Vagotomy (TV) Group; and C (n = 5) i.e. the Recurrent Ulcer (RU) Group. Urinary pH was measured by a pocket digital pH meter. RESULTS: Postprandial urinary alkaline tide in the control group was significantly higher compared to the fasting levels. Liquid diet did not elicit a significant urinary alkaline tide response. There was a statistically significant fall in both fasting urinary pH (5.34 +/- 0.70 vs. 4.80 +/- 0.61, p = 0.031) and the postprandial alkaline tide (6.99 +/- 0.79 vs. 4.94 +/- 0.63, p = 0.0001) after taking proton pump inhibitors. In the truncal vagotomy and gastrojejunostomy group it was found that there was a significant fall in both the mean fasting (5.28 +/- 0.58, vs. 4.92 +/- 0.66, p = 0.032) and the postprandial urinary pH (6.29 +/- 0.92 vs. 5.09 +/- 0.73, p = 0.0001) following surgery. CONCLUSION: This study establishes that simple measurement of the urinary pH before and after a standard test meal can be used as an accurate routine test for the completion of vagotomy. It also showed that proton pump inhibitors abolish the alkaline tide and therefore must be discontinued before measuring the alkaline tide. Liquid test meal was not effective in eliciting an alkaline tide as compared to a solid meal.

[Objectivization of expert evaluation of the quality and efficiency of medical care for patients with gastric and duodenal ulcer with the help of a standard algorithm].

Criteria for the efficiency of medical care being provided to patients with gastric and duodenal ulcer are discussed. The method and the algorithm are proposed for expert evaluation of the reliability and quality of medical attendance.

Clinical practice and evidence in endoscopic treatment of bleeding peptic gastroduodenal ulcer.

OBJECTIVE: To investigate treatment practice in non-variceal upper gastrointestinal bleeding (NVUGIB) caused by gastroduodenal ulcer and how it adheres to the best evidence as documented in randomized studies and meta-analyses. MATERIAL AND METHODS: The literature was surveyed to identify appropriate practices, and a structured multiple choice questionnaire developed and mailed to all departments in Denmark treating UGIB. RESULTS: All 42 departments responded. All had therapeutic gastroscopes and equipment necessary for endoscopic haemostasis; 90% of departments had written guidelines. Adjuvant pharmacologic treatment included tranexamic acid in 38%. Proton-pump inhibitors (PPIs) were used by all departments, with 29% starting prior to endoscopic treatment. Eight departments (19%) used continuous PPI infusion, three of them starting with a bolus dose. In 50% of departments an anaesthesiologist was always present regardless of whether endotracheal intubation (routinely used by 10%) was used or not. Ten percent did not treat Forrest IIa and IIb ulcers, while IIc ulcers were treated by 36%. In 10% of departments clots were never removed, while in 2/3 attempts were made to remove resistant clots by mechanic means. Seven departments (17%) used monotherapy with epinephrine, while 59% always used dual therapy; 19% injected less than 10 ml. In rebleeding, 92% attempted endoscopic treatment before surgery, and used epinephrine in 79% of cases, while the remainder used epinephrine or polidocanol at the discretion of the endoscopist. Two out of three departments used high-dependency or intensive-care units for surveillance. Seventeen percent applied scheduled second-look gastroscopy. CONCLUSIONS: Practice is variable, even in areas with established evidence based on randomized controlled studies, such as dosage and way of administration and duration of PPI treatment, injection treatment used as monotherapy and the volume used, including ulcers with clots for treatment, and the use of scheduled second-look endoscopy. Since the rebleeding rate has remained unchanged for decades, and rebleeding implies increased surgery and mortality rates, appropriate practices must be promoted in order to improve results. Development and implementation of national guidelines may facilitate the process.

["Scanner" therapy of duodenal ulcers: new approaches to alternative non-medication treatment]. / "Skénar"-terapiia iazvennoi bolezni dvenadtsatiperstnoi kishki: novye podkhody k al'ternativomu nemedikamentoznomy lechebniiu.

Scanner therapy in the treatment of patients having duodenal ulcer relapse combines high pharmacoeconomic efficiency with safety providing for clinical and endoscopic remission of the disease.

Risk assessment and prediction of rebleeding in bleeding gastroduodenal ulcer.

BACKGROUND AND STUDY AIMS: The aims of this study were to identify risk factors for recurrence of hemorrhage in bleeding gastroduodenal ulcers after endoscopic injection therapy, and to develop a simple and relevant prognostic score which could be used to assess the early risk of recurrence and the residual risk of rebleeding. PATIENTS AND METHODS: A prospective study was conducted from January 1995 to December 1998, in 738 patients who were admitted to our department for acute bleeding peptic ulcer and who underwent endoscopic examination. Ulcers with active bleeding or signs of recent bleeding were treated with injection therapy using epinephrine (1/10,000) and 1% polidocanol. RESULTS: Multivariate analysis revealed that liver cirrhosis, recent surgery, systolic blood pressure below 100 mmHg, hematemesis, Forrest classification, and ulcer size and site were significantly predictive variables for the recurrence of hemorrhage. Among these, Forrest classification was the most important. The overall accuracy of the predictive model was 71% (95% CI = 63 - 79%). The model showed a better sensitivity of 90% for early rebleeding (< 48 hours) than for late rebleeding (> or = 48 hours) where the sensitivity was 65 %. A prognostic score was obtained and patients were classified into four risk classes: very low (VL), low (L), high (H), and very high (VH). The rebleeding rates for the four classes were 0%, 7.9%, 31.8% and 67.9%, and the mortality rates were 5.9%, 8.6%, 13.9% and 35.7%, respectively. The residual risk of rebleeding after 48 hours was 0%, 3.3%, 10.4%, and 14.3% in the VL, L, H and VH classes, respectively. After 5 days the residual risk was under 4% in all classes. CONCLUSIONS: This study demonstrates that the proposed prognostic score, which is easily obtained after emergency endoscopy, is useful in clinical practice because it can identify patients with different levels of rebleeding risk. It can be helpful in patient management and decision making for discharge.

Role of acid suppressants in intensive care medicine.

Bleeding from stress-induced mucosal lesions continues to be a potential problem in critically ill patients, although its incidence has decreased dramatically over the past decade. Patients considered to be at risk are those with respiratory failure, coagulopathy, severe burns or tetraplegia. The most important cause of stress ulcer bleeding is tissue hypoxia. Provided that appropriate dosage regimens are administered, all agents approved for stress ulcer prophylaxis may reduce the incidence of overt as well as clinically important bleeding. However, the efficacy of stress ulcer prophylaxis does not correlate with the efficacy of gastric acid inhibition. Although numerous studies have demonstrated that an alkaline gastric juice is associated with gastric Gram-negative bacterial overgrowth, controversy remains over whether the pharmacological suppression of gastric acid in critically ill patients facilitates nosocomial pneumonia. The reasons for these divergent results are discussed, as is a possible association between gastric acid suppression and other systemic infections. Finally, several cost-effectiveness analyses performed over recent years have demonstrated that, in properly selected critically ill patients, stress ulcer prophylaxis is cost-effective.

Peptic disease: can we afford current management?

BACKGROUND: While surgery has the potential to cure peptic disease (ulceration and reflux), the development in the 1970s of H2 receptor antagonists saw them replace surgery in the management of peptic symptoms, controlling disease while the medication was taken. Medical cure at least in the case of a duodenal ulcer is now also possible by the use of anti-Helicobacter therapy. METHODS: Australian Pharmaceutical Benefits Scheme (PBS) and Medicare data on the treatment of peptic disease were reviewed. RESULTS: The data showed that medical cure of duodenal ulcer is rarely attempted. While elective surgical treatment for duodenal ulcer, highly selective vagotomy, has decreased 10-fold in 10 years, prescriptions for antisecretory agents (H2 and proton pump) are doubling every 2 years (increasing from 6.7 to 7.8% of PBS budget). Meanwhile upper gastrointestinal endoscopy rates are doubling every 5 years. By comparison, the most appropriate treatment, anti-Helicobacter therapy, is prescribed at 1/50th the rate of antisecretory agents and over 2 years decreased to 1/80th. Antisecretory treatment has not been effective in reducing mortality from duodenal ulcer, at least not in New South Wales. CONCLUSIONS: If the principle of treatment is to decrease cost and prevent complications by curing duodenal ulcer, then current practice is a failure. A management algorithm for peptic symptoms which has the potential to relieve symptoms, cure ulcer when present, minimize surgery and reduce complications and cost is proposed for the purpose of debate.

Recurrent peptic ulceration.

Recurrent peptic ulcer disease has traditionally posed problems for practicing physicians. While many treatment options have been promoted in the past, recent understanding of the role of Helicobacter pylori has completely altered our approach to this clinical problem. Since most ulcers are related to H. pylori infection or to ingestion of aspirin or non-steroidal anti-inflammatory drugs, improved understanding of these factors and the development of rational treatment approaches should limit recurrent peptic ulceration in the future. This should help improve our patients' quality of life and should have a positive economic impact on the long-term treatment of peptic ulcer by reducing the requirement for continuous medical treatment. The issue of recurrent peptic ulceration and some approaches to management are discussed in this article.

Evaluation of initial noninvasive therapy in pediatric patients presenting with suspected ulcer disease.

OBJECTIVE: To compare the clinical and economic effects of five likely treatment strategies in children with dyspepsia: initial diagnostic endoscopy (EGD) with biopsy for Helicobacter pylori infection; initial EGD without biopsy; H. pylori serology screening and treatment for H. pylori if positive; empiric treatment with antisecretory therapy; and empiric treatment for H. pylori with antibiotics and antisecretory therapy. METHODS: Our decision analysis model incorporated data from published literature on the incidence of duodenal ulcer disease and effect of H. pylori infection. Cost inputs were derived from payments made by third-party payers. For the three noninvasive strategies that did not include immediate endoscopy, endoscopy was performed on the first episode of symptom recurrence. RESULTS: The estimated costs per child evaluated for each strategy were: EGD with biopsy, $1458; EGD alone, $1248; H. pylori serology, $1224; antisecretory, $1160; and antisecretory-antibiotic, $1164. Results were sensitive to the costs of EGD and the likelihood of recurrent symptoms in children. When the cost of endoscopy fell below $950 or if over 65% of patients without ulcers eventually underwent endoscopy, there was no longer a cost advantage for initial noninvasive treatment when compared with EGD alone strategy. CONCLUSION: In a decision analysis model, empiric antisecretory treatment in children with dyspepsia was most cost-effective, eliminating 40% of endoscopies and leading to antibiotic use in only those patients with H. pylori (4%). Further studies to determine the actual recurrence rate of symptoms after empiric antisecretory treatment of children with dyspepsia are required.

Cost-effectiveness of Helicobacter pylori eradication for the long-term management of duodenal ulcer in Canada.

BACKGROUND: A 1994 National Institutes of Health consensus panel recommended that eradication of Helicobacter pylori should be first-line therapy for persons with duodenal ulcer. OBJECTIVE: To assess the cost-effectiveness of H pylori eradication relative to alternative pharmacologic strategies in the long-term management of persons with confirmed duodenal ulcer. METHODS: Decision analysis model to estimate expected costs and symptomatic ulcer recurrences during a 12-month period for three general treatment strategies: (1) immediate H pylori eradication; (2) H pylori eradication at first ulcer recurrence; and (3) continuous maintenance therapy with a histamine2 receptor antagonist (ranitidine hydrochloride). Two H pylori eradication therapies were compared: classic triple therapy and omeprazole plus amoxicillin. Probabilities for ulcer recurrence are by meta-analysis of published randomized trials. Health care resources used in the management of duodenal ulcer recurrence were by expert physician panel. All costs are in 1993 Canadian dollars. RESULTS: Duodenal ulcer recurrence at 6 months (symptomatic and asymptomatic) with placebo was 65.4% and 12.8% with maintenance ranitidine therapy. Where eradication of H pylori was successful (85% of patients), the ulcer recurrence rate to 12 months was 3.7%. Treatment with ranitidine and triple therapy to eradicate H pylori on first presentation has an expected 1-year cost of $253 with 15 symptomatic recurrences per 100 patients; H pylori eradication by omeprazole plus amoxicillin had similar expected costs ($272) and outcomes (15 recurrences per 100 patients). Both of these early H pylori eradication strategies were dominant (less costly with same or better outcomes) over intermittent or continuous maintenance ranitidine therapy or delayed (after first recurrence) H pylori eradication. CONCLUSION: Our analysis provides economic evidence in support of the recent guidance that for persons with duodenal ulcer, early attempts to eradicate H pylori are recommended.

Association of nonsteroidal antiinflammatory drugs with upper gastrointestinal disease: epidemiologic and economic considerations.

One of the major concerns regarding the use of nonsteroidal antiinflammatory drugs (NSAID) in the treatment of patients with arthritis is the high incidence of gastrointestinal (GI) side effects. Important issues regarding NSAID and upper GI complications include the following: (1) the magnitude of the association between NSAID therapy and clinically important gastric or duodenal ulcers or upper GI bleeding; (2) the subgroup(s) of patients who are at increased risk for upper GI side effects; and (3) the economic impact of NSAID induced upper GI toxicity. A causal association between NSAID use and the development of clinically important ulcer disease or its complications, including upper GI bleeding, is supported by available epidemiologic data. Furthermore, data suggest that up to one third of all direct costs of care may be attributed to the treatment of NSAID induced GI side effects. Approaches to this problem, such as the development of safer NSAID that are equally effective, need to be pursued.

[Economic effectiveness of conservative and surgical methods of treatment of duodenal ulcer in young patients]. / Ekonomicheskaia éffektivnost' konservativnogo i khirurgicheskogo metodov lecheniia iazvennoi bolezni dvenadtsatiperstnoi kishki u lits molodogo vozrasta.

The work evaluates the results of treatment of duodenal ulcer in 152 young patients. The state's financial losses connected with their treatment by various methods are counted up. Prolonged nonoperative treatment was applied in 52 patients (group I), organ-preserving operations were carried out in 100 patients (group II). Group I patients felt much worse, most of them suffered from annual recurrences of the disease, 21% underwent various operative interventions later due to the development of complications. Good and excellent results were recorded in 86% of group II patients. It was established that not only are the clinical results better in group II patients, but the economical losses in timely performance of organ-preserving operations are half those in prolonged nonoperative therapy.

Assessment of mucus glycoprotein erosion by measurement of sialic acid in gastric secretions: pathophysiologic and therapeutic aspects.

The quantification of mucus glycoproteins (GPs) faces paramount difficulties in terms of methods and interpretation. Mucus glycoprotein erosion, however, might be quantified in gastric juice by measurement of GP-bound sialic acid. Basal sialic acid content was low in normal healthy subjects (N) and in nonulcer dyspepsia (NUD) patients. They were five to six times higher in duodenal ulcer (DU), or more in Zollinger-Ellison patients. Pentagastrin stimulation induced a five- to sixfold rise in N and NUD patients although it did not affect DU patient sialic acid contents. Relationships between sialic acid content and pepsin output in DU indicate that pepsin exerts a variable mucolytic activity depending on disease evolution. In addition to pepsin, duodenogastric reflux exerts a potent mucolytic effect. Therapeutically, highly selective vagotomy without recurrent ulcer markedly reduced mucus erosion. The reduction of mucus erosion by protective drugs has been observed in some cases but in other cases sialic acid measurement did not allow to verify a protective effect. Adherent mucus analysis by high-performance liquid chromatography (HPLC) should allow one to appreciate GP fractions qualitatively. Combination of both methods should allow further determination of the mucus protective role, simultaneously investigating the adherent mucus quality and eroded GPs.