Prospective Study
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World J Gastroenterol. Dec 14, 2014; 20(46): 17568-17577
Published online Dec 14, 2014. doi: 10.3748/wjg.v20.i46.17568
Upper-gastrointestinal bleeding secondary to peptic ulcer disease: Incidence and outcomes
Samuel Quan, Alexandra Frolkis, Kaylee Milne, Natalie Molodecky, Hong Yang, Elijah Dixon, Chad G Ball, Robert P Myers, Subrata Ghosh, Robert Hilsden, Sander Veldhuyzen van Zanten, Gilaad G Kaplan
Samuel Quan, Alexandra Frolkis, Kaylee Milne, Natalie Molodecky, Hong Yang, Robert P Myers, Subrata Ghosh, Robert Hilsden, Gilaad G Kaplan, Departments of Medicine, University of Calgary, Calgary T2N-4N1, Alberta, Canada
Samuel Quan, Alexandra Frolkis, Kaylee Milne, Natalie Molodecky, Hong Yang, Robert P Myers, Robert Hilsden, Gilaad G Kaplan, Departments of Community Health Sciences, Calgary T2N-4N1, Alberta, Canada
Elijah Dixon, Chad G Ball, Departments of Surgery, University of Calgary, Calgary T2N-4N1, Alberta, Canada
Sander Veldhuyzen van Zanten, Department of Medicine, University of Alberta, Edmonton T6G-2R7, Alberta, Canada
Author contributions: Quan S and Kaplan GG, participated in conceiving the study idea and developing the study design; Yang H, Hilsden R and Kaplan GG prepared the data; Frolkis A, Molodecky N and Yang H analyzed the data; Kaplan GG supervised the data analysis; Quan S, Frolkis A, Milne K, Molodecky N, Dixon E, Ball CG, Myers RP, Ghosh S, Hilsden R, van Zanten SV and Kaplan GG contributed to the interpretation of the data and results; Quan S and Kaplan GG wrote the manuscript; Frolkis A, Milne K, Molodecky N, Yang H, Dixon E, Ball CG, Myers RP, Ghosh S, Hilsden R and van Zanten SV edited the manuscript for intellectual content; Kaplan GG confirms that he has had full access to all the data in the study and had final responsibility for the decision to submit for publication.
Supported by Summer studentships (2010, 2011, and 2012) by Alberta Innovates - Health Solutions. Alexandra Frolkis is funded by an Alberta Innovates - Health Solutions studentship to Samuel Quan; A New Investigator Award from the Canadian Institute of Health Research and a Clinical Investigator Award from Alberta Innovates - Health Solutions to Dr. Myers; A New Investigator Award from the Canadian Institute of Health Research and a Population Health Investigator Award from Alberta Innovates - Health Solutions to Dr. Kaplan
Correspondence to: Gilaad G Kaplan, MD, MPH, FRCPC, Associate Professor, Departments of Medicine, University of Calgary, 3280 Hospital Drive NW, Room 6D56, Calgary, AB T2N-4N1, Canada. ggkaplan@ucalgary.ca
Telephone: +1-403-5925015 Fax: +1-403-5925090
Received: March 2, 2013
Revised: May 15, 2014
Accepted: May 26, 2014
Published online: December 14, 2014
Abstract

AIM: To evaluate the incidence, surgery, mortality, and readmission of upper gastrointestinal bleeding (UGIB) secondary to peptic ulcer disease (PUD).

METHODS: Administrative databases identified all hospitalizations for UGIB secondary to PUD in Alberta, Canada from 2004 to 2010 (n = 7079) using the International Classification of Diseases Codes (ICD-10). A subset of the data was validated using endoscopy reports. Positive predictive value and sensitivity with 95% confidence intervals (CI) were calculated. Incidence of UGIB secondary to PUD was calculated. Logistic regression was used to evaluate surgery, in-hospital mortality, and 30-d readmission to hospital with recurrent UGIB secondary to PUD. Co-variants accounted for in our logistic regression model included: age, sex, area of residence (i.e., urban vs rural), number of Charlson comorbidities, presence of perforated PUD, undergoing upper endoscopy, year of admission, and interventional radiological attempt at controlling bleeding. A subgroup analysis (n = 6356) compared outcomes of patients with gastric ulcers to those with duodenal ulcers. Adjusted estimates are presented as odds ratios (OR) with 95%CI.

RESULTS: The positive predictive value and sensitivity of ICD-10 coding for UGIB secondary to PUD were 85.2% (95%CI: 80.2%-90.2%) and 77.1% (95%CI: 69.1%-85.2%), respectively. The annual incidence between 2004 and 2010 ranged from 35.4 to 41.2 per 100000. Overall risk of surgery, in-hospital mortality, and 30-d readmission to hospital for UGIB secondary to PUD were 4.3%, 8.5%, and 4.7%, respectively. Interventional radiology to control bleeding was performed in 0.6% of patients and 76% of these patients avoided surgical intervention. Thirty-day readmission significantly increased from 3.1% in 2004 to 5.2% in 2010 (OR = 1.07; 95%CI: 1.01-1.14). Rural residents (OR rural vs urban: 2.35; 95%CI: 1.83-3.01) and older individuals (OR ≥ 65 vs < 65: 1.57; 95%CI: 1.21-2.04) were at higher odds of being readmitted to hospital. Patients with duodenal ulcers had higher odds of dying (OR = 1.27; 95%CI: 1.05-1.53), requiring surgery (OR = 1.73; 95%CI: 1.34-2.23), and being readmitted to hospital (OR = 1.54; 95%CI: 1.19-1.99) when compared to gastric ulcers.

CONCLUSION: UGIB secondary to PUD, particularly duodenal ulcers, was associated with significant morbidity and mortality. Early readmissions increased over time and occurred more commonly in rural areas.

Keywords: Epidemiology, Peptic ulcer hemorrhage, Digestive system surgical procedures, Mortality, Endoscopy, Validation studies, Incidence

Core tip: In our population-based study the overall risk of surgery, in-hospital mortality, and 30-d readmission for hospitalized upper gastrointestinal bleeding (UGIB) secondary to peptic ulcer disease (PUD) was 4.3%, 8.5%, and 4.7%, respectively. Duodenal ulcers had a worse prognosis than gastric ulcers. Readmission was more common among rural residents, which might be due to decreased access to resources or practice differences between urban and rural centers. Interventional radiology was uncommonly utilized (0.6%) and limited to urban centers, but prevented surgery in 3/4 of patients. These findings suggest that greater access to medical services may improve outcomes for UGIB secondary to PUD.