Published online Nov 14, 2019. doi: 10.3748/wjg.v25.i42.6342
Peer-review started: May 27, 2019
First decision: July 21, 2019
Revised: September 11, 2019
Accepted: November 1, 2019
Article in press: November 1, 2019
Published online: November 14, 2019
The two main causes of gastric ulcer bleeding are Helicobacter pylori (H. pylori) infection and ulcerogenic medicines, although the number of cases caused by each may vary with age. In Japan, the rate of H. pylori infection has fallen over the last decade and the number of prescriptions for non-steroidal anti-inflammatory drugs (NSAIDs) and antithrombotic drugs is increasing as the population ages. In Japan, the aging population is advancing rapidly. Methods of treatment for gastric ulcer bleeding have advanced with the advent of hemostatic forceps and potassium-competitive acid blocker (P-CAB).
The causes and treatments for gastric ulcer bleeding have changed over the last decade. However at present, gastric ulcer bleeding is common disease. Hence, we examined whether overtime there was a change in the trend of causes and treatment that may possibly reveal an effective treatment for decreasing gastric ulcer bleeding in the future.
The main aim was to examine whether there was a change in the trend of causes, treatments, and prognosis of gastric ulcer bleeding over 10 years. The secondary aim was to examine the relationship between factors that cause gastric ulcer bleeding, and whether this was related to age or time.
Data from patients admitted to the National Hospital Organization Tokyo Medical Center with a gastric ulcer between 2006 and 2016 were examined retrospectively. Patients were selected from the database of inpatients. We excluded gastric cancer patients. Collected data included age, medication history, H. pylori infection, method of treatment, rate of rebleeding, and length of hospitalization. Factors associated with gastric ulcer bleeding were evaluated using Fisher’s exact test, Pearson’s Chi-squared test or Student’s t-test as appropriate. The Jonckheere-Terpstra test was used to evaluate trends. A per-protocol analysis was used to examine the rate of H. pylori infection.
There was a significant increase in the mean age over time (P < 0.01). The rate of H. pylori infection tended to decrease over the study period (P = 0.10), whereas the proportion of patients taking antithrombotic agents or NSAIDs tended to increase (P = 0.07). Over time, the use of NSAIDs and antithrombotic drugs increased with age. By contrast, the rate of H. pylori infection during the study period fell with age. H. pylori-induced ulcers accounted for the majority of cases in younger patients (< 70 years old); however, the rate decreased with age (P < 0.01). The method of treatment trend has changed significantly over time. The main method of endoscopic hemostasis has changed from clipping and injection to forceps coagulation (P < 0.01), and frequently prescribed medicines have changed from proton pump inhibitor to P-CAB (P < 0.01). The rate of rebleeding during the latter half of the study was significantly lower than that in the first half. The rate of Forrest Ia, Ib and IIa patients was not significantly different in the first half and the latter half (P = 0.24).
The mean age of gastric ulcer patients increased significantly in this decade. The rate of H. pylori infection decreased and the percentage of patients taking any antithrombotics or NSAIDs tended to rise over time. Gastric ulcers caused by ulcerogenic drugs are increasing with age and H. pylori-induced ulcers are more common in younger patients. H. pylori induced ulcer is more common in younger patients. H. pylori induced ulcer would decrease and the main cause of gastric ulcer would be ulcerogenic medicines in the future. Expansion of antacid administration for preventing injury from ulcerogenic drugs may decrease gastric ulcer bleeding. Expansion of eradication therapy of H. pylori and administration of antacid for preventing injury from ulcerogenic drugs may decrease gastric ulcer bleeding.
The mean age of gastric ulcer bleeding patients was increasing. There was the trends, that the gastric ulcers caused by ulcerogenic drugs were increasing with age and H. pylori-induced ulcers were more common in younger patients. Advancement in treatment, both endoscopic hemostasis and medicine, may contribute to reduction of rebleeding. This study suggests forceps coagulation and P-CAB are superior methods of treatment for gastric ulcer bleeding. Further research is needed to confirm this hypothesis. Equally important is to clarify and understand the cause and effective treatment for idiopathic ulcer. To confirm the superiority of forceps coagulation and P-CAB for the prevention of gastric ulcer bleeding, randomized prospective study is warranted. In addition, a large multi-center study may be useful in clarifying the characteristics of idiopathic ulcer.