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. Three-
year 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 Males Females –Lowest = E. Midlands
(89). Highest = London
E&W 99 (97- 100 (97- 99 (96-
(112)
101) 103) 101)
–Industrial areas = 114,
NE 111 (102- 124 (110- 100 (88- London suburbs = 111,
121) 139) 113) 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 Valid? Reliable? Complete Timely Accessible Relevant

source ? ? ? ?

Cochrane √ (RCTs / √ (RCTs / Treatment √ √ Partial

reviews meta- meta- focus
analyses) analyses)
PubMed Some Some Epidemiol √ √ √
articles small small focus
studies studies

NEPHO √ ONS √ ONS Regional 1999 & √ √

data data life years 2001
lost data –
London
only
 Data sources
Data Valid? Reliable? Complete? Timely Accessibl Relevant
source ? e? ?

NCHOD √ ONS √ ONS Age-specific √ √ NEPHO √

data. data. rates not Update website
Updated Updated split by sex d 2007
though though (small
based on based on numbers)
death death
certification certification
HPA √ √ Based on Testing & √ √ √
reporting trend
from monitoring.
primary No routine
care publications
 Data sources
Data Valid? Reliable? Complete Timely? Accessible Relevant
source ? ? ?
Patient √ NICE √ NICE Patient √ Based √ √
UK guidance & guidance info. on recent
review & review guidance
articles. articles. & articles
Written by Written by
clinicians. clinicians.
Reviewed Reviewed
18monthly 18monthly
Patient √ Peer √ Peer Clinical √ Based √ Partial
Plus reviewed. reviewed. focus – on recent
Based on Based on diagnosis guidance
NICE NICE and & articles
guidance & guidance managem
review & review ent
articles. articles.
Written by Written by
clinicians. clinicians.
 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 discrete-
event 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).