Frequency of Bleeding Duodenal Ulcer in Patients Presenting with Upper Gastrointestinal Bleeding: Frequency of Duodenal Ulcer in patients with Gastrointestinal Bleeding

Abstract

Acute upper gastrointestinal bleeding is a well-known complication of peptic ulcers and erosions. The prevalence of Upper Gastrointestinal bleeding ranges from 48-160 patients per 100,000 people, with consistent reports of higher incidence among elderly and men. Objective: To determine the incidence of duodenal ulcer bleeding in patients admitted to the tertiary care hospital with bleeding from the upper gastrointestinal tract. Methods: The study included 270 patients, 20 to 70 years of age, of both sexes with upper gastrointestinal bleeding within 24 hours of symptom onset. A detailed interview and complete physical examination were performed. Endoscopic examination protocols were followed and accomplished within 48-hrs of the start of symptoms as bleeding. All of the above information, including age, sex and duodenal ulcer, was documented in a formerly designed proforma. The data were analyzed and entered in SPSS 22.0. Results: The mean age and SD were 54.5 + 10.54. 110 (40.74%) patients were 20-45 years old and 160 (59.25%) subjects were 46-70 years old. 190 (70.37%) patients were male and 80 (29.62%) females. While in this study duodenal ulcer was seen in 64 (23.70%) patients, 206 (76.29%) patients did not have duodenal ulcer. Conclusions: Upper Gastrointestinal bleeding is secondary to duodenal ulcers due to an increase in early readmissions over time, as observed in this local population, resulting in a higher incidence of duodenal ulcers in our local population.

Full text

Original Article
Bleeding from the upper gastrointestinal tract is a
communal symptom i n m ed ical i ns tituti ons a nd
gastroenterology clinics [1]. It has multiple causes that
varies greatly in different geographic regions of the world
[2]. De sp ite d evel op men ts i n t re at me nt , u pp er
gastrointestinal bleeding secondar y to peptic ulcer
remains a serious medical risk with signicant mortality,
morbidity and healthcare costs. The peptic ulcer disease is
ass umed to be reduced due to im prov ements in
endoscopic techniques, decreased Helicobacter pylori
DOI: https://doi.org/10.54393/pjhs.v3i06.308
Fahim M et al.,
Frequency of Bleeding Duodenal Ulcer in Patients presenting with Upper
Gastrointestinal Bleeding
1 2 3 4* 2
Muhammad Fahim, Muhammad Sohail , Muhammad Sajjad Khan , Fahim Ullah Khan , Salman ur Rashid , Shakeel
5
Akhter
¹MTI, Mardan Medical Complex, Mardan, Pakistan
²Primary Health Services Mardan, Pakistan
³Primary Health Services Bannu, Pakistan
⁴Primary Health Services D.I.Khan, Pakistan
⁵MTI, Bacha Khan Medical Complex Swabi, Pakistan
incidence and an increased use of acid-inhibiting drugs.
However, advances in peptic ulcer treatment have not
necessarily reduced the number of hospitalizations for
upper gastrointestinal bleeding following peptic ulcer
disease or the risk of adverse events, counting mortality.
Conicts in previous studies results can be claried by
various factors. Gastric ulcer epidemiology has evolved and
is no longer driven by H. pylori. An aging population has
increased use of non-steroidal anti-inammatory drugs
(NSAIDs), counting aspirin. This results in more frequent
Frequency of Duodenal Ulcer in patients with Gastrointestinal Bleeding
I N T R O D U C T I O N
Acute upper gastrointestinal bleeding is a well-known complication of peptic ulcers and
erosions. The prevalence of Upper Gastrointestinal bleeding ranges from 48-160 patients per
100,000 people, with consistent reports of higher incidence among elderly and men. Objective:
To determine the incidence of duodenal ulcer bleeding in patients admitted to the tertiary care
hospital with bleeding from the upper gastrointestinal tract. Methods: The study included 270
patients, 20 to 70 years of age, of both sexes with upper gastrointestinal bleeding within 24
hours of symptom onset. A detailed inter view and complete physical examination were
performed. Endoscopic examination protocols were followed and accomplished within 48-hrs
of the start of symptoms as bleeding. All of the above information, including age, sex and
duodenal ulcer, was documented in a formerly designed proforma. The data were analyzed and
entered in SPSS 22.0. Results: The mean age and SD were 54.5 + 10.54. 110 (40.74%) patients
were 20-45 years old and 160 (59.25%) subjects were 46-70 years old. 190 (70.37%) patients were
male and 80 (29.62%) females. While in this study duodenal ulcer was seen in 64 (23.70%)
patients, 206 (76.29%) p atie nts did not ha ve du oden al u lcer. Conclusions: U pper
Gastrointestinal bleeding is secondary to duodenal ulcers du e to an in crease in early
readmissions over time, as observed in this local population, resulting in a higher incidence of
duodenal ulcers in our local population.
A R T I C L E I N F O A B S T R A C T
How to Cite:
Fahim, M. ., Sohail, M. ., Sajjad Khan, M., Khan, F. U. .,
Ur Rashid, S. ., & Akhter, S. . (2022). Frequency of
Bleeding Duodenal Ulcer in Patients Presenting with
Upp er Gas trointest inal B leedi ng: Frequ ency of
Duodena l Ulcer in pati ents with Gastrointestinal
Bleeding. Pakistan Journal of Health Sciences, 3(06).
https://doi.org/10.54393/pjhs.v3i06.308
Key Words:
Gast rointestina l surge ry, Peptic ulcer bleedi ng,
Endoscopy and Mortality
*Corresponding Author:
Fahim Ullah Khan
Primary Health Services, D.I.Khan, Pakistan
fahimkhan757@gmail.com
Received Date: 31th October, 2022
th
Acceptance Date: 15 November, 2022
th
Published Date: 30 November, 2022
PAKISTAN JOURNAL OF HEALTH SCIENCES
https://thejas.com.pk/index.php/pjhs
Volume 3, Issue 6 (November 2022)
PJHS VOL. 3 Issue. 6 November 2022
Copyright © 2022. PJHS, Published by Crosslinks International Publishers
88

bleeding from the upper gastrointestinal tract following
peptic ulcer disease in the elderly people. The utmost
communal symptoms are bloody vomiting in acute bleeding
and melaena in cases which were chronic. It has been
observed that duodenal ulcer is common in cirrhosis
patients than in the over-all population [3]. In previous
years, most bleeding in patients with cirrhosis was
attributed to esophageal varices [4]. The widespread use
of upper gastrointestinal endoscopy has shown that in
many cases it can cause erosions, gastritis, or other
injuries such as peptic ulcers, especially duodenal ulcers
[5]. The prevalence of upper gastrointestinal bleeding
ranges from 48-160 patients per 100,000 people, with
consistent reports of higher incidence among elderly and
men [6]. The acute upper gastrointestinal bleeding most
communal reason is not varicose veins, and bleeding from
peptic ulcer (PIU) accounts for 28% to 59% of cases [7].
Most peptic ulcer disease patients are successfully treated
by H. pylori infection treatment and / or using suitable
antisecretory therapy and avoiding NSAIDs usage [8]. In
USA, triple therapy based on proton pump inhibitors (PPIs)
is the recommended primary treatment for H. pylori
infection. Peptic ulcers are defects in the lining of the
duodenum or stomach that cover along the mucosal
membrane [9]. The gastric and duodenal epithelial cells
secrete mucus as a consequence of the cholinergic
stimulation and epithelial lining irritation. The supercial
part of the duodenal and gastric mucosa is in the gel layer
form that is not-permeable to pepsin and acids. Other cells
in the stomach and duodenum secrete bicarbonate, which
helps buffer the acid near the mucosa [10]. Type E
prostaglandins (PGEs) play a vital protective part as PGEs
increase the secret ion of bo th m ucosal layer a nd
bicarbonate [11]. The aim of the study was to govern the
incidence of duodenal ulcer bleeding in patients admitted
to the tertiary care hospital with bleeding from the upper
gastrointestinal tract in order to determine the morbidity
and mortality associated with duodenal ulcer in our local
population. No comparable analysis has been performed at
our facility in the previous 5-years, this analysis will provide
the most up-to-date and latest information on the
frequency of duodenal ulcer bleeding in upper GI bleeding
patients. This study outcomes will be benecial for other
healthcare professionals and can be the reference for
further studies.
assessment were performed. Inclusion Criteria: All
pati ents reporting upper gastroi ntestinal bleeding
reporting within 24 hours of symptom onset, Patients aged
20-70, Patients of both sexes. Exclusion criteria: Patients
with severe shock (BP 90/160), patients with coagulation
disorders, recent myocardial infarction, severe respiratory
disease, arrhythmias or unstable angina were omitted from
the study. Hospital ethics committee approval and
approval from CPSP REU department were obtained. A
detailed interview and complete physical examination
were performed. Endoscopic examination protocols were
followed. Compulsory baseline tests, including complete
blood count, were obtained; occult blood faeces, eggs /
cysts; bleeding prole; hepatitis serology; ECG, abdominal
ultrasound, X-ray chest at admission before the procedure.
Patients were registered for endoscopic evaluation of the
upper gastrointestinal tract after obtaining informed
consent. Upper gastrointestinal endoscopy was
accomplished within 48-hrs of the start of symptoms as
bleeding. Local anesthesia of the throat was provided with
a 4% xylocaine spray. The entire procedure was performed
under the supervision of a gastroenterologist with at least
ve years of experience. All of the above information,
including age, sex and duodenal ulcer, was documented in a
formerly designed proforma. The data were analyzed and
entered in SPSS 22.0. Means and S.D were calculated for
quantitative variables such as size of the lesion and age.
The frequency and percentages were calculated by gender
and bleeding duodenal ulcer. Duodenal ulcer was graded
with gender and age to determine the effect modication.
The chi-square te st was used after s trati cation,
considering the P value <0.05 as signicant. All results are
presented in graphs and tables.
R E S U L T S
270 total patients of both sexes, 20 to 70 years of age,
selected by sequential sampling of improbable samples
with bleeding from the upper gastrointestinal tract within
24 hours of symptom onset, were registered in the study. A
comp rehensive in terview and complete physica l
M E T H O D S
Age Group
Table 1: Shows the patients demographic features (n=270)
Th e stud y was condu cted on 270 p ati ents at the
Department of Gastroenterology at MTI-Lady Reading
Hospital in Peshawar. The results are given below: - Mean
and SD for age were 54.5 ± 10.54. 110 (40.74%) patients were
20-45 years old and 160 (59.25%) patients were 46-70 years
old. 190 (70.37%) patients were male and 80 (29.62%)
females. (Table 1).
Frequency (%)
20-45 Years
46-70 Years
Total
110 (40.74%)
160 (59.26%)
270 (100%)
Male
Female
Total
Mean age
190 (70.37%)
80 (29.62%)
270 (100%)
54.5 ± 10.54 SDs
Gender
DOI: https://doi.org/10.54393/pjhs.v3i06.308
Fahim M et al., Frequency of Duodenal Ulcer in patients with Gastrointestinal Bleeding
PJHS VOL. 3 Issue. 6 November 2022
Copyright © 2022. PJHS, Published by Crosslinks International Publishers
89

While in this study duodenal ulcer was registered in 64
(23.70%) patients, 206 (76.29%) patients did not have
duodenal ulcer. (Table 2).
study duodenal ulcer was seen in 64 (23.70%) patients, 206
(76.29%) patients did not have duodenal ulcer. Of these
ulcers, 45 (6.5%) were graded as Forrest I and Forrest II was
seen in 113 (16.2%) cases. Gastric ulcer was identied in 488
cases (2.5%), and symptoms of bleeding were observed in
61 cases (12.3%) in Fallah et al., study [14]. Compared to this
study, where the mean age and SD was 54.5 ± 10.54, 19
patients (3.9%) have Forrest 1 grading and 41 patients
(8.4%) had Forrest 2. The gastric ulcers incidence
remained stable over time, while the duodenal ulcers
incidence decreased [15, 16]. It has been observed that
duodenal ulcer is common in cirrhosis patients than in the
over-all population. In previous years, most bleeding in
patients with cirrhosis was attributed to esophageal
varices. The widespread use of upper gastrointestinal
endoscopy has shown that in many cases it can cause
erosions, gastritis, or other injuries such as peptic ulcers,
especially duodenal ulcers. The prevalence of upper
gastrointestinal bleeding ranges from 48-160 patients per
100,000 peo ple, w ith consiste nt reports of hi gher
incidence among elderly and men. The acute upper
gastrointestinal bleeding most communal reason is not
varicose veins, and bleeding from peptic ulcer accounts for
28% to 59% of cases. Most peptic ulcer disease patients
are successfully treated by H. pylori infection treatment
and / or using suitable antisecretory therapy and avoiding
NSAIDs usage. In USA, triple therapy based on proton pump
inhibitors (PPIs) is the recommended primary treatment for
H. pylori infection [17, 18]. In this study, patients with
bleeding duodenal ulcers had a worse prognosis than
patients with bleeding gastric ulcers. Duodenal ulcers were
associated w ith increas ed m ort ality, surger y, and
admission rates [19, 20]. Bleeding from duodenal ulcers
has been related with an augmented risk of mortality and
surgery in some, but not all as shown in previous studies
[21, 22]. Duodenal ulcers may be associated with a poorer
prognosis as duodenal ulcers may be technically more
dicult to manage; especially in the case of endoscopy
performed in rural areas with little experience in the
treatment of upper gastrointestinal bleeding secondary to
peptic ulcer disease [6, 23].
C O N C L U S I O N S
Bleeding from the upper gastrointestinal tract is a
communal symptom i n m ed ical i ns tituti ons a nd
gastroenterology clinics. It has multiple causes that varies
greatly in different geographic regions of the world. The
utmost communal symptoms are bloody vomiting in acute
bleeding and melaena in cases which were chronic. In this
study, the mean age and SD were 54.5 + 10.54. 110 (40.74%)
patients were 20-45 years old and 160 (59.25%) patients
were 46-70 years old. 190 (70.37%) patients were male and
80 (29.62%) females. While in this study duodenal ulcer was
registered in 64 (23.70%) patients, 206 (76.29%) patients
did not have duodenal ulcer. In total, 20,006 upper GI
endoscopies were accomplished in one study [12, 13].
Duodenal ulcer was diagnosed in 696 (3.5%) cases and
bleeding symptoms were observed in 158 (22.7%) cases,
mean and SD for age was 54.5 + 10.54 compared to this
study. 110 (40.74%) patients were 20-45 years old and 160
(59.25%) patients were 46-70 years old. 190 (70.37%)
patients were male and 80 (29.62%) females. While in this
D I S C U S S I O N
Table 2: Frequency and Percentages for Duodenal Ulcer (n=270)
Upper gastrointestinal bleeding is secondary to duodenal
ulcers due to an increase in early readmissions over time,
as observed in this local population, resulting in a higher
incidence of duodenal ulcers in our local population. The
limitation of this study was the six-month period, which
was too short to meaningfully assess the time trends in our
local population.
Duodenal Ulcer Frequency (%)
Yes
No
Total
64 (23.70%)
206 (76.29%)
270 (100%)
Age and Gender was controlled through stratication and
therefore can be seen at Table 3 and 4 respectively. Table 3
shows the incidence of duodenal ulcer with respect to the
age; 14(5.18%) subjects out of 110 were found positive for
duodenal ulcer in 20-45 years of age while 50(18.51%)
patients out of 160 have duodenal ulcer in 20-45 years of
age patients.
Age P Value
Yes
No
Yes
No
14 (05.18%)
96 (35.55%)
50 (18.51%)
110 (40.74%)
Duodenal Ulcer Frequency (%)
20-45 Years
46-75 Years
0.0004
Table 3: Stratication of Duodenal Ulcer with Age (N=270)
Table 4 shows the incidence of duodenal ulcer with respect
to the gender; 39(14.4%) male subjects out of 190 were
found positive for duodenal ulcer while 25(9.25%) female
patients out of 80 have duodenal ulcer.
Gender P Value
Yes
No
Yes
No
39 (14.44%)
151 (55.92%)
25 (09.25%)
55 (12.96%)
Duodenal Ulcer Frequency (%)
Male
Female
0.058
Table 4: Stratication of Duodenal Ulcer with Gender (N=270)
C o n  i c t s o f I n t e r e s t
The authors declare no conict of interest
DOI: https://doi.org/10.54393/pjhs.v3i06.308
Fahim M et al., Frequency of Duodenal Ulcer in patients with Gastrointestinal Bleeding
PJHS VOL. 3 Issue. 6 November 2022
Copyright © 2022. PJHS, Published by Crosslinks International Publishers
90

The author(s) received no nancial support for the
research, authorship and/or publication of this article.
Nunziale A, Bertini L, et al. Prospective study
comparing multi-detector row CT and endoscopy in
acute gastrointestinal bleeding. World Journal of
Surgery. 2009 Oct; 33(10):2209-17. doi: 10.1007/
s00268-009-0156-6.
Lam KL, Wo ng JC, Lau JY. Pha rmaco logic al
treatment i n upper gastrointestinal bleeding.
Current Treatment Options in Gastroenterology. 2015
Dec; 13(4):369-76. doi: 10.1007/s11938-015-0063-x.
Curdia-Goncalves T, Rosa B, Cotter J. New insights
on an ol d m edi ca l em er ge ncy: no n-p or tal
hy perten sion relat ed uppe r g astr ointe stinal
bleeding. Revist a es panola de enfe rmedad es
digestivas. 2016 Oct; 108(10):648-56. doi: 10.17235/
reed.2016.4240/2016.
Lirio RA. Management of upper gastrointestinal
bleeding in children: variceal and nonvariceal.
Ga stro inte sti nal End osco py Clin ics o f North
America. 2016 Jan; 26(1):63-73. doi: 10.1016/j.giec.
2015.09.003.
Fallah MA, Pra kash C, Edmundowicz S. Acute
gastrointestinal bleeding. Medical Clinics of North
America. 2000 Sep; 84(5):1183-208. doi: 10.1016/
s0025-7125(05)70282-0.
Pongpr aso bch ai S , Nim itv ila i S, C has awat J,
Manatsathit S. Upper gastrointestinal bleeding
etiology score for predicting variceal and non-
variceal bleeding. World Journal of Gastroenterology.
2009 Mar; 15(9):1099-104. doi: 10.3748/wjg.15.1099.
Straube S, Tramer MR, Moore RA, Derry S, McQuay HJ.
Mortality with upper gastrointestinal bleeding and
perforation: effects of time and NSAID use. BMC
Gastroenterology. 2009 Jun; 9:41. doi: 10.1186/1471-
230X-9-41.
Yavorski RT, Wong RK, Maydonovitch C, Battin LS,
Furnia A, Amundson DE. Analysis of 3,294 cases of
upper gastrointestinal bleeding in military medical
facilities. The American Journal of Gastroenterology.
1995 Apr; 90(4):568-73.
Stabile BE and Stamos MJ. Surgical management of
gastrointestinal bleeding. Gastroenterology Clinics
of North America. 2000 Mar; 29(1):189-222. doi: 10.
1016/s0889-8553(05)70112-6.
Cheung FK and Lau JY. Management of massive
peptic ulcer bleeding. Gastroenterology Clinics of
North America. 2009 Jun; 38(2):231-43. doi: 10.1016/j.
gtc.2009.03.003.
Tiriveedhi K, Simon J, Cerulli MA. Does gastric lavage
reduce the detection of Helicobacter pylori in the
biopsy specimens? Gastrointestinal Endoscopy.
2007 Apr; 65(5):AB312. doi: 10.1016/j.gie.2007.03.756.
Boonpongmanee S, Fleischer DE, Pezzullo JC, Collier
Farrukh S, Raja S, Junaid K, Sahibzada NM, Naseer A.
F re q ue nc y o f d if fe r en t c au se s o f u pp er
gastro in testinal bleeding using endoscopic
procedure at a tertiary care hospital. Causes of Upper
Gastrointestinal Bleeding. Pakistan Armed Forces
Medical Journal. 2014 Sep; 64(3):410-413.
Marcel
JM, Ernst JK, Bettina EH, Rob JT. Incidence of
duodenal ulcers and gastric ulcers in a Western
population: Back to where it started. Canadian
Journal of Gastroenterology. 2009 Sep; 23(9):604–
08. doi: 10.1155/2009/181059.
Farah S, Rizwan A, Muhammad A. Frequency of
duodenal ulcer in cirrhosis of liver. Pakistan Journal
of Medical Health Sciences. 2010 Jan; 4(1):56-60.
Budimir I, Stojsavljevic S, Nikolic M, Kralj D, Biscanin
A, K iri gin LS , e t a l. Bl ee din g p ep tic ul ce r:
epidemiology, treatment and prognosis. Acta Clinica
Croatica. 2017 Dec; 3(1):1007. doi: 10.20471/acc.
2017.56.04.18.
Ch ey WD and Wong BC. Amer ica n col leg e of
gastroenterology guideline on the management of
helicobacter pylori infection. The American Journal
of Gastroenterology. 2014 Aug; 102(8):1808-25. doi:
10.1111/j.1572-0241.2007.01393.x.
Sung JJ, Tsoi KK, Ma TK, Yung MY, Lau JY, Chiu PW.
Causes of mortality in patients with peptic ulcer
bleeding: a prospective cohort study of 10,428 cases.
The American Journal of Gastroenterology. 2010 Jan;
105(1):84-9. doi: 10.1038/ajg.2009.507.
Quan S, Frolkis A, Milne K, Molodecky N, Yang H ,
Dixon E, et al. Upper-gastrointestinal bleeding
secondary to peptic ulcer disease: Incidence and
outcomes. World Journal of Gastroenterology. 2014
Dec; 20(46):17568–577. doi: 10.3748/wjg.v20.i46.
17568.
Gralnek IM, Dumonceau JM, Kuipers EJ. Diagnosis
a n d m a n ag e me n t o f n o nv a ri c ea l u pp e r
gastrointestinal hemorrhage: European Society of
Gastrointest inal E ndosc opy (ESGE) Guideline.
Endoscopy. 2015 Oct; 47(10):a1-a46. doi: 10.1055/s-
0034-1393172.
al-Assi MT, Genta RM, Karttunen TJ, Graham DY. Ulcer
site and complications: relation to Helicobacter
pylori infection and NSAID use. Endoscopy. 1996 Feb;
28(2):229-33. doi: 10.1055/s-2007-1005433.
Frattaroli FM, Casciani E, Spoletini D, Polettini A,
S o u r c e o f F u n d i n g
REFERENCES
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
DOI: https://doi.org/10.54393/pjhs.v3i06.308
Fahim M et al., Frequency of Duodenal Ulcer in patients with Gastrointestinal Bleeding
PJHS VOL. 3 Issue. 6 November 2022
Copyright © 2022. PJHS, Published by Crosslinks International Publishers
91

K, Mayoral W, Al-Kawas F, et al. The frequency of
peptic ulcer as a cause of upper-GI bleeding is
exaggerated. Gastrointestinal Endoscopy. 2004 Jun;
59(7):788-94. doi: 10.1016/S0016-5107(04)00181-6.
Elmunzer BJ, Young SD, Inadomi JM, Schoenfeld P,
Laine L. Systematic review of the predictors of
recurrent hemorrhage after endoscopic hemostatic
therapy for bleeding peptic ulcers. The American
Journal of Gastroenterology. 2008 Oct; 103(10):2625-
32. doi: 10.1111/j.1572-0241.2008.02070.x.
Leaper DJ. Surgery JD Corson RCN Williamson (eds)
297 × 254 mm Pp 1660 Illustrated 2001 London: Mosby.
British Journal of Surgery. 2002 Nov; 88(9):1269. doi:
10.1046/j.0007-1323.2001.01887.x
[22]
[23]
DOI: https://doi.org/10.54393/pjhs.v3i06.308
Fahim M et al., Frequency of Duodenal Ulcer in patients with Gastrointestinal Bleeding
PJHS VOL. 3 Issue. 6 November 2022
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