EPIDEMIOLOGICAL PROFILE OF PATIENTS WITH NON-VARICEAL UPPER GASTROINTESTINAL BLEEDING SECONDARY TO PEPTIC DISEASE IN A TERTIARY REFERRAL BRAZILIAN HOSPITAL

FORGERINI, Marcela; URBANO, Gustavo; NADAI, Tales Rubens de; ZAPATA-CACHAFEIRO, Maruxa; KEMP, Rafael; MASTROIANNI, Patrícia de Carvalho

doi:10.1590/S0004-2803.202100000-36

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Arquivos de Gastroenterologia

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ORIGINAL ARTICLE • Arq. Gastroenterol. 58 (02) • Apr-Jun 2021 • https://doi.org/10.1590/S0004-2803.202100000-36 copy

EPIDEMIOLOGICAL PROFILE OF PATIENTS WITH NON-VARICEAL UPPER GASTROINTESTINAL BLEEDING SECONDARY TO PEPTIC DISEASE IN A TERTIARY REFERRAL BRAZILIAN HOSPITAL

Perfil epidemiológico de pacientes com hemorragia gastrointestinal alta não varicosa decorrente de doença péptica em um hospital brasileiro terciário de referência

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND:

Non-variceal upper gastrointestinal bleeding (NVUGIB) secondary to peptic ulcer disease is a medical digestive emergency and could be one of the most serious adverse drug reactions.

OBJECTIVE:

To identify the frequency of diagnosis of NVUGIB secondary to peptic ulcer disease.

METHODS:

Prospective and epidemiological study conducted in a tertiary referral Brazilian hospital, from July 2016 to December 2019. Upper gastrointestinal endoscopies (UGE) reports were evaluated daily. The diagnosis of NVUGIB secondary to peptic ulcer disease was defined through endoscopic findings of peptic ulcer and erosive gastric lesions, and clinical symptoms. The frequency of diagnosis of NVUGIB secondary to peptic ulcer disease was estimated through the ratio between the number of patients diagnosed and the number of patients underwent UGE in the same period.

RESULTS:

A total of 2,779 endoscopic reports (2,503 patients) were evaluated, and 178 patients were eligible. The total frequency of diagnosis of NVUGIB secondary to peptic ulcer disease was 7.1%. The annual frequency of diagnosis between 2017 and 2019 ranged from 9.3% to 5.7%. Most patients were men (72.8%); self-declared white (71.8%); older people (56.7%); and, had no familiar or personal history of gastrointestinal diseases (60.1%). 90% of the patients had a peptic ulcer and melena (62.8%). Patients made chronic use of low-dose aspirin (29.3%), other antiplatelet agents (21.9%) and, oral anticoagulants (11.2%); and non-steroidal anti-inflammatories use in the week a prior to the onset of clinical symptoms (25.8%).

CONCLUSION:

Seven in every 100 patients admitted and underwent UGE in a tertiary hospital were diagnosed with NVUGIB secondary to peptic ulcer disease.

Keywords:
Gastrointestinal endoscopy; gastrointestinal hemorrhage; epidemiology; hospitalization; patient safety; peptic ulcer

Variable	Data source and measurement
Non-variceal upper gastrointestinal bleeding and frequency of diagnoses

Non-variceal upper gastrointestinal bleeding (NVUGIB) secondary to peptic ulcer disease	Diagnosis through upper gastrointestinal endoscopy (endoscopic findings of ulcer, cardiac or pyloric erosions, acute gastric mucosal lesions, and erosive gastritis or duodenitis, with or without active or recent bleeding) and clinical symptomatology (hematemesis, melena, hematochezia, intense sweating, dizziness, abdominal pain, nausea or vomiting).
Total frequency of non-variceal upper gastrointestinal bleeding secondary to peptic ulcer disease	Upper gastrointestinal endoscopies were evaluated for 42 months (July 2016 to December 2019). The total frequency was calculated using the ratio of the number of patients diagnosed with non-variceal upper gastrointestinal bleeding secondary to peptic disease during the study and divided by the total number of upper gastrointestinal endoscopies performed.
Frequency of non-variceal upper gastrointestinal bleeding secondary to peptic ulcer disease	The study four periods: (1) July 2016 to December 2016; (2) year 2017; (3) year 2018; and, (4) year 2019. The frequency in the four periods was calculated using the ratio of the number of patients diagnosed with non-variceal upper gastrointestinal bleeding secondary to peptic disease in the respective period and divided by the total number of upper gastrointestinal endoscopies performed in the same period.
Variables recorded in the face-to-face interview

Sex, age and, ethnicity	Recorded through self-report in the interview.
Body mass index (kg/m²)	Weight and height were recorded through interviews and confirmed by electronic medical records.
Comorbidity	Diabetes mellitus, high blood pressure, dyslipidemia, cardiovascular disease, migraine, arthorosis and, arthiritis were recorded through interviews and electronic medical records as a secondary source of information.
Personal history of gastrointestinal diseases and family history of ulcer	Personal history of dyspepsia (pain, burning in the stomach and/or feeling of slow digestion); bleeding (melena and/or hematemesis); ulcer (gastric and/or duodenal); previous Helicobacter pylori infection and family history of ulcer were recalled through self-report during the interviews.
Drug therapy	The drug therapy used in the two months prior to the onset of signs and symptoms of NVUGIB were recalled through self-reports during the interviews and electronic medical records as a secondary source of information.
Smoking habit	The habit of smoking was recalled through self-reporting during the interviews and was stratified into: non-smokers; ex-smokers and smokers. The amount of tobacco consumed by smokers was stratified as “moderate” (1 to 15 cigarettes/day) and “heavy” (>15 cigarettes/day)¹⁷17. Figueiras A, Estany-Gestal A, Aguirre C, Ruiz B, Vidal X, Carvajal A, et al. CYP2C9 variants as a risk modifier of NSAID-related gastrointestinal bleeding: A case-control study. Pharmacogenet Genomics. 2016;26:66-73..
Alcohol consumption	Alcohol consumption was recalled through self-report during the interviews and was stratified into: non-consumption (abstainer) and “little” consumption (0 to ≤30 grams of alcohol/day), “moderate” (30 to ≤90 grams of alcohol/day) and “heavy” (>90 grams of alcohol/ day). In addition, alcohol consumption was stratified into fermented beverages (beer, red and white wine) and distilled beverages (whiskey, cachaça and vodka)¹⁷17. Figueiras A, Estany-Gestal A, Aguirre C, Ruiz B, Vidal X, Carvajal A, et al. CYP2C9 variants as a risk modifier of NSAID-related gastrointestinal bleeding: A case-control study. Pharmacogenet Genomics. 2016;26:66-73..
Reliability of interview	Interview reliability was measured using scores from 0 to 10. The interviewer assigned the score according to the reliability of the information provided by the patient and/or family member during the interviews.

Period*	Period 1 (32 patients)	Period 2 (70 patients)	Period 3 (39 patients)	Period 4 (37 patients)
Variable	N	N	N	N
Sex
Male/Female	26/06	48/22	27/12	27/10
Age
Median (interquartil range)	57.0	65.0	66.0	61.0
Interquartil range (Q1; Q3)	48.5-73.2	50.2-74.5	50.0-74.5	50.2-71.7
Patients >60 years old	15	42	24	20
Reliability of interview
6-7	16	35	20	12
7-9	10	34	17	19
>9	6	1	2	6
Body mass index (kg/m²)
Under-weight (<18)	3	2	2	1
Normal (≥18≤24)	15	33	11	9
Overweight (≥25≤30)	9	19	14	13
Obesity (≥30≤35)	2	9	8	10
Moderate obesity (≥35≤40)	0	5	4	3
Severe obesity (>40)	2	2	0	1
Without knowledge	1	0	0	0
Ethnicity
White	25	46	24	27
Black	7	23	15	10
Oriental	0	01	0	0
Personal history of gastrointestinal disorders
Ulcer	8	13	9	7
Bleeding	10	10	7	7
Dyspepsia	12	22	13	3
Comorbidity
Cardiovascular disease	10	19	16	5
High blood pressure	14	42	22	21
Diabetes mellitus	5	15	10	8
Elevated cholesterol	5	8	1	5
Migraine	3	0	1	0
Arthritis	1	1	1	0
Arthrosis	2	1	2	1
Drug exposure
Non-steroidal anti-inflammatories	14	25	14	11
Proton pump inhibitor	11	11	6	0
H2 receptor antagonists	1	1	0	0
Low-dose aspirin**	13	24	9	7
Antiplatelet agents (not including low-dose aspirin)	1	25	7	6
Oral anticoagulant	5	8	6	1
Smoking
Non-smoker	13	34	16	19
Ex-smoker	9	20	9	11
Smoker	10	16	14	7
Moderate consumption	4	5	4	3
Heavy consumption	6	11	10	4
Alcohol consumption
Abstainer	15	39	22	17
Alcohol consumption	17	31	17	20
Consumption of fermented alcoholic beverages***	17	29	16	17
Consumption of distilled alcoholic beverages***	4	13	7	8
Little	13	21	13	14
Moderate	3	10	4	6
Heavy	1	0	0	0

Instituto Brasileiro de Estudos e Pesquisas de Gastroenterologia e Outras Especialidades - IBEPEGE. Rua Dr. Seng, 320, 01331-020 São Paulo - SP Brasil, Tel./Fax: +55 11 3147-6227 - São Paulo - SP - Brazil
E-mail: secretariaarqgastr@hospitaligesp.com.br

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[1] Corresponding author: Patrícia de Carvalho Mastroianni. E-mail: patricia.mastroianni@unesp.br