Epidemiology of perforating peptic ulcer: A population-based retrospective study over 40 years

Abstract

Background: The incidence of peptic ulcer disease has decreased during the last few decades, but the incidence of reported peptic ulcer complications has not decreased. Perforating peptic ulcer (PPU) is a severe form of the disease.

Aim: To assess trends in the incidence, presentation, and outcome of PPU over a period of 40 years.

Methods: This was a single-centre, retrospective, cohort study of all patients admitted to Levanger Hospital, Norway, with PPU from 1978 to 2017. The patients were identified in the Patient Administrative System of the hospital using International Classification of Diseases (ICD), revision 8, ICD-9, and ICD-10 codes for perforated gastric and duodenal ulcers. We reviewed the medical records of the patients to retrieve data. Vital statistics were available for all patients. The incidence of PPU was analysed using Poisson regression with perforated ulcer as the dependent variable, and sex, age, and calendar year from 1978 to 2017 as covariates. Relative survival analysis was performed to compare long-term survival over the four decades.

Results: Two hundred and nine patients were evaluated, including 113 (54%) men. Forty-six (22%) patients were older than 80 years. Median age increased from the first to the last decade (from 63 to 72 years). The incidence rate increased with increasing age, but we measured a decline in recent decades for both sexes. A significant increase in the use of acetylsalicylic acid, from 5% (2/38) to 18% (8/45), was observed during the study period. Comorbidity increased significantly over the 40 years of the study, with 22% (10/45) of the patients having an American Society of Anaesthesiologists (ASA) score 4-5 in the last decade, compared to 5% (2/38) in the first decade. Thirty-nine percent (81/209) of the patients had one or more postoperative complications. Both 100-day mortality and long-term survival were associated with ASA score, without significant variations between the decades.

Conclusion: Declining incidence rates occurred in recent years, but the patients were older and had more comorbidity. The ASA score was associated with both short-term mortality and long-term survival.

Keywords: American Society of Anaesthesiologists classification; Charlson Comorbidity Index; Clavien-Dindo classification of complications; Duodenal ulcer; Epidemiology; Gastric ulcer; Incidence; Mortality; Perforated peptic ulcer.

Figure 1

Effects of age and calendar year on the number of patients presenting with perforated peptic ulcer. Data are Poisson regression with fractional polynomials. 95% confidence intervals are shaded grey, and the y-axis is a logarithmic scale. Left, males. The effect of age was linear in both males and females, without an upper limit. Incidence increased, peaking 10 yr earlier in males than in females.

Figure 2

Effect of calendar year on the number of patients presenting with perforated gastric ulcer (left) and duodenal ulcer (right). Data were Poisson regression with fractional polynomials. 95% confidence intervals are shaded grey, and the y-axis is a logarithmic scale. The incidence of gastric ulcer perforations peaked around 1984, whereas the peak of duodenal ulcer perforations was approximately 15 yr later.

Figure 3

Relative survival in each American Society of Anesthesiologists group of patients who survived the first 100 postoperative days. ASA: American Society of Anesthesiologists.