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
Implications for
care of older
people
(Bardhan et al. 2004,
Digestive & Liver Disease
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)
• Rarely…Zollinger-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?
But what about differing
temporal changes of CU
and DU and between men
and women?
Barron & Sonnenberg (2002)
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 Accessibl
?
e?
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
√
√
Relevant
?
√
√
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, 35–64 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).