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Epidemiology of gastric and

duodenal ulcers
Sarah Bowman

April 2008

What is an ulcer?
Acid breaks through protective
substances on gut wall
Duodenum (1st part small intestine)
most common site
Gastric ulcers in stomach
Pain, bloating, nausea, fullness,
weight loss, tiredness
Complications: bleeding,
perforation, obstruction

Diagnosis
Endoscopy (>55yrs, first time). Capture all cases?
Faecal / breath tests for H. pylori
GI series (rare)
False positive tests
Missed cases? risk of transmission / disease progression

Why are they important?


HPA infectious disease but main effects are from
chronic burden
Potential medical emergency
Chronic symptoms health and economic costs
H. pylori also linked to:
Functional dypepsia
Cancer (2-6x more likely, though still rare)
Differential clinical outcome - interaction between
bacterial properties (phenotypic variation), genetics and
environmental / behavioural factors

Emergency
admission for
perforation
Rates per million
resident
population. Threeyear moving
averages
(Bardhan
et al. 2004,
Implications
for
Digestive & Liver Disease
care of older
36(9), 577-588)

Causes?

Ulcers are only found in white people,


usually in long thin types given to worry
and irritability (Robinson & Bruce 1940)

Causes & Risk Factors


Helicobacter pylori
90% duodenal ulcers
70-75% gastric ulcers
NSAIDs
Lifestyle factors increase risk smoking, physical stress,
salt (GU)
Genetic susceptibility / protection against H. pylori
infection (twin studies, mouse models)
RarelyZollinger-Ellison syndrome & others

Treatment & Outcome (NICE)


10% cases fail treatment (HPA)
1 course of combination therapy clears most cases (74%
duodenal ulcers)
Relapse greater for gastric ulcers (affected by lifestyle
factors). At 3-12 months:
Duodenal ulcers: 39% clear (acid suppression only);
91% (combination therapy)
Gastric ulcers: 45% clear (acid suppression only);
77% (combination therapy)

Consequences
Primary care GP consultations, drug costs (increasing
resistance)
Secondary care complications, surgery
Tertiary care rarely needed
Socio-economic cost: Standardised average annual
years of life lost (up to age 75) = 2.6 (per 10,000)
(Females=1.8; Males=3.5) (1999 & 2001 pooled data,
ONS)

Consequences
Mass eradication of H pylori is impractical because of
generating antibiotic resistance, so we need to know
how to target prophylaxis. (Calam & Baron 2001)
Ulcers occurring in absence of H. pylori or NSAIDs /
aspirin. Combination therapies less effective in absence
of H. pylori data needed
Screening? Cost-effective cost/LYS < 10,000 over
80yrs. But effects of eradication on morbidity / mortality?

Time, Person, Place

UK Incidence & Prevalence (Time)


Increases due to:
Increase in H.pylori?
Different strain of H.
pylori?
Another concurrent gut
infection?

Barron & Sonnenberg (2002)

But what about differing


temporal changes of CU
and DU and between men
and women?

UK Incidence & Prevalence (Time)


Evidence of cohort effect 1970-1986: (Primatesta et al.
1994)
Decreased hospitalized morbidity and mortality
Related more to changes in risk factors (e.g. smoking) in
different cohorts than new pharmacological treatments? implications for public health!
OR: Genetic factors may be more important (Malaty et al.
1994)

UK Incidence & Prevalence


(Person)
H. pylori infection
Incidence: 1-3% of adults p.a. (HPA)
Prevalence infection: 40% population (HPA: >50% of
50+yr olds)
Ulceration
Incidence:
DU in 30-50yrs old; higher incidence in men
GU in >60yr olds; higher incidence in women
Low prevalence in younger age groups
Duodenal ulcer: up to 10% of population

UK Incidence & Prevalence


(Person)
Current trends:
Annual age-standardized period prevalence decreased
1994-1998, particularly deprived areas (men 3.3/1000 - 1.5/1000;
women 1.8/1000 - 0.9/1000)

Sex incidence evening out decreasing incidence in


young men; increasing in older women
But emergency admission rates for complications
unchanged in last 30yrs
Kang et al. (2006) increase in case fatality for DU. Due
to concomitant comorbidity / increasing ulceration
(NSAIDs) / H.pylori (i.e. changing natural history)?
Future decrease in prevalence?

International prevalence (Place)

Place
Worldwide. Prevalence 100% in developing countries
Potential for re-spread in UK through travel?
H. pylori - oral / faeco-oral transmission associated with
poverty / overcrowding in childhood
Increased prevalence in children with history of ulcer in
the mothers due to common environmental factors?
Variation between ethnic groups even within countries

Place Regional variation (NCHOD)


2004-06 pooled data from ONS
SMR
All
E&W 99 (97101)
NE

Males

Females

100 (97103)

99 (96101)

111 (102- 124 (110121)


139)

100 (88113)

Lowest = E. Midlands
(89). Highest = London
(112)
Industrial areas = 114,
London suburbs = 111,
London cosmopolitain =
153

Directly standardised age specific death rates (per 100,000


European standard population) - regional centres higher
than national average
High rates affected by lifestyle factors & e.g. aspirin in
deprived areas (raised CVD risk)?

NCHOD data - critique


Based on original underlying cause of death (death
certification)
Numerator - mortality data 1993-2006 (ONS) with codes
assigned using postcode of usual residence
Changes to coding causes of death in England & Wales.
Data based on new coding
Denominator data - latest revisions of ONS mid-year
population estimates, current at Oct 2007 - quite
accurate
NCHOD regularly updated

Data sources
Other potential sources: HES, primary care records, prescribing database
Data
source

Valid?

Reliable?

Complete Timely
?
?

Accessible
?

Relevant
?

Cochrane
reviews

(RCTs /
metaanalyses)

(RCTs /
metaanalyses)

Treatment
focus

Partial

PubMed
articles

Some
small
studies

Some
small
studies

Epidemiol
focus

NEPHO

ONS
data

ONS
data

Regional
1999 &
life years 2001
lost data
London
only

Data sources
Data
source

Valid?

Reliable?

Complete?

Timely Accessible Relevant


?
?
?

NCHOD

ONS
data.
Updated
though
based on
death
certification

ONS
data.
Updated
though
based on
death
certification

Age-specific
NEPHO
rates not
Update website
split by sex d 2007
(small
numbers)

HPA

Based on
reporting
from
primary
care

Testing &
trend
monitoring.
No routine
publications

Data sources
Data
Valid?
source

Reliable?

Complete Timely?
?

Accessible
?

Relevant
?

Patient NICE
UK
guidance &
review
articles.
Written by
clinicians.
Reviewed
18monthly

NICE
guidance
& review
articles.
Written by
clinicians.
Reviewed
18monthly

Patient
info.

Based
on recent
guidance
& articles

Patient Peer
Plus
reviewed.
Based on
NICE
guidance &
review
articles.
Written by
clinicians.

Peer
reviewed.
Based on
NICE
guidance
& review
articles.
Written by
clinicians.

Clinical
focus
diagnosis
and
managem
ent

Based
on recent
guidance
& articles

Partial

Conclusion

Disease mechanism / transmission poorly understood


Risk factors multiple & interacting
H. pylori is main cause but has changing natural history
Each generation has carried its own particular risk of
bearing ulcers throughout adult life (Susser & Stein
1962)
Current pattern = exposure to H. pylori + genetics +
exposure to drugs + environmental / behavioural factors
DU / GU likely to continue causing significant chronic
disease burden and personal / societal cost. Predicting
future pattern difficult

Questions?
References

Bardhan, K. D., Williamson, M., Royston, C., Lyon, C. (2004) Admission rates for peptic ulcer in the Trent
Region, UK, 1972-2000: Changing pattern, a changing disease? Digestive and Liver Disease, 36, 577-588

Barron & Sonnenberg, Gut (2002), 50(4), 568-570

Malaty, H., Engstrand, L., Pederson, N., Graham, D. (1994), "Helicobacter pylori infection genetic and
environmental influences, a study of twins", Annals of Internal Medicine, Vol. 120 pp.982-6

Primatesta et al. (1994), Int. J. Epidemiol. 23(6), 1206-1217

Robinson, S.C., Bruce, R.M. (1940), "The body build of the ulcer patient", American Journal of Digestive
Diseases, Vol. 7

Roderick P, Davies R, Raftery J, Crabbe D, Pearce R, Patel P. The cost-effectiveness of screening for
Helicobacter pylori to reduce mortality and morbidity from gastric cancer and peptic ulcer disease: a discreteevent simulation model. Health Technol Assess, 2003;7(6). Available at:
http://www.cinahl.com/cexpress/hta/summ/summ706.pdf

Bardhan et al. 2004


Elective surgery. Rates per million resident
population. Three-year moving averages.
The number of elective anti-ulcer operations has
declined, and more markedly so for DU. The
greatest decline for both groups was in younger
men, 3564 years, in whom such operations
were most commonly performed (Fig. 4). The
rate of decline, however, was no greater in the
era of modern medical treatment (Table 3).