Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 21, 2020; 26(35): 5302-5313
Published online Sep 21, 2020. doi: 10.3748/wjg.v26.i35.5302
Epidemiology of perforating peptic ulcer: A population-based retrospective study over 40 years
Aydin Dadfar, Tom-Harald Edna
Aydin Dadfar, Tom-Harald Edna, Department of Surgery, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger 7600, Norway
Tom-Harald Edna, Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim 7491, Norway
Author contributions: Dadfar A made substantial contributions to the conception and design of the study, acquisition, analysis, and interpretation of data, and drafting the article; Edna TH made substantial contributions to the conception and design of the study, acquisition, analysis, and interpretation of data, and drafting the article; all authors read and approved the final manuscript.
Institutional review board statement: This study was reviewed and approved by the Levanger Hospital Institutional Review Board Committee on Human Rights Related to Research Involving Human Subjects (2018/2760 – 33974/2018).
Informed consent statement: Not necessary according to the Regional Committee for Medical and Health Research Ethics (REC), Helse Midt (2018/1510).
Conflict-of-interest statement: The authors declare the absence of conflicts of interest.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement – checklist of items, and the manuscript was prepared and revised according to the STROBE Statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Aydin Dadfar, MD, Surgeon, Department of Surgery, Levanger Hospital, Nord-Trøndelag Hospital Trust, Kirkegata 2, Levanger 7600, Norway.
Received: March 24, 2020
Peer-review started: March 24, 2020
First decision: April 25, 2020
Revised: June 23, 2020
Accepted: August 29, 2020
Article in press: August 29, 2020
Published online: September 21, 2020

The incidence of peptic ulcer disease has decreased during the last few decades, but the incidence of reported peptic ulcer complications has not decreased. Perforating peptic ulcer (PPU) is a severe form of the disease.


To assess trends in the incidence, presentation, and outcome of PPU over a period of 40 years.


This was a single-centre, retrospective, cohort study of all patients admitted to Levanger Hospital, Norway, with PPU from 1978 to 2017. The patients were identified in the Patient Administrative System of the hospital using International Classification of Diseases (ICD), revision 8, ICD-9, and ICD-10 codes for perforated gastric and duodenal ulcers. We reviewed the medical records of the patients to retrieve data. Vital statistics were available for all patients. The incidence of PPU was analysed using Poisson regression with perforated ulcer as the dependent variable, and sex, age, and calendar year from 1978 to 2017 as covariates. Relative survival analysis was performed to compare long-term survival over the four decades.


Two hundred and nine patients were evaluated, including 113 (54%) men. Forty-six (22%) patients were older than 80 years. Median age increased from the first to the last decade (from 63 to 72 years). The incidence rate increased with increasing age, but we measured a decline in recent decades for both sexes. A significant increase in the use of acetylsalicylic acid, from 5% (2/38) to 18% (8/45), was observed during the study period. Comorbidity increased significantly over the 40 years of the study, with 22% (10/45) of the patients having an American Society of Anaesthesiologists (ASA) score 4-5 in the last decade, compared to 5% (2/38) in the first decade. Thirty-nine percent (81/209) of the patients had one or more postoperative complications. Both 100-day mortality and long-term survival were associated with ASA score, without significant variations between the decades.


Declining incidence rates occurred in recent years, but the patients were older and had more comorbidity. The ASA score was associated with both short-term mortality and long-term survival.

Keywords: Perforated peptic ulcer, American Society of Anaesthesiologists classification, Charlson Comorbidity Index, Gastric ulcer, Duodenal ulcer, Epidemiology, Incidence, Clavien-Dindo classification of complications, Mortality

Core Tip: We sought to review the epidemiology of perforated peptic ulcer in a stable population at a primary hospital over a period of 40 years. The incidence rate has declined in recent decades for both sexes, though median age and comorbidity have both increased. Complications occurred more frequently and were more serious in recent decades, in older patients, in patients with comorbidities, and in patients with higher American Society of Anaesthesiologists (ASA) scores. Both short- and long-term survival were associated with ASA score, without significant variation between the decades.