Time Trends and Impact of Upper and Lower Gastrointestinal Bleeding and Perforation in Clinical Practice

Abstract

Over the past decade, there has been a progressive change in the overall picture of GI events leading to hospitalization, with a clear decreasing trend in upper GI events and a significant increase in lower GI events, causing the rates of these two GI complications to converge. Overall, mortality has also decreased, but the in-hospital case fatality of upper or lower GI complication events has remained constant. It will be a challenge to improve future care in this area unless we develop new strategies to reduce the number of events originating in the lower GI tract, as well as reducing their associated mortality.

Epidemiology of Upper Gastrointestinal Bleeding

“…This is contrary to global reports of peptic ulceration declining as a result of falling Helicobacter pylori and peptic ulcer prevalence. 5,12,90 Large differences in incidence also exist between regional studies within the UK, as discussed in section 2.2.1, and these are often thought to be due to deprivation. Identifying whether such a strong socioeconomic gradient exists is important as it points towards identifiable and modifiable risk factors; for example Helicobacter pylori can be eradicated, the consumption of alcohol reduced, and the prescribing of NSAIDs curtailed.…”

“…[3][4][5] Although the overall incidence of gastro-duodenal ulcer bleeding has remained stable during the 1990s, in the elderly it increased by over 30%. 6,7 It is likely that this increase is related to higher rates of co-morbidities, increased prescriptions for these co-morbidities and interactions between the two.…”

NSAID enteropathy and bacteria: a complicated relationship

“…There are also no proven-effective treatments for NSAID enteropathy once it has occurred [1,2,4]. With improved means of detection, such as video capsule endoscopy, physicians are becoming more aware that the small intestinal damage caused by NSAIDs is much more common and much more serious than previously recognized [4,[6][7][8][9][10][11]. The prevalence of NSAIDinduced damage in the small intestine was highlighted by data showing that various features consistent with damage are common among long-term NSAID users: inflammation in 60-70 %, ulceration in 30-40 %, increased permeability in up to 70 %, bleeding/anemia in 30 %, and malabsorption in 40-70 % [4].…”

“…An additional problem with detecting NSAID enteropathy is that patients often do not have symptoms that would alert them or their physician to a problem. Moreover, as compared with upper GI tract events requiring hospitalization, lower GI tract events were associated with higher rates of mortality and relapse, and significantly longer periods of hospitalization [11].…”

“…In 2009, Lanas et al [11] reported that hospitalizations due to lower GI tract adverse events had been steadily rising during the 1990s and the first decade of this century, when use of proton pump inhibitors (PPIs) and selective cyclooxygenase 2 inhibitors became prevalent. During the same period, hospitalizations due to upper GI tract adverse events declined significantly.…”