Acute Upper Gastrointestinal Bleeding: Comparison Between Recent Users and Nonusers of Nonsteroidal Anti-Inflammatory Drugs

Background and Study Aims: To determine clinical, endoscopic, and outcome differences between recent users and nonusers of nonsteroidal anti-inflammatory drugs (NSAIDs) presenting with upper gastrointestinal bleeding (UGIB).
Patients and Methods: A total of 330 consecutive patients who presented with clinical manifestations of UGIB underwent urgent endoscopy after clinical assessment within 12 h of admission. The patients were divided into two groups, depending on whether there was a positive or negative history of recent NSAID use. Urgent endoscopy followed by endoscopic hemostasis and/or biopsy, as needed, was performed by the same endoscopist, who was blinded to the patients’ clinical status.
Results: The baseline characteristics, clinically estimated severity of UGIB, and outcome did not differ between the two groups. Recent NSAID users were found to bleed from an ulcer more frequently (P = 0.009) than nonusers of NSAIDs, the latter more often having a history of peptic ulcer or UGIB (P = 0.02). Bleeding ulcers were mostly duodenal in the NSAID group and gastric in the non-NSAID group (P < 0.001). Helicobacter pylori infection was significantly more common among NSAID users (P < 0.01). The group of NSAID users included a significantly greater proportion of alcohol abusers (P = 0.01), who were found to bleed mostly from erosive gastritis.
Conclusions: Recent NSAID users were found to bleed from ulcers, mostly duodenal, and to have H. pylori infection more frequently than UGI bleeders with a negative history of NSAID consumption. Alcohol abuse was also more common among NSAID users. The severity of bleeding and the outcome did not differ between the two groups.

References

• 1 Wolfe M M, Lichtenstein D R, Singh G. Gastrointestinal toxicity of nonsteroidal anti-inflammatory drugs.  N Engl J Med. 1999;  340 1888-1899
• 2 Langman M JS. Epidemiologic evidence on the association between peptic ulceration and antiinflammatory drug use.  Gastroenterology. 1989;  96 640-646
• 3 Singh G, Triadafilopoulos G. Epidemiology of NSAID-induced gastrointestinal complications.  J Rheumatol. 1999;  26 (Suppl 56) 18-24
• 4 Henry D, Dobson A, Turner C. Variability in the risk of major gastrointestinal complications from nonaspirin nonsteroidal anti-inflammatory drugs.  Gastroenterology. 1993;  105 1078-1088
• 5 Hansen J M, Hallas J, Lauritsen J M. et al . Non-steroidal anti-inflammatory drugs and ulcer complications: a risk factor analysis for clinical decision-making.  Scand J Gastroenterol. 1996;  31 126-130
• 6 Yeomans N D, Tulassay Z, Juhasz L. et al . A comparison of omeprazole with ranitidine for ulcers associated with nonsteroidal anti-inflammatory drugs.  N Engl J Med. 1998;  338 719-726
• 7 Hawkey C J, Karrasch J A, Szczepanski L. et al . Omeprazole compared with misoprostol for ulcers associated with nonsteroidal anti-inflammatory drugs.  N Engl J Med. 1998;  338 727-734
• 8 Lanza F L. A guideline for the treatment and prevention of NSAID-induced ulcers.  Am J Gastroenterol. 1998;  93 2037-2046
• 9 Cooper G S, Blades E W. Indications, contraindications, and complications of upper gastrointestinal endoscopy. In: Sivak MV (ed) Gastroenterologic Endoscopy. 2nd ed. Philadelphia; Saunders 1999
• 10 Tytgat G NJ. Upper gastrointestinal endoscopy. In: Yamada T, Alpers DH, Owyang C et al (eds) Textbook of gastroenterology.  Philadelphia; Lippincott 1995: 2566-2567
• 11 Pilotto A, Franceschi M, Leandro G. et al . The effect of Helicobacter pylori infection on NSAID-related gastroduodenal damage in the elderly.  Eur J Gastroenterol Hepatol. 1997;  9 951-956
• 12 Archimandritis A, Tzivras M, Sougioultzis S. et al . Rapid urease test is less sensitive than histology in diagnosing Helicobacter pylori infection in patients with non-variceal upper gastrointestinal bleeding.  J Gastroenterol Hepatol. 2000;  15 369-373
• 13 Lee J M, Breslin N P, Fallon C. et al . Rapid urease tests lack sensitivity in Helicobacter pylori diagnosis when peptic ulcer disease presents with bleeding.  Am J Gastroenterol. 2000;  95 1166-1170
• 14 Kawanishi M, Fukuda S, Kawaguchi H. et al . Significance of rapid urease test for identification of Helicobacter pylori in comparison with histological and culture studies.  J Gastroenterol. 1995;  30 16-20
• 15 SPSS .Statistical Package for the Social Sciences. Windows version, release 10.0 Chicago; SPSS Inc 2000
• 16 Armitage P, Berry G. Statistical methods in medical research. 2nd ed. Oxford; Blackwell Scientific 1987
• 17 Tabachnick B G, Fidell L S. Using multivariate statistics. 4th ed. Boston, MA; Allyn and Bacon 2001
• 18 Armstrong C O, Blower A L. Non-steroidal antiinflammatory drugs and life-threatening complications of peptic ulcerations.  Gut. 1987;  28 527-532
• 19 Singh G, Ramey D R, Mortfeld D. et al . Gastrointestinal tract complications of non-steroidal anti-inflammatory drug treatment in rheumatoid arthritis: a prospective observational cohort study.  Arch Intern Med. 1996;  156 1530-1536
• 20 Graham D Y, Smith J L. Aspirin and the stomach.  Ann Intern Med. 1986;  104 390-398
• 21 Hla T, Neilson K. Human cyclooxygenase-2 cDNA.  Proc Natl Acad Sci USA. 1992;  89 7384-7388
• 22 Hochain P, Berkelmans I, Czernichow P. et al . Which patients taking non-aspirin non-steroidal anti-inflammatory drugs bleed? A case-control study.  Eur J Gastroenterol Hepatol. 1995;  7 419-426
• 23 Barkin J. The relation between Helicobacter pylori and non-steroidal anti-inflammatory drugs.  Am J Med. 1998;  105 22S-27S
• 24 Chan F KL, Sung J JY, Chung S CS. et al . Randomised trial of eradication of Helicobacter pylori before non-steroidal anti-inflammatory drug therapy to prevent peptic ulcers.  Lancet. 1997;  350 975-979
• 25 Hawkey C J, Tullassay Z, Szczepanski L. et al . Randomized controlled trial of Helicobacter pylori eradication in patients on non-steroidal anti-inflammatory drugs: HELP NSAIDs study.  Lancet. 1998;  352 1016-1021
• 26 Bianchi-Porro G, Parente F, Imbesi V. et al . Role of Helicobacter pylori in ulcer healing and recurrence of gastric and duodenal ulcers in long-term NSAID users: response to omeprazole dual therapy.  Gut. 1996;  39 22-26
• 27 Huang J Q, Hunt R H. H. pylori (Hp) infection and non-steroidal anti-inflammatory drugs (NSAIDs) have an additive effect on peptic ulcer (PU) bleeding: a meta-analysis of case-control studies.  Gut. 2001;  49 (Suppl. 3) A1155
• 28 Hawkey C J. Nonsteroidal anti-inflammatory drug gastropathy.  Gastroenterology. 2000;  119 521-535
• 29 Barr M, Buckley M, O’Morain C. Non-steroidal anti-inflammatory drugs and Helicobacter pylori.  Aliment Pharmacol Ther. 2000;  14 43-47
• 30 McIntosh J H, Byth K, Piper D W. Environmental factors in aetiology of chronic gastric ulcer: a case-control study of exposure variables before the first symptoms.  Gut. 1985;  26 789-798