Prevalence of Peptic Ulcer Disease and Associated Factors Among Dyspeptic Patients At Endoscopy Unit, University of Gondar Hospital, Northwest Ethiopia

Abstract

Background: Dyspepsia is a common complaint in upper gastrointestinal disorders. It is described as predominant epigastric pain lasting for at least one month. Peptic Ulcer Disease (PUD) occurs in 5-15% of patients with dyspepsia. Helicobacter pylori (H.pylori) infection and non-steroidal anti-inflammatory drugs (NSAIDs)/aspirin (ASA) use are widely known risk factors for PUD. This research article aimed to determine the prevalence of PUD and associated factors among dyspeptic patients at the endoscopy unit, University of Gondar hospital, Northwest Ethiopia.
Methods: A hospital-based cross-sectional study was conducted at University of Gondar hospital. A sample of 218 adults who presented with the complaint of dyspepsia, and underwent endoscopic evaluation were interviewed from June 1 to November 30, 2020. A consecutive sampling method was used to recruit the study subjects. Relevant clinical history was obtained from patients’ medical records. Upper gastrointestinal endoscopy was used to confirm the presence of peptic ulcer disease. The Data were entered into EpiData version 4.6.0.2 and exported to SPSS version 20 for analysis. Logistic regression analysis was used to identify associated factors with the occurrence of PUD among dyspeptic patients. P-value <0.05 was used to declare a statistically significant association.
Results: A total of 218 dyspeptic patients who underwent upper gastrointestinal endoscopic evaluations were included in the study. The PUD was diagnosed in one-third of patients with dyspepsia. Dyspeptic patients with active H. pylori infection (AOR=6.3, 95%CI: 2.96-13.38) and NSAIDs/ASA use (AOR=6.2, 95%CI: 2.93-13.36) were at higher risk of developing PUD.
Conclusion: The magnitude of active H. pylori infection among symptomatic PUD patients was high. So then, a “test-and-treat” strategy is advised. Cautious use of NSAIDs/ASA is required as it is readily available over-the-counter.

Full text

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Prevalence of Peptic Ulcer Disease and Associated
Factors Among Dyspeptic Patients At Endoscopy
Unit, University of Gondar Hospital, Northwest
Ethiopia
Belete Assefa
University of Gondar
Abilo Tadesse
University of Gondar
Zinahebizu Abay
University of Gondar
Alula Abebe
University of Gondar
Tsebaot Tesfaye
University of Gondar
Melaku Tadesse
University of Gondar
Ayenew Molla Lakew (  mayenew15@gmail.com )
University of Gondar
Research Article
Keywords: Dyspepsia, Peptic ulcer disease, H. pylori, NSAIDs, Northwest Ethiopia
Posted Date: December 15th, 2021
DOI: https://doi.org/10.21203/rs.3.rs-1152130/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License. 
Read Full License

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Abstract
Background: Dyspepsia is a common complaint in upper gastrointestinal disorders. It is described as
predominant epigastric pain lasting for at least one month. Peptic Ulcer Disease (PUD) occurs in 5-15% of
patients with dyspepsia.Helicobacter pylori (H.pylori) infection and non-steroidal anti-inammatory drugs
(NSAIDs)/aspirin (ASA) use are widely known risk factors for PUD. This research article aimed to
determine the prevalence of PUD and associated factors among dyspeptic patients at the endoscopy unit,
University of Gondar hospital, Northwest Ethiopia.
Methods: A hospital-based cross-sectional study was conducted at University of Gondar hospital. A
sample of 218 adults who presented with the complaint of dyspepsia, and underwent endoscopic
evaluation were interviewed from June 1 to November 30, 2020. A consecutive sampling method was
used to recruit the study subjects. Relevant clinical history was obtained from patients’ medical records.
Upper gastrointestinal endoscopy was used to conrm the presence of peptic ulcer disease. The Data
were entered into EpiData version 4.6.0.2 and exported to SPSS version 20 for analysis. Logistic
regression analysis was used to identify associated factors with the occurrence of PUD among dyspeptic
patients. P-value <0.05 was used to declare a statistically signicant association.
Results: A total of 218 dyspeptic patients who underwent upper gastrointestinal endoscopic evaluations
were included in the study. The PUD was diagnosed in one-third of patients with dyspepsia. Dyspeptic
patients with active H. pylori infection (AOR=6.3, 95%CI: 2.96-13.38) and NSAIDs/ASA use (AOR=6.2,
95%CI: 2.93-13.36) were at higher risk of developing PUD.
Conclusion: The magnitude of active H. pylori infection among symptomatic PUD patients was high. So
then, a “test-and-treat” strategy is advised. Cautious use of NSAIDs/ASA is required as it is readily
available over-the-counter.
Background
Dyspepsia is a common complaint in upper gastrointestinal disorders. It is described as predominant
epigastric pain lasting for at least one month. It can be associated with abdominal fullness, bloating,
nausea, early satiety and epigastric burning. Globally, dyspepsia occurs in 10-20% of adults, and
accounts for 3% of medical oce visits. Dyspepsia has an impact on quality of life of patients and
expenses to the health care service (1, 2). Peptic ulcer disease (PUD) occurs in 5-15% of patients with
dyspepsia (3, 4). Imbalances in defensive and aggressive factors play a role in gastroduodenal mucosal
injuries (3, 4). Helicobacter pylori (H.pylori) infection and nonsteroidal antiinammatory drugs
(NSAIDs)/aspirin (ASA) use are the major components of aggressive factors (3–8). H. pylori is the most
prevalent human pathogen, which establishes chronic infection. H. pylori is widely known to cause
gastritis and peptic ulcer disease. Also, it is attributed to gastric cancer and gastric B-cell lymphoma (3–
6). Use of NSAIDs is recognized to cause erosive gastritis and peptic ulcer disease. Its use is ubiquitous
worldwide and has increased occurrence of PUD by 3-to-5 fold (7–9). Other less frequently implicated risk

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factors include genetics, stress, diet, alcohol and smoking (10, 11). This study aimed to determine the
prevalence of peptic ulcer disease and associated factors among dyspeptic patients at the University of
Gondar hospital, northwest Ethiopia.
Methods
Study design and setting
A hospital-based cross sectional study was conducted at the endoscopy unit, University of Gondar
hospital between June 1, 2020 and November 30, 2020. The hospital is located in Northwest Ethiopia,
which is 750 km away from the capital, Addis Ababa. The hospital had a catchment population of 5
million people. Endoscopy unit at University of Gondar hospital provides endoscopic services for patients
with gastrointestinal disorders.
Study population and study subjects
All patients who underwent endoscopic evaluation at endoscopy unit, University of Gondar hospital were
the study population. Adults 18 years or older who presented with a complaint of dyspepsia, and
underwent endoscopic evaluation at the endoscopic unit, University of Gondar hospital during the study
period were the study subjects. The sample size was calculated using a single population proportion
formula with the assumption of 95% condence level, 5% margin of error, and taking a 15% estimated
proportion of peptic ulcer disease among dyspeptic patients. The estimated sample size was 218 and
consecutive sampling method was used to recruit them. Adults 18 years or older who presented with a
complaint of dyspepsia, and underwent endoscopic evaluation at the endoscopic unit during the study
period were included in the study, while study subjects who were on antibiotics or PPI in the last three
weeks, had alarm symptoms, had contraindication to endoscopy or refused to undergo endoscopic
evaluation were excluded from the study.
Study variables and data collection procedures
The dependent variable for this study was Peptic Ulcer Disease (PUD), and the independent variables
were socio-demographic characteristics (include age, gender, residence, marital status, and
socioeconomic status), Clinical characteristics (include H. pylori infection, NSAIDs/ASA use, presence of
co-morbidities) and Behavioral factors (include smoking and alcohol consumption)
Data were collected through an investigator administered pre-designed questionnaire. The questionnaire
was prepared in English and translated into the local language (Amharic) for data collection, and then re-
translated back to English while maintaining its consistency. Patients were interviewed to obtain socio-
demographic data, and relevant clinical history was obtained from patients’ medical records. Lidocaine
(2%) throat spray and IV midazolam (2mg/ml) were used as local anesthetic and sedative agents,
respectively, before the procedure. A exible ber optic endoscope (Olympus, GIF-H170) was used for the
procedure. All endoscopic procedures were conducted by trained physicians (internists and surgeons).

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Diagnoses of endoscopic appearances were at the discretion of the endoscopist. Endoscopic ndings
were documented on endoscopy registry book and patients’ medical records. Diagnosis of H. pylori
infection was made using the H.pylori Ag Rapid Test CE (CTK Biotech) (13).
Data management and analysis
Data were entered into EpiData version 4.6.0.2 and exported to SPSS version 20 for analysis.
Categorical variables were reported as counts (percentages) and continuous variables as mean with
standard deviation. The results were summarized by using frequency, tables and graphs. Bi-variate and
multi-variate logistic regression models were constructed to identify independently associated factors
with peptic ulcer disease among dyspeptic patients. Those variables with a P-value < 0.25 in the bi-variate
analysis were exported to multi-variate. The crude odds ratio (COR) and adjusted odds ratio (AOR) were
reported. P-value < 0.05 was used to declare a statistically signicant association.
Ethical considerations
The research protocol complied with the Declaration of Helsinki and ethical clearance was obtained from
the Institutional Review Board (IRB) of the College of Medicine and Health Sciences, University of Gondar
(19/02/2020, IRB No. 1267/02/2020). Study subjects were recruited only after written informed consent
was obtained. All data obtained were treated condentially. Those patients who were found to have
peptic ulcer disease among H. pylori positive patients were taken care of as per the recommendation of
2017 ACG clinical guideline: Treatment of Helicobacter pylori infection (14).
Denition of Terms
Dyspepsia is predominant epigastric pain lasting for at least one month.
Peptic ulcer disease is a defect in the gastric or duodenal mucosa that extends through the muscularis
mucosa layer of the wall.
Alarm symptoms are symptoms likely indicate serious gastrointestinal diseases including malignancy,
such as intractable vomiting, dysphagia, anemia, weight loss, or hematemesis or melena.
The endoscopy unit is a dedicated place in the University of Gondar hospital where endoscopic
procedures are performed to visualize both upper and lower gastrointestinal structures. The procedures
are performed by trained physicians (internists and surgeons) and the unit has additional staff members
such as nurses and cleaners.
Results
Socio-demographic characteristics of study subjects

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A total of 218 dyspeptic patients underwent upper gastro intestinal endoscopic evaluations were included
in the study. The mean age of patients was 42 years (± 16.3 SD). Among the study subjects, more than
half (54%) were males and urban dwellers (58%). More than a third (36%) had a history of alcohol
consumption, while less than ve percent (4.6%) of them smoked cigarettes (Table-1).
Table-1: Socio-demographic characteristics of dyspeptic patients, who underwent upper gastrointestinal
endoscopic evaluation at endoscopy unit, University of Gondar hospital, June 1 to November 30, 2020
Characteristics Category Frequency Percentage
Age 18-28
29-40
41-55
56+
59
56
51
52
27.1
25.7
23.4
23.8
Sex Male
Female
118
100
54.1
45.9
Marital Status Single
Married
Divorced
Widowed
58
139
14
7
26.6
63.8
6.4
3.2
Residence Urban
Rural
126
92
57.8
42.2
Religion Orthodox Christian
Protestant Christian
Muslim
186
7
25
85.2
3.2
11.6
Level of Education Didn’t join school
Elementary school
Secondary school
College graduate
Degree graduate and above
72
44
40
31
31
33.1
20.2
18.3
14.2
14.2
Clinical characteristics of study subjects
Endoscopic ndings

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Peptic ulcer disease (PUD) was diagnosed in one-third (35%) of patients with dyspepsia. Two-thirds
(72%) of PUD cases had duodenal ulcers. Other organic causes of dyspepsia were gastritis/doudenitis
(19%), gastric mass (6%) and pyloric obstruction (4%). About one-third (36%) had functional dyspepsia
(Figure-1).
H. pylori infection rate
Half (49%) of dyspeptic patients had active H. pylori infection. Two-thirds (71.1%) of PUD patients had
active H. pylori infection. The majority (85%) of H. pylori infections among PUD cases had duodenal
ulcer.
NSAIDs/ASA users
NSAIDs/ASA were used by forty percent (39.5%) of dyspeptic patients. More than half (54.7%) of
NSAIDs/ASA users were diagnosed to have PUD.
Co-morbidities
One-third (29%) had co-morbidities, including cardiovascular diseases, rheumatologic diseases, chronic
airway diseases, and HIV infection.
Factors associated with risk of developing PUD among dyspeptic patients
Multivariable logistic regression analysis revealed dyspeptic patients with active H. pylori infection and
NSAIDs/ASA use were at risk of developing PUD, while unmarried study subjects were protected from
developing PUD (Table-2).
Table-2:Bi-variable and multi-variable regression analysis of factors associated with peptic ulcer disease
in upper gastrointestinal endoscopy evaluated dyspeptic patients at endoscopy unit, University of Gondar
hospital, northwest Ethiopia, June 1 to November 30, 2020

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Variables PUD COR (CI) AOR (CI)
Yes No
Age 18-28 19 40 1 1
29-40 20 36 0.897(0.407-1.978) 0.416(0.143-1.209)
41-55 19 32 1.049(0.476-2.314) 0.796(0.274-2.309)
+55 18 34 1.122(0.501-2.509) 0.542(0.178-1.670)
Sex Male 44 74 0.791(0.451-1.388) 1.406(0.702-2.817)
Female 32 68 1 1
Residence Urban 45 81 1.093(0.621-1.924) 0.739(0.368-1.484)
Rural 31 61 1 1
Marital Status Unmarried 20 59 0.502(0.273-0.925) 0.367(0.154-0.887) *
Married 56 83 1 1
Alcohol drinking Yes 24 54 0.752(0.417-1.358) 0.488(0.227-1.047)
No 52 88 1 1
Cigarettes smoking Yes 6 4 2.957(0.808-10.823) 3.153(0.585-16.998)
No 70 138 1 1
Co morbidity Yes 13 30 0.770(0.375-1.583) 0.721(0.276-1.881)
No 63 112 1 1
H-Pylori infection Positive 54 53 4.122(2.259-7.519) 6.298(2.965-13.378)*
Negative 22 89 1 1
NSAIDS/ASA use Yes 47 39 4.280(2.369-7.734) 6.252(2.925-13.362) *
No 29 103 1 1
Key: * indicates P<0.05
Dyspeptic patients with active H. pylori infection had six times higher odds of having PUD compared with
their counter facts (AOR=6.3, 95%CI: 2.96-13.38). Patients who used NSAIDs/ASA had also six times
higher of PUD compared with those who did not (AOR=6.25, 95%CI: 2.92-13.3. Unmarried individuals
reduced the odds of developing PUD by 63.3% (AOR=0.367, CI=0.15 - 0.89).
Discussion

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Among a total of 218 dyspeptic patients, active H. pylori infection was documented in half (49%) of study
subjects. Likewise, the H. pylori infection rate among PUD patients was 71%. These ndings were
congruent with hospital-based sub-Saharan African (SSA) reports. The African reports veried that 40-
65% of dyspeptic and 60-90% PUD patients were positive for H. pylori infection (16–19). The Ethiopian
pooled prevalence of H. pylori infection was 52% in a recent hospital-based meta-analysis (20). The
global magnitude of H. pylori infection was 34% in Western Europe, 37% in Northern America, and 70% in
Africa (12). The global difference in the magnitude of the H. pylori infection rate could be explained by
the difference in socio-economic status, environmental sanitation, living conditions, and personal
hygiene. In this study, PUD (35%) was the commonly observed abnormal endoscopic lesion, followed by
gastritis/duodenitis (19%) and gastric mass (6%). A Ghanaian study reported that PUD (54%) followed by
gastric cancer (12%) were the most frequently detected endoscopic ndings. While studies in Tanzania,
Nigeria and Kenya witnessed gastritis (61-86%) followed by PUD (14-24%) were the commonly observed
endoscopic pathologies. The difference in the type of gastroduodenal lesions among dyspeptic patients
in African reports could be explained by differences in patient characteristics (age, genetics), H. pylori
virulence strain, NSAIDs/ASA exposure rate, lifestyle preferences (smoking, alcohol), and other
environmental factors (16–18). This study revealed that nearly forty percent (39%) of dyspeptic patients
had a history of NSAIDs/ASA use, and more than half (55%) of NSAIDs/ASA users developed PUD.
Western literature reviews documented that dyspepsia occurred in up to half (50-60%) of patients taking
NSAIDs/ASA, and up to a third (15-30%) of patients using NSAIDs/ASA developed PUD (7–9). On
multivariable logistic regression analysis, odds of developing PUD was 6 fold higher among dyspeptic
patients with H. pylori infection than those with negative H. pylori infections (AOR=6.298, 95%CI: 2.965 -
13.378). It was conrmed that H. pylori establishes prolonged gastro duodenal mucosal infection, and
leads to chronic active gastritis and PUD (3–6, 16–19). Dyspeptic patients who use NSAIDs/ASA had 6
fold increased risk of developing PUD compared to non-NSAIDS/ASA users (AOR=6.252, 95%CI: 2.925-
13.362). NSAIDs/ASA interfere with the cyclo-oxygenase (COX) pathway and deplete biosynthesis of
gastric prostaglandins. In addition, NSAIDS/ASA are weak acids which cause direct gastric mucosal toxic
injury (3, 4, 7–11). Study subjects with unmarried status were 60% protected from developing PUD as
compared to their counter parts (AOR=0.367, 95%CI=0.154-0.887). Reduced family size and non-crowded
living condition among unmarried subjects might contribute to reduced H. pylori infection rate and
occurrence of PUD.
Strength And Limitation Of The Study
The major strength of this study was its prospective study design, which allowed collecting reliable data.
The limitation of the study was selection bias as referred patients with dyspepsia were included.
Conclusions
Peptic ulcer disease (PUD) was diagnosed in one-third of patients with dyspepsia. Two-thirds of PUD
patients had active H. pylori infection. NSAIDs/ASA were used by forty percent of dyspeptic patients. Half

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of NSAIDs/ASA users were diagnosed to have PUD. Dyspeptic patients with active H. pylori infection and
NSAIDs/ASA use were at risk of developing PUD. The magnitude of active H. pylori infection among
symptomatic PUD patients was high. So then, a ‘test-and-treat’ strategy is advised. Cautious use of
NSAIDs/ASA is required as it is readily available over-the-counter.
Abbreviations
ACG: American College of Gasrtoenterology; ASA: Aspirin; AOR: Adjusted Odds Ratio; CI; Condence
Interval; COR: Crude Odds Ratio, H.pylori, Helicobacter pylori, IV: Intravenous; NSAIDs, Nonsteroidal Anti-
inammatory Drugs; PPI: Proton Pump Inhibitors; PUD: Peptic Ulcer Disease
Declarations
Ethics approval and consent to participate
The study was performed in accordance with the Declaration of Helsinki and approved by the
Institutional Review Board of College of Medicine and Health Sciences, University of Gondar
(19/02/2020, IRB No. 1267/02/2020). Written informed consents for participation were obtained from
study subjects or their caregivers.
Consent for publication
Written informed consent for publication was obtained from study subjects.
Availability of data and materials
All data generated and analyzed were included in this research article.
Funding
Funding for research was obtained from the ‘Research and Publication Oce’ of the College of Medicine
and Health Sciences, University of Gondar. The funding body had no role in the design of the study, data
collection, analysis and interpretation of the data.
Acknowledgements
We are grateful to thank the study participants and their health personnel.
Authors’ contributions
Belete Assefa contributed to the conception, design, data collection, analysis, writing, and review of the
manuscript. Abilo Tadesse contributed to the conception, design, analysis, writing and review of the
manuscript. Zenahbizu Abay, Alula Abebe, Tsebaot Tesfaye, Melaku Tadesse and Ayenew Molla

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contributed to conception, design, analysis and review of the manuscript. All authors read and approved
the nal manuscript and approved its submission for publication.
Competing interests
The authors declare that they have no competing interests.
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Figures
Figure 1

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Endoscopic ndings among patients with dyspepsia University of Gondar hospital, 2020