Systematic Review of the Epidemiology of Complicated Peptic Ulcer Disease: Incidence, Recurrence, Risk Factors and Mortality

Background/Aims: The incidence of uncomplicated peptic ulcer has decreased in recent years. It is unclear what the impact of this has been on the epidemiology of peptic ulcer complications. This systematic review aimed to determine the incidence, recurrence and mortality of complicated peptic ulcer and the risk factors associated with these events. Methods: Systematic PubMed searches. Results: Overall, 93 studies were identified. Annual incidence estimates of peptic ulcer hemorrhage and perforation were 19.4–57.0 and 3.8–14 per 100,000 individuals, respectively. The average 7-day recurrence of hemorrhage was 13.9% (95% CI: 8.4– 19.4), and the average long-term recurrence of perforation was 12.2% (95% CI: 2.5–21.9). Risk factors for peptic ulcer complications and their recurrence included nonsteroidal anti-inflammatory drug and/or acetylsalicylic acid use, Helicobacter pylori infection and ulcer size 6 1 cm. Proton pump inhibitor use reduced the risk of peptic ulcer hemorrhage. Average 30-day mortality was 8.6% (95% CI: 5.8–11.4) after hemorrhage and 23.5% (95% CI: 15.5–31.0) after perforation. Published online: April 14, 2011 Dr. James Y. Lau Department of Surgery Chinese University of Hong Kong Sha Tin, Hong Kong, SAR (China) Tel. +852 2632 1411, E-Mail laujyw @ surgery.cuhk.edu.hk © 2011 S. Karger AG, Basel 0012–2823/11/0842–0102$38.00/0 Accessible online at: www.karger.com/dig D ow nl oa de d by : 54 .7 0. 40 .1 1 10 /6 /2 01 7 5: 54 :3 4 A M Epidemiology of Peptic Ulcer Complications Digestion 2011;84:102–113 103 5.65 billion per year [7] . It is likely that disease-related complications contribute substantially to these costs. A study in the Netherlands calculated the per person costs of hemorrhage, perforation, or a combination of both to be EUR 12,000, EUR 19,000 and EUR 26,000, respectively [8] . The aim of this review is to determine the incidence and recurrence rate of complications associated with peptic ulcer disease in recent years, and to identify risk factors associated with these complications. We also set out to evaluate the mortality associated with these complications and the risk factors associated with this mortality. Materials and Methods The PubMed database was searched for articles that reported the incidence, mortality and associated risk factors for peptic ulcer complications ( fig. 1 ). These searches were performed using the following search string: (peptic ulcer AND obstruction) OR gastric obstruction OR gastric outlet obstruction OR peptic ulcer hemorrhage OR peptic ulcer bleed OR peptic ulcer bleeding OR upper GI bleed OR peptic ulcer perforation AND (incidence OR cohort study OR mortality OR prognosis OR prevalence OR cross-sectional study OR occurrence). We limited our searches to studies in humans that were published in the English literature between 1997 and 2007. Citation list searches were also used to identify additional references. Studies were reviewed manually first by title and abstract and then by full manuscript. Manuscripts were excluded if their study topic was irrelevant, or if they did not report any relevant information. Studies were also excluded if they described uncomplicated peptic ulcer, variceal bleeding or other causes of upper gastrointestinal complications. Studies with fewer than 50 patients were excluded for feasibility reasons. Studies in which data collection started before 1990 were also excluded from our analysis of incidence because we aimed to analyze only recent data. The recurrence rate and 30-day mortality data were synthesized by calculating averages weighted by sample size. The studies varied in their use of odds ratio (OR) and relative risk (RR), and adjusted these measures by different factors; therefore, these have been reported as published rather than synthesized.