Peptic ulcer disease : incidence, associated morbidity and mortality

The incidence and complications of peptic ulcer disease (PUD) have declined during the last decades in Western countries. The Helicobacter pylori (H.pylori) infection and the use of non-steroidal anti-inflammatory drugs are the two main risk factors for peptic ulcer disease. Despite the use of H.pylori eradication therapy and gastroprotective agents, mortality associated with PUD has not decreased as assumed. The aims of this thesis were to evaluate time trends in the incidence of PUD and its complications in hospitalised patients, their short- and long-term mortality, risk factors for mortality. Moreover, the prevalence of PUD among patients suffering from acute gastrointestinal bleeding (GIB) symptoms in the beginning of the 21st century in the capital area of Finland was studied. In the retrospective epidemiological cohort study, data on adult patients hospitalised and diagnosed with PUD was collected from the Hospital District of Helsinki and Uusimaa patient register during 2000-2008. The data was linked with Prescription Register of the Finnish Social Insurance Institution allowed detailed individual medicine purchase data and all patients were followed in the National Cause of Death Register until the end of 2009. In the prospective observational cohort study, data on hospitalised patients referred for acute upper endoscopy during 2012-2014 in Meilahti and Jorvi hospitals were collected. The incidence of peptic ulcers decreased significantly from 121/100000 in 2000-2002 to 79/100000 in 2006-2008. The rate of severe complications was also reduced, mainly due to a reduction in bleedings. The one-year cumulative incidence of recurrent peptic ulcers was 13%. The use of several drugs indicating comorbidity was associated with an increased risk for recurrence. No change in standardized mortality ratio was seen; 3.7% of patients died within 30 days, and 11.8% within 1 year in the retrospective cohort. Both the short- and long-term survival was significantly impaired in women presenting with perforated duodenal ulcer. The main causes of death at one year were malignancies and cardiovascular diseases. Interestingly, previous use of statins was associated with significant reduction in all-cause mortality. Of all patients admitted for acute upper endoscopy during 2012-2014, 23% had PUD. Other specific diagnoses in acute upper endoscopy were oesophagitis (12%), oesophageal or gastric varices (10%), 10% gastroduodenitis (10%), Mallory-Weiss lesion (8%), and malignancy (5%). Of the PUD patients, 31% were H.pylori positive. The 30-day mortality was very low 0.7%. This is most probably explained by the exclusion of unstable or otherwise fragile patients who were not able to give written informed consent at the admission. The one-year mortality was 12.9% which is in line with results of the retrospective study. Comorbidities were associated with decreased survival (p=0.029) and obesity (BMI>=30) was associated with better survival (p=0.023). Of all individual patients referred for endoscopy, the source for acute bleeding or severe anaemia was not evident in 19% of patients. In further examinations, the diverticular disease of the colon was regarded as the most probable source of bleeding in 39% of patients of these patients. In conclusion, both the incidence and complications of PUD have markedly decreased in Finland. However, the one-year mortality associated with PUD remained high with no change. PUD is still the most common cause of acute gastro-intestinal bleeding.